Outsourcing and Telemedicine: Risks and Rewards

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Outsourcing and Telemedicine: Risks and Rewards

  1. 1. Sedgwick © 2013 Confidential – Do not disclose or distribute. Outsourcing & Telemedicine Risks and Rewards
  2. 2. Sedgwick © 2012 Confidential– Do not disclose or distribute. 2 Ann Gaffey SVP, Healthcare Risk Management & Patient Safety Kathy Shostek Sr. Healthcare Risk Management Consultant Jayme Vaccaro Director Professional Liability Claims
  3. 3. Sedgwick © 2013 Confidential – Do not disclose or distribute. 3 Telemedicine • American Telemedicine Association:  “use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment or services” • Transfers medical expertise instead of medical experts and patients
  4. 4. Sedgwick © 2013 Confidential – Do not disclose or distribute. 4 Delivery of telemedicine • Technology  Telephone service  High-speed dedicated line  Internet • Information transmission  Voice  Data  Still images
  5. 5. Sedgwick © 2013 Confidential – Do not disclose or distribute. 5 Telemedicine technology • Store-and-Forward  Sharing information in a time-and-place independent way over the internet  Appropriate to specialties where diagnosis is based on images, such as dermatology and pathology  Because cheaper and doesn’t require sophisticated equipment or broadband, it is being used to simply introduce telemedicine at low cost to developing countries in specialties that traditionally used videoconferencing
  6. 6. Sedgwick © 2013 Confidential – Do not disclose or distribute. 6 Telemedicine technology • Interactive videoconferencing (teleconferencing)  Can consult in “real time” at a distance  Might require only a videophone and connection to the internet  Sophisticated systems include microphones, scanners, cameras, medical instruments and dedicated phone lines  Remote house calls
  7. 7. Sedgwick © 2013 Confidential – Do not disclose or distribute. 7 Is the Doctor In?
  8. 8. Sedgwick © 2013 Confidential – Do not disclose or distribute. 8
  9. 9. Sedgwick © 2013 Confidential – Do not disclose or distribute. 9
  10. 10. Sedgwick © 2013 Confidential – Do not disclose or distribute. 10 Where are we seeing telemedicine used? • Teleradiology • Telepathology • Teledermatology • Telecardiology • Teleneurology  Telestroke  Epilepsy  Parkinson’s Disease • Telepsychiatry • Remote monitoring devices • Telewound care • Telehome care • Telemedicine in prisons • Telenursing • Other applications  Baby CareLink  Smartphone, tablets
  11. 11. Sedgwick © 2013 Confidential – Do not disclose or distribute. 11 Is it what patients and providers want? • PricewaterhouseCoopers survey – 2010  31% consumers would use a smartphone app that tracked their personal health information  40% consumers would buy a device and pay a subscription for an app that would send reminders  40% consumers would buy a device and pay for a service that sends data (heart rate, BP, weight)  56% like remote health care  88% of doctors would like their patients to monitor their health at home  57% doctors would like to monitor their patients via remote devices outside the hospital – but just want “exceptional” information – not all
  12. 12. Sedgwick © 2013 Confidential – Do not disclose or distribute. 12 Rewards and promises • Remote pharmacy services prevents medication errors • Remote pediatric care reduces ED visits • Clinical improvements in chronic condition management using Internet (hypertension)  Think Accountable Care Organizations • Cost savings > 60% with mid-level providers treating common illnesses over Internet  Virtuwell
  13. 13. Sedgwick © 2013 Confidential – Do not disclose or distribute. 13 Telemedicine trends • Teleradiology eICU • Remote monitoring Robotic eyes • Telepsychiatry
  14. 14. Sedgwick © 2013 Confidential – Do not disclose or distribute. 14 What are the top risks? • Risks of outsourcing • Telemedicine  Contracting  Credentialing  Quality monitoring • Risk management strategies • Case studies
  15. 15. Sedgwick © 2013 Confidential – Do not disclose or distribute. 15 Top risk management issues • Contracting • Credentialing and privileging • Quality monitoring  Technology  Privacy and security issues  Information management and documentation
  16. 16. Sedgwick © 2013 Confidential – Do not disclose or distribute. 16 The informed patient • Self Magazine. November 2011 “When to Question Your Scan Results” http://www.self.com/health/2011/11/outsourcing-radiology-dangers?printable=true
  17. 17. Sedgwick © 2013 Confidential – Do not disclose or distribute. 17 Telemedicine regulations, standards, guidelines • Centers for Medicare and Medicaid services • State regulations and licensing  Inconsistent in definition and application • Joint Commission • Professional Association standards and guidelines  American Telemedicine Association  ATA with specialty organizations
  18. 18. Sedgwick © 2013 Confidential – Do not disclose or distribute. 18 Credentialing and privileging • CMS final rule published May 5, 2011  Final Rule (76 FR 25550) effective July 5, 2011  Hospital CoP: Telemedicine Credentialing and Privileging • Credentialing by proxy in line with Joint Commission Standards  Rely on distant site hospital or telemedicine entity credentialing where an agreement exists and medical staff bylaws include such provisions • Joint Commission standards  MS.13.01.01  LD.04.03.09
  19. 19. Sedgwick © 2013 Confidential – Do not disclose or distribute. 19 Telemedicine contracting • Agreements  Duties, responsibilities and rights  Role in patient care  Provisions for credentialing, quality monitoring, insurance, record keeping, billing, and indemnification  Compliance with state/federal laws • The Center for Telehealth and e-Health Law  www.ctel.org
  20. 20. Sedgwick © 2013 Confidential – Do not disclose or distribute. 20 Quality monitoring • Monitoring telemedicine services • Policies and procedures • Providers and staff performance • Integration with risk management and patient safety programs
  21. 21. Sedgwick © 2013 Confidential – Do not disclose or distribute. 21 Technology • Maintenance and user education • Privacy and information security • Information management and documentation
  22. 22. Sedgwick © 2013 Confidential – Do not disclose or distribute. 22 Telemedicine is here to stay • Standard of Care • May mitigate liability risk
  23. 23. Sedgwick © 2012 Confidential– Do not disclose or distribute. 23 Case studies
  24. 24. Sedgwick © 2013 Confidential – Do not disclose or distribute. 24 Themes in Telemedicine claims • The Use of Technology to Deliver Healthcare • Financial Incentives • Straight Forward Errors vs Judgment Calls • “Guinea Pig” Syndrome • Understanding the Depth of Your Technology
  25. 25. Sedgwick © 2013 Confidential – Do not disclose or distribute. 25 Outsourcing: Typo or “Really Egregious”* Juno v Thomas Hospital (Mobile, AL) • 59 year old diabetic female patient admitted to hospital #1 for clogged kidney dialysis access port • The patient was discharged and admitted to hospital #2 when she experienced complications • Hospital # 2 used hospital #1’s physician admitting orders and discharge summary and administered 80 units of Levemir insulin • The amount was 10 times the dosage Rx by the patient’s doctor and the patient died
  26. 26. Sedgwick © 2013 Confidential – Do not disclose or distribute. 26 Outsourcing: Typo • The patient’s physician had certified on a form the medication and dosages the patient should have been prescribed • He then dictated that information into a phone line • Traditionally a hospital medical transcriptionist making $19.50 per hour would have written the information onto the discharge summary
  27. 27. Sedgwick © 2013 Confidential – Do not disclose or distribute. 27 Outsourcing: Typo • Company P, the second largest medical transcription outsourcing company in the US, subcontracted with two Indian Companies, contracted with Hospital #1 to conduct the transcribing for less • Indian workers made $350 per month • The information from the physician went via computer to India • Indian workers prepared the discharge summary • Sent it back to Hospital #1 • The hospital saved 2 cents per line by outsourcing • The acceptable error rate for an Indian company is ½ to 1/12th that of the US in terms of acceptable error rate
  28. 28. Sedgwick © 2013 Confidential – Do not disclose or distribute. 28 Outsourcing: Typo • The US officials testified the Indian subcontractors used American standards • The Indian subcontractors testified that they used Indian standards • There was testimony that the nurse should have used the original document prepared by the doctor • The nurse testified it was not available so she used the discharge summary prepared in India and wrote the medication information onto the physician admission order containing the doctor’s signature • This made it appear that the doctor had confirmed the information
  29. 29. Sedgwick © 2013 Confidential – Do not disclose or distribute. 29 Outsourcing: Typo • Nonetheless, the jury found that had the transcription been correct there would have been no death • If the nurse was allowed to get the document from the records department, there would have been no death • The jury awarded $140 million dollars to the patient’s family • The bulk in punitives based on the financial incentives of Hospital #1
  30. 30. Sedgwick © 2013 Confidential – Do not disclose or distribute. 30
  31. 31. Sedgwick © 2013 Confidential – Do not disclose or distribute. 31 Teleradiology: Adventures in the night • The hospital contracts for radiological services during evening hours with Indian Company • ED examines patient, orders x-ray of knee • X-ray read as normal, patient released • Next morning, x-ray over read by domestic provider, fracture seen • No one follows-up with patient • Patient sees his primary care physician 3 weeks later and correct diagnosis made • Patient suffers permanent injury to knee due to delay in treatment and can no longer work in his physically demanding job
  32. 32. Sedgwick © 2013 Confidential – Do not disclose or distribute. 32 Teleradiology: Adventures in the night • Evidence shows the original x-ray was read by a foreign radiologist • Evidence shows that the hospital chose the global teleradiology model vs a domestic or NightHawk model • The NightHawk model would have involved a American licensed radiologist doing the first read, followed by a local radiologist doing the over read • Instead, a foreign radiologist, non-licensed in the US did the initial read • Evidence shows that the hospital saves a substantial amount of money using the global model • What do think the a jury would do with this financial incentive evidence given the “Typo?” Case study?
  33. 33. Sedgwick © 2013 Confidential – Do not disclose or distribute. 33
  34. 34. Sedgwick © 2013 Confidential – Do not disclose or distribute. 34 Telesurgery: A Work of Art • Da Vinci surgery system  Wide range of laparoscopic surgeries  Surgeon views a virtual reality representation of the patient’s internal organs  Surgery is performed via the manipulation of hand and foot controls that remotely maneuver the machines’ four metal arms  Technically the system allows a doctor in the US to perform telesurgery on a patient anywhere in the world  Hospitals can increase surgery market share
  35. 35. Sedgwick © 2013 Confidential – Do not disclose or distribute. 35 Telesurgery: A Work of Art • Advantages  Superior visualization  Enhanced dexterity  Greater precision and ergonomic comfort  Minimally invasive on complex dissection or reconstruction cases  Less pain, blood loss, shorter hospital stay, quicker recovery
  36. 36. Sedgwick © 2013 Confidential – Do not disclose or distribute. 36 Telesurgery: A Work of Art • Injuries include:  Burns  Tissue damage  Reproduction system damage  Blood vessel injuries  Bowel and intestinal injuries  Urinary tract damage  Nerve and muscle damage
  37. 37. Sedgwick © 2013 Confidential – Do not disclose or distribute. 37 Telesurgery: A Work of Art • Types of complications*  The arm jumped stabbing an artery  The bipolar instrument fired unintentionally during a procedure nicking the uterus  During a hysterectomy the robot hit the patient in the face prompting conversion to an open surgery *FDA Database of Adverse Event Reports
  38. 38. Sedgwick © 2013 Confidential – Do not disclose or distribute. 38 Resources • American Telemedicine Association  http://www.americantelemed.org/ • HRSA Rural Health – Telehealth  http://www.hrsa.gov/ruralhealth/about/telehealth/ • ATA State Telemedicine Policy Center  http://www.americantelemed.org/get-involved/public- policy-advocacy/state-telemedicine-policy • HRSA Telehealth Resource Centers  http://www.telehealthresourcecenter.org/
  39. 39. Sedgwick © 2013 Confidential – Do not disclose or distribute. Questions?

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