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How to Increase Telehealth in Diabetes Care (June 2019 - DData Exchange)

How to Increase Telehealth in Diabetes Care (June 2019 - DData Exchange)

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Dr. Aaron Neinstein, Endocrinology Professor at UCSF, describes the use of diabetes technology and telehealth for diabetes care, barriers that are being overcome, and barriers yet to be. Presented at the June 2019 DiabetesMine DData Exchange.

Dr. Aaron Neinstein, Endocrinology Professor at UCSF, describes the use of diabetes technology and telehealth for diabetes care, barriers that are being overcome, and barriers yet to be. Presented at the June 2019 DiabetesMine DData Exchange.

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How to Increase Telehealth in Diabetes Care (June 2019 - DData Exchange)

  1. 1. Confidential & Proprietary ©2019 The Regents of the University of California. All Rights Reserved. Increasing Telehealth in Diabetes Care Delivery Aaron Neinstein, MD, FAMIA Assistant Professor, Division of Endocrinology University of California, San Francisco Director of Clinical Informatics UCSF Center for Digital Health Innovation
  2. 2. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein2
  3. 3. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein3 Increasing CGM Use Will Drive Increase in Telehealth T1D Exchange Data Foster NC et al. Diabetes Technology & Therapeutics. 2019 Feb.
  4. 4. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein4 Shown with permission
  5. 5. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein5 Overcoming Barriers to Telehealth 1 2 3
  6. 6. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein6 Overcoming Barriers to Telehealth 1 2 3
  7. 7. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein7 Reimbursement is improving 95250: Physician- Provided CGM Placement, hook-up, calibration, training, sensor removal, and printout of recording95249: Patient- provided CGM 95251: CGM Data Interpretation • Medicare reimbursement ~$45, many commercial higher 99457: Remote pt monitoring New in 2019 Video Visits • Video is 16% of overall visit volume at UCSF Endocrinology • UCSF reimbursed at parity (may vary) with face-to-face office visits
  8. 8. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein8 *Informational-only: Does not constitute medical or billing advice* 1 2 3
  9. 9. 9 Patrick Mouratoglou Serena Williams
  10. 10. 10 Teach Support Ask Endocrinologist PWD
  11. 11. Increasing Telehealth in Diabetes Care Delivery | D-Data Exchange 2019 | @aaronneinstein11 What each of us can do: this requires everyone Physicians • Block time for data review • Bill for CGM review & remote monitoring • Use video Patients • Encourage use of video • Encourage remote CGM review and understand you may get billed Device Makers • Wireless upload • Standards • Interoperability Don’t try to trap the data in your system! Software Vendors • Facilitate clinical workflows • Streamline documentation and reports Don’t try to trap the data in your system!

Editor's Notes

  • Want to talk about our experiences with increasing use of telehealth in diabetes care delivery.
  • ... and while these ideas are nothing new, over the decades there have been innumerable barriers to widespread implementation
  • Everyone here is familiar with these data from T1D Exchange showing rapid rise in use of CGM in US adults with type 1 diabetes, as CGM has gotten more accurate, easier to use, and with improving insurance coverage
    Importantly, this chart also represents healthcare data democratization with more and more devices used and more data generated by patients outside traditional healthcare boundaries – this brings increasing pressure on the need for new models of care.
  • Here’s a brief video with an excerpt from a REAL video visit from our office, shown with permission
  • Let's breakdown what we just saw and the elements that comprise more modern diabetes care and a changing relationship between patient and Endocrinologist.

    1 - Data download – Whereas in the past data was stuck on each device, in most cases we can now easily pull data off a device into the cloud.
    2 - Software to review the data - Clinicians really need one tool where they can view aggregated data from all of a patient's devices. While there are fewer silos than there used to be, challenges remain – I’ll say more on this in a minute
    3 - Array of modalities for interaction – This can be Synchronous telehealth like you saw in this example of a Video Visit. Will continue to include face to face in person time. And it also will require Asynchronous telehealth – Messaging back-and-forth about data download or regimen change
  • And of course, most often touted as a barrier, is reimbursement
    But, I'm going to show you that is starting to change
  • There are three billing codes specifically for CGM interpretation and review – 2 of them include set-up of the CGM equipment
    Will focus on 95251 – just analysis of the data
    This can be used like any medical procedure, just as when a Dermatologist removes a mole or a Cardiologist reads an EKG
    Either in conjunction with an in-person or video visit, or without any associated patient-physician visit, once every 30 days.

    There are also new Remote Care billing codes from CMS that don’t have to be done by a physician

    Video visits are increasing at UCSF – now 16% of all Endocrinology visits (not specific to diabetes)
    Payment parity varies by state and by payor
  • Here’s what you need to document in order to bill 95251:
    Upload the data to the chart
    Document some analysis and interpretation
    Explain for billing what we did
  • Who is this?
    This is of course Serena Williams, one of the world’s best athletes

    Why am I showing you Serena Williams?
    What you may not have noticed is the person standing behind her
    This is her coach, Patrick Mouratoglou

    Because… We’ve got data in the cloud, we’ve got software, we’ve got video, we’re even being reimbursed for providing care in these ways
    But we also have to change the traditional, paternalistic medical culture that hasn’t yet adapted practice to truly incorporate patient-generated data

    As we try to change that culture, here is how we teach our students and trainees at UCSF - an endocrinologist has to be like... a coach. Here’s the approach we take.
  • 1 – We start by reviewing the data together with each patient. Rather than trying to have all the answers, use data to trigger questions & discussion - ASK the patient what she thinks is going on
    If we think our job is to look at the data and tell the patient exactly what to do, we’re going to be out of a job... because AI will do it better than us
    2 – Second we look for teachable moments and opportunities to Educate and Arm the patient with tools to manage and problem-solve independently
    3 – Finally... Support - T1D is very complicated – patterns non-existent & changing – It is Frustrating!; Be patient and don’t try to solve everything in one sitting
  • To bring this all together, here’s what each of us stakeholders in this room have to do to advance the ecosystem:

    Physicians actually have to re-orient our schedules to block time for video and for remote care

    Patients should be encouraging us to do this, and be understanding that they may see a bill for remote care

    Software vendors have to provide tools that facilitate not just the data analysis, but these collaborative care workflows, and streamline the documentation that is required

    Device makers have to continue to focus on seamless, wireless data availability - but this does nobody good if the data are trapped in your proprietary cloud.
    The 21st Century Cures Act passed in 2016 mandated that Americans have API access to electronic health information – I believe this should include not just the data you have stored in an Epic EHR, but also the data on your Medtronic pump or your Abbott Freestyle Libre.
    We must have interoperability, and a data sharing agreement is not interoperability. Medtronic and Abbott should take a lesson from Companion, who I'll give a shout out to for sending data from InPen straight into Apple Health.

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