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Jonathan neufeld nuts and bolts
1. The Nuts and Bolts of Building a
Telehealth Program
Jonathan Neufeld, PhD
Georgia Partnership for Telehealth Conference
Savannah, Georgia
March 26, 2015
1
This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) under grant number G22RH24745-03-00 under the Telehealth Resource Center
Grant Program for $325,000. This information or content and conclusions are those of the author and should not be
construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S.
Government.
4. 4
Bureau of Primary
Care
Maternal and Child
Health Bureau
Bureau of Health
Workforce
Office of Rural
Health Policy
Healthcare Systems
Bureau
HIV/AIDS Bureau
HRSA
Office of the
Administrator
Office of the Deputy
Administrator
Health Resources
and Services
Administration
(HRSA)
6. UMTRC Services
• Presentations & Trainings
• Individual and Group Consultation
• Technical Assistance
• Connections with other programs
• Program Design and Evaluation
• Information on current legislative and
policy developments
6
7. Introduction to Telehealth
• Telehealth refers to a set of methods for
delivering health care services
– NOT the services themselves or a specific type
of service
• For example, “tele-radiology” is just radiology
performed from a remote site
• The provider would do the same thing if they were
on site, the patient would receive the same care
– NOT all health care technologies
• EMRs, use of computers and tablets, robotics
7
8. “Telehealth” vs. “Telemedicine”
• Often used interchangeably (ATA)
• Two types of distinctions are made -
• “Telemedicine” = billable interactive clinical
services performed at a distance
• “Telehealth” =
• All remote health activities (CME, etc.)
• Clinical remote monitoring (usually at home)
9. Types of Telehealth
• Specialty/Subspecialty
• Allergy/Immunology
Anesthesia
Cardiology
Critical Care
Dentistry
Dermatology
Otolaryngology (ENT)
Endocrinology
Family/General Practice
Gastroenterology
Infectious Diseases
Internal Medicine
Maternal/Fetal Medicine
Mental/Behavioral Health
Neurology
Oncology/Hematology
Ophthalmology/Optometry
Orthopedics
Pathology
Pediatrics
Psychiatry
Pulmonology
Rehabilitative Medicine
Rheumatology
Surgery
Urology
• Services
• Case Management
Correctional telehealth
Deaf/hearing services
Diabetic retinopathy screening
Dietician services
Disease management
Doctor-to-doctor consultation
Enterostomal therapy
Forensic/court services
Genetic counseling
Long-term Care
Neonatal/Pediatric intensive care unit
Pain management
Palliative care
Pre/post-natal care
Speech therapy
Spine therapy
Telestroke
Wound care
Adult, Individual and Group Therapy
Behavioral psychology and health
Chemical dependency aftercare
Chemical dependency therapy (Addiction therapy)
Consultation to Schools
Couples’ counseling
Developmental (lifespan) counseling
Psychiatric medication therapy management
Psychological Assessment
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14. 14
Murphy RL, Bird KT. Telediagnosis: a new community health
resource. Observations on the feasibility of telediagnosis based on
1000 patient transactions. Am J Public Health. 1974;64(2):113-119.
17. The Bare Necessities
• Clinical Business Model
• Team of Champions
• Solid Partners
• Appropriate Technology
17
18. Clinical Business Model
• Identifiable need(s)
– Assessment tools
– Consensus value
• Value-bearing service to meet the need(s)
– Reimbursement, cost savings, or other value
• Services that fit within best practices and
legal limitations
– Licensing boards (regulations)
– Payers (conditions of payment)
18
19. Legal Limitations
19
• Professionals (doctors, nurses, counselors,
etc.) are regulated by state licensing boards
• Medicare: Pays for certain outpatient
professional services (CPT codes) for
patients accessing care in rural counties and
HPSAs in rural census tracts.
*Codified as “conditions of payment”
• Medicaid: Most states (46) cover at least
some telehealth services.
20. Three Domains of Telehealth
• Hospital & Specialty Care
• Specialists see and manage patients remotely
• Integrated Primary Care
• Mental health and other specialists work in
primary care settings (e.g., PCMH’s, ACO’s)
• Transitions & Monitoring
• Patients access care (or care accesses patients)
where and when needed to avoid complications
and higher levels of care
**Value proposition differs among these types**
20
22. Three Domains of Telehealth
• Hospital & Specialty Care
• Specialists see and manage patients remotely
• Integrated Primary Care
• Mental health and other specialists work in
primary care settings (e.g., PCMHs, ACOs)
• Transitions & Monitoring
• Patients access care (or care accesses patients)
where and when needed to avoid complications
and higher levels of care
**Value proposition differs among these types**
22
24. Three Domains of Telehealth
• Hospital & Specialty Care
• Specialists see and manage patients remotely
• Integrated Primary Care
• Mental health and other specialists work in
primary care settings (e.g., PCMH’s, ACO’s)
• Transitions & Monitoring
• Patients access care (or care accesses patients)
where and when needed to avoid complications
and higher levels of care
**Value proposition differs among these types**
24
26. Three Domains of Telehealth
• Hospital & Specialty Care
• Specialists see and manage patients remotely
• Integrated Primary Care
• Mental health and other specialists work in
primary care settings (e.g., PCMH’s, ACO’s)
• Transitions & Monitoring
• Patients access care (or care accesses patients)
where and when needed to avoid complications
and higher levels of care
**Value proposition differs among these types**
26
28. Three “Hard Lines” in Telehealth
Encounter Patient Location Service Type
Live video
Healthcare facility
(hospital, clinic,
office, etc.)
Individually coded
and billed services
Store & Forward
(images)
Non-facility
(home, etc.)
Monitoring &
Management
28
NOT:
telephone,
email, fax
29. Multiple Business Models Apply
Strategies Dependent Upon:
• Revenue Stream
• Cost Avoidance
• Added Value
• Shared Savings
**Each may apply to different stakeholders
29
30. Business Models for Telehealth
• Tele[specialty] Services
• Travel Reduction/Resource Distribution
• Remote Hiring/Recruiting/Retention
• Remote Monitoring & Access
• Kiosks and mHealth
30
31. Business Models for Telehealth - 1
SPECIALISTS TO REMOTE SITES
• Traditional “Hub & Spoke” arrangement
• Standard Pro-fee Payment (CPT-based)
goes to Specialist or Hub (“remote site”)
• Facility fee goes to Patient or Spoke Site
– Called “originating site”
– Commonly $22-$25 per encounter
– NOT the same as “facility fee” in Part A
31
32. Telemedicine - The Standard Model
Professional Fee
(Part B)
Facility Fee
(Part B)
Rural
“originating
site”
Specialist
at “distant
site”
33. Business Models for Telehealth - 2
TRAVEL REDUCTION/SERVICE DISTRIBUTION
• Site-to-site within an organization
• No real “hub” or “spoke”
• Facility fees excluded (?)
• Goals:
– Reduced travel
– Increased capacity
– Increased efficiency
33
34. Business Models for Telehealth - 3
REMOTE HIRING, RECRUITMENT & RETENTION
• Recruit from anywhere to anywhere
• Recruit from lower cost locales
• Retain staff when they move
• Key consideration: Licensure
– Services occur at the site of the patient
– Providers must be licensed and credentialed at
the patient's location
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35. Business Models for Telehealth - 4
REMOTE MONITORING & ACCESS
• Moving the care site to the home (or street)
• Multiple privacy/confidentiality issues
– Informed consent is critical
• Tremendous potential for cost savings
• Overall quality of life improvements
– Staying out of the hospital = better
35
36. Business Models for Telehealth - 5
HEALTH KIOSKS AND mHEALTH
• Standalone diagnostic centers and smart
phone/tablet apps
• Developed and distributed by providers,
payers, or third parties
• Targeted directly to consumers
– Enhanced access, self-care, motivation
• Used doctor to doctor or hospital
– Image distribution, diagnosis, consultation
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37. Business Models for Telehealth - 5
HEALTH KIOSKS AND mHEALTH
• FDA has moved to regulate health apps
– Regulated if it measures or calculates data
• Direct patient payments are a small part of
all health care dollars
• Goals are varied (and sometimes unclear)
– Access (to doctors, labs, charts, etc.)
– Outreach (to patients)
– Health behavior change (diet, exercise)
37
38. The Triple Aim - A Realistic Approach
• Services done right will
improve Patient Experience
(Better Care)
38
• Providing the right
services will improve
Population Health
• Better Health will
lead to Lower Cost
39. Telehealth in a Triple Aim Context
The right tool changes
everything…
39
40. A Team of Champions
• Leadership must understand and
communicate the vision
• Key players must be flexible and open to
new ideas, processes, and technologies
• Knowledgeable support – The TRCs
40
41. Key Players
• Key players must be flexible and open to
new ideas, processes, and technologies
– Start with those most interested and easiest to
work with
– Let excited team members recruit peers
– Leave the last 20%
41
42. A Note About Physicians
• Trained to lead
• Compliance is their livelihood
• Deathly allergic to “not knowing”
SO…
• Build trust
• Test in “non-critical” environments
• Emphasize relationships not technology
42
43. The Right Partners
• Multiple types of partnerships are available
• Build on existing relationships
• Ask for what you want –
Be the Hub!
43
44. Telemedicine - The “Legacy” Model
Professional Fee
(Part B)
Facility Fee
(Part B)
Rural
“originating
site”
Specialist
at “distant
site”
45. Direct Contracting – P2P
• Newer model
• Driven by:
– Accessibility of technology
– More sophisticated primary care
– Demand for services closer to patient
– Breakdown of traditional “Hub & Spoke”
spheres of influence
45
51. Connectivity
The Foundation of Telehealth
• T-1 (minimum necessary, 1.5 Mbps)
• Business cable internet (3-10 Mbps upload)
• Top-shelf options (fiber, business ethernet)
• Latency and Quality of Service are as
important as bandwidth
• Keep the line free of competing demands
51
52. Site of Service
Hard line: Office vs Home
• Privacy & Security
• Connectivity
– Rely on what’s available, or…
– Take connection to the site (4G hotspot)
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54. Equipment
• H.323 Standard Video End Point ($5k-$50k)
• LifeSize, Polycom, Cisco/Tandberg
• 32” HDTV (monitor + speakers)
• Desktop stand or rolling cart
• Web-based System ($1k+)
• Software (Zoom, Vidyo, etc.)
• Mini computer + HD webcam
• 26-32” HDTV monitor + speakers
• Desktop stand or rolling cart
56. Equipment
• Key considerations for DIY telemedicine
• Good USB webcams beat built-in (laptop) webcams
• USB speakerphones beat built-in mics and speakers
• Wired beats wireless internet
• Monitors need only 720p (“low HD”)
• Keyboard/mouse inputs needed
57. Peripherals
Exam Camera – Dermatology, wound evaluation
• Tremendous detail, resolution, lighting options
• Unnecessary for many applications
Stethoscope –
• Several very good models available
• Bluetooth (wireless) connections, excellent audio
Otoscope –
• Multiple models available
• Modular, easy to use
57
61. Skillsets
• Technology + Skillsets = Capabilities
• Capabilities + Practice = Execution
Training without practice is (mostly) wasted
61
62. Skillsets
• Rollout schedule that includes practice
• Low-pressure exposure (meetings, training)
• Mock codes/encounters with debriefing
• Process helpers/kits (laminated cards, etc.)
The biggest hurdle in implementation is
fear of the unknown
62
63. Technology Considerations
● High speed internet at both sites
– 1-3 Mbps or more (nominal) for HD
– Test at www.internetfrog.com/mypc/speedtest/
● Endpoints – Two Major Classes
– H.323 – Standalone system
● Hardware based, often older and/or larger
● Tandberg, Polycom, LifeSize, Sony, etc.
– SIP/Web-based – Client/server system
● Software based (using a host computer)
● Skype, Oovoo, Vsee, ClearSea, Zoom, etc.
● Mobile apps
63
65. HIPAA Considerations
• Communications involving PHI (including
live video) must be encrypted
• Any entity that stores PHI must sign a
Business Associate Agreement (BAA)
• As long as live video is encrypted and not
stored, BAA is not technically required
Some type of signed agreement to enforce this
is likely to be helpful and is recommended
65
66. Peripherals
Exam Camera – Dermatology, wound evaluation
• Tremendous detail, resolution, lighting options
• Unnecessary for many applications
Stethoscope –
• Several very good models available
• Bluetooth (wireless) connections, excellent audio
ENT Scope –
• Multiple models available
• Modular, easy to use
66
67. Staff Training & Integration
Manipulation of peripherals
• Document training in equipment use
Professional Skills (within scope of licensure)
• Telemedicine (in general)
• Palpation, other specific techniques “under direct
supervision” (up to licensed providers pending rule)
Key Strategies
1. Trust – Develop strong working relationships
2. Documentation
– Policies & Procedures for TM (“same standard of care”)
– Case/Progress Notes (start & stop times, locations, consent)
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68. Technology Resource - TTAC
Telehealth Technology Assessment Center
– HRSA-funded technology-focused TRC
http://www.telehealthtechnology.org/toolkits
● Objective introductions to technologies
**Information ages quickly, newest and most
expensive equipment isn’t covered
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69. Special Considerations
• Almost any client will adapt quickly to
technology, given sensitive guidance
(providers take longer)
• Clinical skills are the same – rapport is key
• Recognize and foster client understanding
• Refer to technology experiences outside TM
• Involve family/caregivers throughout
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70. Conclusions
• Telemedicine is a complex and
rapidly changing field
• Telemedicine offers a range of
potential benefits to a variety of
stakeholders
• Careful examination of business
models, clinical strategies, and
technologies is necessary to
maximize benefit
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71. Questions
• Introduction to UMTRC
• Introduction to Telehealth
• Business Models for Telehealth
• Telehealth Regulation and Reimbursement
• Telehealth Technology Considerations
• Conclusions
• Questions
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