Evolving Models of Care• Deliveredover HIPAA-compliant means • No audio-only phone, email, IM,...

9/8/2017

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Eight questions to ask before diving into telemedicine

Models of CareEvolving

Advisory NoticeThis presentation has been abridged from a variety of sources and is intended for informational and advisory purposes only for UMIA policyholders. UMIA does not undertake to establish any standards of medical practice. This presentation is has been provided as guidance relating to risk management and claim prevention. Specific legal advice should be obtained from a qualified attorney, when necessary.

If you have any questions please contact UMIA.

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Can telemedicine help?

Patients embrace technology

of adults are ok with teleconsultation for non-urgent care

- Intel Healthcare Innovation Barometer

Patients embrace technology

of young adults preferconsultation with their doctor via mobile device

- MD Live

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And …

Potential for $1.8 to $6 billion in savings over 10 years

Win-win-win!

Definingtelemedicine

CMSTwo-way, real-time interactive communication through telecom equipment

ATAMedical info exchanged from one site to another electronically for purpose of patient care

TJC Use of technology to support long-distance clinical health care

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Montana Code

• Use of interactive technology• Real-time video or store-and-forward• Related to diagnosis or treatment• Delivered over HIPAA-compliant means• No audio-only phone, email, IM, or fax

Montana Code Ann. 33-22-138 & 37-3-102

Practice with

awareness

Goal of today

Eight questions

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Eight questionsAm I licensed for this?Am I creating a physician/patient relationship?Am I providing the same standard of care as in person?Am I protecting privacy and security?

1.2.3.

4.

Eight questionsHow is my care getting into the medical record?Can I bill for this?Does my professional liability policy cover this?Do I need special informed consent?

5.6.7.8.

1Am I licensed for this?

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The patient’s state• Rapidly evolving area of state regulation• Some give telemedicine-only license• Some give exceptions for consultations or

emergencies• Montana requires a full license

Center for Connected Health Policy: http://cchpca.org/

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Online prescribing• Check your patient’s state

– Montana has no prescribing restrictions• DEA rules on e-signatures and reporting breaches• Held to same standard of care• Questionnaires are not okay


Controlled substances• Ryan Haight Act of 2008

– Must conduct an in-person medical evaluation first– Exception:

• Patient is located and being treated in a facility with valid DEA registration,

• You have DEA registration in home state, and • Communication is two-way real-time audio and video

• Some states go even further


Can the systemimprove?

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• Verify licensing in the location of the patient

• Make sure you stay in good standing

• Check on others in the healthcare team

Riskstrategies

2Am I creating a physician/ patient relationship?

Case example• Dermatology website where users upload photos • “Board-certified dermatologist” will reply with

identification and treatment options• Most of the dermatologists are overseas• Diagnosis and recommendations are unreliable• CEO says too bad-- no doctor-patient relationship

because both sides are anonymous

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Defining the P/P relationshipMAYBE

• Tends to being when individual reaches out to you

YES

• Definitely when you take on diagnosis or recommend care

IMPORTANCE

• Duty to treat under standard of care

• Duty to follow up with care plans

• You can be sued for malpractice

• You can be sued for abandonment

• If you diagnose or recommend care, you’re in a relationship

• If you don’t want the relationship- break up ASAP

• Think through continuity– You own your orders– Who picks up care next

Riskstrategies

3Am I providing the same standard of care as in person?

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Case example• E-visit for wheezing, shortness of breath to point

of dizziness• History of asthma• Home location is dark, images are distorted,

sound is delayed and sometimes lost• MD location is outside patio with kids• Diagnosis: Asthma flare• Missed diagnosis: Acute coronary syndrome

Standard of care issues

Patient/condition selection

Physical environment

Fastest-growing segment is one-time video

of large employers offer virtual visits

Patient/condition selection

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ATA recommendations

Acute conditions primary or urgent care

Chronic conditionsprimary care

• Uncomplicated allergy/asthma

• Chronic bronchitis• Conjunctivitis• Genitourinary• Low back pain• Otitis media• Rashes• Upper respiratory

infections

• Mental illness• Behavioral health• COPD• Asthma• Congestive heart failure• Diabetes• Hypertension• Overall wellness

Is it an emergency?

Physical environment

GOALSame ability to

communicate and treat as if they were

in front of me

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Is it safe to talk?

webside manner?What is my

• Would an in-person, hands-on exam be better for this issue?

• Can I see, hear, and communicate as well as I could in person?

• Is it safe to talk?• What’s my webside

manner?

Riskstrategies

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4Am I protecting privacy and security?

Case example• Family doc conferencing with patients over Skype• No encryption• No HIPAA security certifications• No BAA with Skype• Physician doesn’t know that encounters are being

stored in the cloud• Data is breached

HIPAA & Montana Law say:

YOU must protect confidentiality, integrity,

and security(no matter the platform or devices)

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Vendors

• Demand proof of HIPAA and HITECH compliance

• Demand BAAs• Where is the data backed

up? (on premises vs. cloud)• Who owns the data?• Negotiate liability for

breaches

Devices

• What all is involved (phone, PC, email)?

• Are they encrypted?• Remote deletion?• Passwords?• Anti-virus and security?

Vendors

• Demand proof of HIPAA and HITECH compliance

• Demand BAAs• Where is the data backed

up? (on premises vs. cloud)• Who owns the data?• Negotiate liability for

breaches

Devices

• Encryption?• Passwords?• Anti-virus and security?• Plan if lost or stolen?

• Get IT expert help• Think through all

devices and platforms the encounter goes through

• Understand where the data goes

Riskstrategies

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5How is this getting into the medical record?

Case example• Tele-radiology arrangement• Radiologist and PCP use online platform to view

the images together and discuss• Neither creates a record of this discussion• PCP texts radiologist more historical information

and radiologist responds via text• Neither creates a record, neither saves texts

What goes inthe record?

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What would I have from an in-person visit?

What did I rely on to make decisions and recommend treatment?

What do I need to support billing claims?

Unusual items to include• Mode of service delivery• Time-stamps in multiple time zones• Location of you both• Any technical difficulties

Where is the record?

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• Set standards for record-keeping

• Understand how and where the record is stored

• Have a plan for access– How– What do they look like

Riskstrategies

6Can I bill for this?

15% of family physicians are using telemedicine

would if they were confident about reimbursement

concern from patients is insurance coverage

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Private insurers• Around ½ of states require private insurance

reimbursement at some level– Montana requires coverage and parity

• Health insurers are increasingly accepting care provided remotely– UnitedHealth and Anthem = 20 million insureds with

telemedicine benefits in 2016

Medicare• Slow to accept, very limited• Allowed in

– some defined rural areas, and – must be real-time and interactive audio and video

• Possibly more with Medicare Advantage plans• Medicare paid $17.6 million in telemed in 2015

– (program is around $634 billion)• To be continued…

– New legislation passed to study need and expansion

Medicaid• More closely follows private insurers• Almost all states provide coverage at some level• Montana reimburses if:

– Medically-necessary service – Eligible member– Enrolled provider


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• Call to verify payment• Ask the patient to call

to verify as well• Make sure your record

is complete

Riskstrategies

7Does my professional liability policy cover this?

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Where will the claim arise?

Insurance issues• Am I staying within my

scope of practice?• Do I need cyber liability

coverage?– You might already have

coverage

• Check with your insurance carrier first

• Ask about help to review telemedicine policies & procedures

Riskstrategies

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8Do I need special informed consent?

Security

Equipment failures

Limits on assessments

© 2017 UMIA All rights reserved

FSMB Model Policy Patient agrees that physician determines if this

care is appropriate for telemedicine Privacy and security risks and safeguards Technical failure risk and plans Types of transmissions permitted (e.g.

prescription refills, scheduling, education) Disclosure of any third parties with access

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Best ResourcesAmerican Telemedicine Association (ATA), www.americantelemed.orgFederation of State Medical Boards (FSMB), www.fsmb.orgCenter for Connected Health Policy, www.cchpca.org

Evolving Models of Care• Deliveredover HIPAA-compliant means • No audio-only phone, email, IM,...

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Transcript of Evolving Models of Care• Deliveredover HIPAA-compliant means • No audio-only phone, email, IM,...