Chapman

Virginia Telehealth Summit March 18, 2010 Institute Conference Center Danville Virginia Telehealth in FQHCs Howard Chapman, Jr., Executive Director Southwest Virginia Community Health Systems, Inc.

SVCHS Site Map

SVCHS Patient Origin Map

UVA Telemedicine Program

Telemedicine: History  Alexander Graham Bell  Hugo Gernsback (vision)  Massachusetts General  University of Nebraska  NASA  Dept of Defense  University of Virginia

Motivating Factors that prompted entry into Telemedicine  Access to Specialty Care - HRSA Grant provides access for primary care and prevention - There is a shortage of area Specialty Providers in the rural areas we serve - These area Specialists have heavy schedules of paying and insured patients - They have no requirement or provision to provide care to indigent or uninsured patients

Motivating Factors that prompted entry into Telemedicine (continued) - When specialty services are not available to patients they usually go without or the primary care physician tries to offer what level of care they can - Too often this results in their completing procedures over their head or that the practice is not equipped to provide - This becomes a “Risk” issue, especially with FTCA coverage and practicing within the approved Scope of Services

UVA Telemedicine

Cancer outreach: Mobile digital mammography

UVA Teleradiology  SVCHS installed two Digital X-Ray Units from our CIP Grant from the Economic Stimulus Funding  We now use the UVA Department of Radiology for our X-Ray interpretations  SVCHS is charged a flat fee per X-Ray procedure  SVCHS then bills for both the professional and technical component  UVA Radiologist is available to consult with SVCHS providers for STAT readings  STAT readings during evening and Saturday hours is through the link with the ER at UVA

Other Motivating Factors  Rural Isolation  Telemedicine Removes much of the “Rural Isolation” and makes it easier to recruit and retain physicians and providers  Providers and staff can receive CME Training and credits through Telemedicine  It puts the resources of a major university at the fingertips of a rural physician  Grand Rounds schedules are available through UVA for our providers who want to participate  Poison Control is available through the UVA Telemedicine Link 24/7

Other Motivating Factors  Patient Education  Shortage of other Health Care Resources and Ancillary Care Providers (i.e., Health Educators, nutritionist, etc.)  Patient Education Programs - Established Format - Customized Programs for our Patients  Important for the participation in the Health Disparities Collaborative and Patient Self-Management Goals  CDC First Responders Training was provided through the UVA Telemedicine Link at our Saltville site for the Anthrax terror alert

Planning Steps  The University of Virginia (UVA) was working to establish the Southwest Virginia Telemedicine Health Alliance and had grant money to support the program  There was no investment on our part except for the space and staff time devoted to training and using the equipment  SVCHS had to agree to make the telemedicine equipment and services available to the entire community and other area providers as part of our commitment  After two years we had to pick up the cost of the communication lines (same lines we use for our EMR and practice management System)  Universal Services Administration assistance with the communications and connectivity cost  UVA’s first connection in rural southwest Virginia was over $4,000 per month for a T-1 line in 1994

Planning Steps (continued)  SVCHS was added in 2001 and the cost was about $1,000 - $1,200 for a rural T-1 connection (Universal Service Administration assistance moved that to about $450 / month)  Now a broadband fiber connection is about $400 / month without the Universal Services Administration Assistance  Communication lines are now required for EMR and data exchange anyway  The cost of Telemedicine Equipment is down as well. In 2001 the equipment was around $60,000 and now the cost around $22,000

Implementation Schedule  SVCHS has been operational since 2001 with the UVA Telemedicine Program  Expansion to other sites include initial UVA training and orientation  We have our Telemedicine Manager conduct training and orientation with the provider (NP) that will be using the equipment and the providers and staff that will be making the referrals

Facilitators/Impediments in the Process  Karen Rheuban, M.D., Medical Director for the UVA Telemedicine Program is a great Champion and Facilitator for the use of telemedicine  UVA has been doing this for years and is one of the most advanced and recognized programs in the nation  Impediments include:  Reimbursement Issues (must be at least a mid-level provider operating the equipment)  Reliable Connectivity for the system  Laws and regulations around licensure  JCAHO and other credentialing issues

Challenges  Funding of telehealth (Stark, Anti-kickback Laws)  Reimbursement  Outcomes  Confidentiality  JCAHO  Licensure  Malpractice  Telecommunications venue/costs  Integration with EMRS/RHIOS  Interagency alignment related to policies Federal (definition of rural, rural vs urban) State (eligible plans, coverage of store and forward)

Reimbursement varies by state  Reimbursement - Virginia Medicaid (urban and rural) - TennCare MCOs - Medicare (rural) - Private payers - Anthem grant for Virginia - Contracts - Peds cardiology - Psychiatry - Dept of Corrections  Formal request of Virginia Medicaid 1995, expanded 2003

Licensure  No portability  Primarily serve Virginians  Primarily provide consultations  International patients easier than other states  Discussion surrounding model of nurse compact  Tennessee BOM references a “telemedicine license” for out of state providers

JCAHO  2000 JCAHO standards required credentialing and privileging at all the remote sites  2004 JCAHO standards revisions (more coming)  Credentialing and privileging at a JCAHO accredited consult origination site  Remote hospital medical staff to agree to telehealth relationship  Link to quality data for feedback  Agreements between institutions

Successes and Accomplishments  SVCHS is one of the most highly utilized UVA Telemedicine Sites  SVCHS has a great working relationship with the UVA Telemedicine Program  We now have telemedicine equipment in 6 of our 7 sites (plans to add 2 additional telemedicine sites by December 2008)  UVA offers access to 33 separate specialties and services through telemedicine  They accept the SVCHS Sliding Fee Payment as Payment in Full for our indigent patients  They have private grant funding to support payment for patients whose insurance carrier does not cover telemedicine services  They have provided a digital retina camera for eye exams for our diabetic patients that can be emailed to the UVA Ophthalmology Department and the results emailed back

Southwest Virginia Community Health Systems, Inc UVA Specialty/Subspecialty Participants  Cardiology  Obesity  Dermatology  Oncology/Tumor boards  Diabetes  Pain management  Emergency Medicine  Pediatric cardiology  Endocrine  Pediatric nephrology  ENT  Pediatric oncology  Gastroenterology  Genetics  Plastic surgery  Geriatrics  Psychiatry  Gynecology  Pulmonary medicine  Hematology  Radiology  Infectious Disease  Rheumatology  Nephrology  Surgery  Neurology  TCV  Neurosurgery  Toxicology/Poison control  Ophthalmology  Urology  Orthopedic  Wound care

Lessons Learned  To receive Credit for the telemedicine encounters they must be provided by a mid-level (NP/PA) or physician.  This allows for the user and encounter data for BPHC and the UDS Report to count  Reimbursement as a consult visit (incident to visit) to be reimbursed to the specialist and the provider using the equipment and conducting the exam at the site  This is not the most ideal care for the insured patients, but they have transportation and the resources to seek care elsewhere  For our indigent and uninsured patients it is often the only option for access to specialty care  Video Conferencing is often a great way to conduct meetings and business among remote sites  UVA allows a bridge for that to happen, but connections are limited  For a fee more links can be accommodated for these meetings

Health Center Controlled Networks – IT Funding  Community Care Network of Virginia (CCNV)  Owned by Virginia FQHCs  Statewide EHR Network (eClinical Works)  Quality Improvement Grant working with HRSA required data  Tracking Healthy People 2020 Guideline data as a quality measure  Patient Kiosk to enter patient data (PHQ-9 and other data)  IT Committee looking at “Enhancements” to current system (i.e., case mgt., patient call reminders, dental, mental health, etc.)  CCNV is included in the Regional Health Center Grants to connect to HIEs  CCNV is also part of the QI Grants that went to VHD  Collaborative partner on several Beacon Community Grants

Health Information Exchanges  CareSpark and MedVirginia operational in Virginia  Collaboration of Patient Care by sharing data among community/regional providers  More informed and better decisions in managing patient care  New insurance Products (Active Health)  Reduction of Costly Procedures – MRIs, Cat Scans, etc.  Reduction of Medication Errors through e- prescribing  Pay-for-performance

Thank You! Contact Information: Howard Chapman, Jr., Executive Director Southwest Virginia Community Health Systems, Inc. P. O. Box 729 /319 Fifth Avenue T. K. McKee Hospital Building Saltville, Virginia 24370 Telephone: (276) 496-4492 Ext. 108 Fax: (276) 496-4839 Email: hchapman@svchs.com Web Site: www.svchs.com

Chapman

by Virginia Rural Health Resource Center

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