TELEHEALTH TODAY

Successful Applications and Valuable Resources in Kansas

TELEHEALTH

This way to Successful Applications and Valuable Resources. . .

Phone (toll-free): 877- 643 – HTRC(4872)

Email: GAlloway@HeartlandTRC.org

IP: 169.147.3.125 ext.7010109

WWW: HeartlandTRC.org

Gordon AllowayProject Director, HTRC

The Telehealth Resource CenterGrant Program

www.telehealthresourcecenter.org

Technical assistance forstarting or expanding telehealth services.

What is Telemedicine?

Telemedicine:… delivery of health care when distance separates a physician from the patient.

Telehealth: … broader form of telemedicine that includes additional technologies, providers and health education.

What is Telehealth?

How does it work?

Telemedicine is NOT a new techniqueVillemard, 1910 Correspondance Cinéma - Phono - Télégraphique Chromolithographie Paris, BNF, Estampes http://expositions.bnf.fr/utopie/grand/3_95b2.htm

Hugo Gernsback - 1924

Telemedicine has been

around long time.

Now. . .New Forms of Communication =

New Delivery Options

New Forms of Communication =

New Application Opportunities.

Telemedicine in the 1990s

• Very few telemedicine programs• Expensive, bulky equipment• Expensive telephone lines• Minimal insurance reimbursement (In Kansas,

Medicare and Blue Cross/Blue Shield)• Limited research

Telemedicine in the 1990’s

Telemedicine in Kansas: 1991

Hays AHEC Kansas City

Telemedicine in KansasClinical Consults: 1993-2001

1993 1994 1995

19961997

19981999

2000

2001

0

500

1000

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Telemedicine Today

• Smaller, less expensive equipment• High quality, high definition (HD) technology• Less expensive internet connectivity• Mobile, wireless capability• Improved insurance reimbursement• More extensive research

Telemedicine Today

• In 2013:– KUCTT

• Over 60 sites interacted with KUCTT• More than 4,000 clinical visits conducted

– Total KS activity unknown

Group Sessions and Educational Events

Specialty Consultation via ITV

Telestroke / Physician-to-Physician

School-Based Programs

Intra-Oral Scope (Tele-Sleep Study)

What Tele-Sleep Presenter Sees

Oncology Care (Hospital Exam Room)

Disease Management – Home Monitoring

Clinical Models• Level and frequency of telemedicine use can vary,

based on comfort of provider and specialty needs– TelePsychiatry – completely by telemedicine, no in-

person

– TeleOncology – hybrid model of some in-person (often 1st appt.) and some telemedicine follow-up

– TeleRehabMedicine – more in-person, less telemedicine

Kansas Best Practices – Telehealth / Telemedicine

Telemedicine Services at Goodland Regional Medical Center

Kansas Best Practice - Telehealth / Telemedicine

Kansas Best Practice - Telehealth / Telemedicine

Hays Daily NewsBy KALEY CONNER

10/25/2013

Kansas Best Practice - Telehealth / Telemedicine

South Central Kansas Special Education CooperativeSchool-Based Telemedicine• Behavioral Clinics

Psychology

Psychiatry

• Mental Health Clinic

CCHD Autism Diagnostics

• Healthy Hawks Clinic

Weight ManagementShelly Brensing, RN(With her Polycom HDX 7000)

Historical Challenges for Telemedicine

1. Limited adoption by providers– Federal & State reimbursement slow to expand

• Medicare - Adding CPT/HCPCS codes annually• Medicaid – Varies by state

– Private reimbursement not standardized– Seemingly not integrated in clinic flow– Technology concerns

• Initial investment of equipment• Ongoing support• Lack of standardization• Inconsistent broadband internet service

2. Privacy / confidentiality

3. Liability / Licensure

Good News! There Is Reimbursement

• Medicare (2001)• Medicaid varies by state, but generally follows

Medicare guidelines– Kansas (2004)

• Reimbursement available from all health insurance providers (no need for KS legislative mandate)

• Also, Federal grants & loans available

2014Medicare

Benefit Policy –

Telehealth Services

Galloway@HeartlandTRC.org

Telehealth Service CPT / HCPCS Codes

Emergency department or initial inpatient consultations HCPCS codes G0425 – G0427

Follow-up inpatient consultations (hospitals or SNFs) HCPCS codes G0406 – G0408

Subsequent hospital care services, limitation 1 telehealth visit every 3 days CPT codes 99231 - 99233

Subsequent nursing facility care services, limitation 1 telehealth visit every 30 days CPT codes 99307 - 99310

Office or other outpatient visits CPT codes 99201 -- 99215

Individual and group diabetes outpatient self-management training (DSMT) services, with a minimum of 1-hr. of in-person instruction to be furnished in the initial year training period to ensure effective injection training

HCPCS codes G0108 and G0109

Individual and group Kidney Disease Education (KDE) services HCPCS codes G0420 and G0421

End Stage Renal Disease (ESRD) related services CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961

Individual and group Medical Nutrition Therapy HCPCS code G0270 and CPT codes 97802 -- 97804Individual and group health and behavior assessment and intervention (HBAI) services CPT codes 96150 - 96154

Psychiatric diagnostic interview examination CPT code 90791 and 90792Individual psychotherapy CPT codes 90832 -- 90834 and 90836 -- 90838Pharmacologic management CPT code 90862Neurobehavioral Status Exam CPT codes 96116

Smoking cessation services HCPCS codes G0436 and G0437, andCPT codes 99406 and 99407

Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services HCPCS codes G0396 and G0397

Annual alcohol misuse screening, 15 minutes HCPCS code G0442Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes HCPCS code G0443

Annual depression screening, 15 minutes HCPCS code G0444

High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes

HCPCS code G0445

Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes HCPCS code G0446

Face-to-face behavioral counseling for obesity, 15 minutes HCPCS code G0447

Transitional care management services CPT code 994951 and 994962

Telehealth originating site facility fee (short description: “telehealth facility fee”) Q03014

Medicare Benefit Policy – Telehealth ServicesNEW for 2014

(Effective 01/01/14)

Transitional care management services CPT code 994951 and 994962

1. Communication with patient and/or caregiver within 2 business days of discharge; face-to-face visit within 14 calendar days of discharge and moderate complexity of medical decision-making during service period

2. Communication with patient and/or caregiver within 2 business days of discharge, face-to-face visit within 7 calendar days of discharge and high complexity of medical decision-making during service period

Email: Galloway@HeartlandTRC.org

Telehealth Guidelines

• Patient location:– Physician/Practitioner’s office– Hospital (inpatient or outpatient)– Critical Access Hospital (CAH)– Rural Health Clinic (RHC)– Federally Qualified Health Center (FQHC)– Skilled Nursing Facility (SNF)– Hospital-based or CAH-based Renal Dialysis Centers– Community mental health center (CMHC)– HPSA county outside metro area

Telehealth Guidelines• Physician/Provider location (“distant site”)

– No limitation on location– Must be licensed in state where patient is located

• Who may receive payment– Physician, PA, Nurse practitioner, Nurse midwife, Clinical

nurse specialist, Clinical Psychologist, Clinical social worker, Registered dietitian / nutrition professional

• Telepresenters– Not required– Unique to event/specialty

Telehealth Guidelines

• Interactive audio and video telecommunication must be used in real-time communication– Patient must be present and participating

• Payment is equal to the current Physician Fee Schedule amount

• Telehealth Facility Fee (for originating site)– Billable separately under Part B

Telemedicine in U.S.Multiple Federal Funding Resources

– HRSA – Network Planning and Network Development

• Grant assistance for upfront planning and initial development

– http://www.grants.gov/web/grants/search-grants.html

– USAC – Rural Health Care Support

• Will pay for % of Internet access cost

– http://wireless.fcc.gov/outreach/index.htm?job=funding

– Dept. of Commerce – National Telecomm. and Information Admin.

• Expanding broadband Internet access

• State Broadband Initiative & Tech Opp. Pgm.

• http://www.ntia.doc.gov/grants-combined

Telemedicine in U.S.Multiple Federal Funding Resources

– USDA – Rural Development (RD) – Grants & Loans

• Community Facilities (CF) Program - $70 million Direct Loans / $10 million Grants

– Areas/towns up to 20,000 pop.

– Construction or renovation of hosp., NF, Clinic (inc. necessary equipment)

– Purchase of specific equipment (new CT scanner), technology, software

• Application is once a year (end of May/early June)

• Announced 60 days in advance of due date

• RD staff assistance available for application process

• http://www.rurdev.usda.gov

Telemedicine in U.S.Federal Funding Support - Kansas

USDA – Rural Development (RD) – CF Program

Onaga, KSArea: 410 acresPop: 707 (2012)

$5 million CF Direct Loan

Bundled variety of needs:

• EMR hardware/software in hosp. & clinics

• Renovations/enhancements to existing hospital

• Purchased diagnostic equipment

• Refinanced existing debt

USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc

Telemedicine in U.S.Federal Funding Support - Kansas

USDA – Rural Development (RD) – CF Program

WHO: Great Plains Health Alliance, Inc.

WHAT: 24-Hospital NetworkWHERE: Phillipsburg, KS

$2.2 million bank loan guarantee

$3 million CF Direct Loan

Acted as borrower for hospital network:

• EHR hardware/software for 22 CAHs

• Enabled them to provide telemedicine services, virtual consults, diagnostic exams and imaging, and remote monitoring of patients.

USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc

Telemedicine in U.S.Multiple Federal Funding Resources

– USDA – Rural Development (RD) – Grants & Loans

• Distance Learning and Telemedicine (DLT) Program - $15 million

– Areas/towns up to 20,000 pop.

– 15% matching requirement

– Minimum grant award: $50,000; maximum: $500,000

– Purchase of computer hardware/software, computer network components, terminal equip., inside wiring, and inside equip. warranties

• Application is once a year (end of May/early June)

• Announced 60 days in advance of due date

• RD staff assistance available for application process

• http://www.rurdev.usda.gov

Insurance & Licensure

• Standard malpractice insurance covers telehealth

• Very low risk service to date– 3-4 known cases (2 were online

prescribing)

– 2 New Mexico cases bring up telehealth use – If available and not used, there may be liability

• No national physician license– A few states require telemedicine license

• Supplemental licensing

Credentialing & Privileging

• Where patient is located is place of service

• Providers need to be credentialed / privileged/ licensed at each place of service

Effective July 2011 – hospital’s governing body still responsible for all privileging decisions, but can accept credentials from distant-site Medicare hospital for telemedicine providers. CMS

Privacy/Security Issues

• Generally, all current videoconferencing systems include encryption technology.

• Security Rule does not require encryption (“Live” events are not ePHI), but technology easily encripts

• Privacy rule DOES apply• Telemedicine room should be private just like any other

clinic room• Use private connections when possible

HIPAA Security Rule• “The standards and specifications of the Security Rule are

specific to electronic protected health information (e-PHI). . . E-PHI does not include paper-to-paper faxes or video teleconferencing or messages left on voice mail, because the information being exchanged did not exist in electronic form before the transmission. In contrast, the requirements of the Privacy Rule apply to all forms of PHI, including written and oral.”US Dept. of Health & Human Serviceshttp://www.hhs.gov/ocr/privacy/hipaa/faq/securityrule/2010.html

Connectivity in Kansas Hospitals*

• 66% - Have videoconferencing equipment• 31% - Using telemedicine (2010)

– Daily 55%– Weekly 20%

• 23% - Receiving reimbursement for telemedicine (25% - Not sure)

• 50% used same equipment for education and training

* Kan-ed Telemedicine Capacity and Readiness Survey, KS Office of Edu. Innovation & Evaluation / Kan-ed , 2010

Connectivity in Kansas

• Internet access via Internet Service Provider (ISP) is available throughout Kansas

• ISP Internet connectivity is adequate for high-quality videoconferencing

• Multiple Internet-based videoconferencing services now available via ISP connectivity

Source: Kansas Board of Regents: Evaluating the Effects of Eliminating the Kan-ed Program, Legislative Post Audit Committee, Legislative Division of Post Audit, State of Kansas, January 2012.

Interactive Tele-Video (ITV)Putting technology concerns into the past.

PROVIDER’S OFFICEw/ Desk Top Computer

TABLET

SMARTPHONE

Telemedicine on Smaller Scale

Telehealth Peripherals

http://www.telehealthtac.org/toolkits/patient-exam-cameras-technology-overview#Patient_Exam_Cameras

Digital Stethoscopes

Electronic Otoscope for Pediatrics

What the provider or practitioner sees.

(Actual otoscope image)

Technology Specific to Health Care

• Peripheral devices– Otoscope– Stethoscope– Dermascope– Ophthalmascope– General exam camera– Handheld retina camera

Telehealth Peripherals

http://www.telehealthtac.org/toolkits/patient-exam-cameras-technology-overview#Patient_Exam_Cameras

Total Exam Camera

AdvantagesSame FeaturesLess expensiveEasily Available

Digital Camera/Camcorders

FeaturesDigital

Records imageHas own lighting

HD

VS

Technical Advances

• Smaller, less expensive equipment

• From analog to digital

• From telephone lines to internet lines

• Wireless

• Encryption

• Integration

Technical Advances

• Next generation:

The Wireless World of Hospitals

Telemedicine Today

How ToLearn More.

1-877-643-HTRC (4872)

www.HeartlandTRC.org

Questions@HeartlandTRC.orgBecome a fan:

www.facebook.com/HeartlandTRC.org

The Telehealth Resource CenterGrant Program

www.telehealthresourcecenter.org

Technical assistance forstarting or expanding telehealth services.

Who do the TRCs serve? Rural Clinics Federally-Qualified Health

Centers (FQHC) Critical Access Hospitals (CAH) Community & Urban Hospitals Primary Care Clinics Providers Health Care Organizations Ambulatory Care Centers Nursing Homes and others…

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http://www.telehealthresourcecenter.org

How TRCs can help. . .• Proven resources

- Legislation/Regulations- Forms & Protocols- Toolkits- Event Announcements

• Staff training- Onsite - Basic Protocols Telepresenters

• Peer-to-peer connections- Learn from other’s mistakes- Tele-All (Stroke, ICU, etc.)- No regional limitations

http://www.telehealthresourcecenter.org

How TRCs can help. . .• Technical Assistance

- Assessmentso Market Conditionso Needs & Prioritizationo Organizational Readinesso Technologyo Peer Comparison

- Basic strategic planningo Sources for revenue generationo Expense reductionso Cost Center/Residual benefitso Start Up / Replacement funding

http://www.telehealthresourcecenter.org

How TRCs can help. . .

• Technical Assistance (cont’d.)- Business Model Development

o Equipment Selectiono Program developmento Operational supporto Education on Insuranceo Reimbursemento Quality Assessment

http://www.telehealthresourcecenter.org

The National Telehealth Resource Center Webinar Series

www.telehealthresourcecenters.org

Key telehealth topics from experts!• 3rd Thursday of Every Month• 1:00 PM Central Time

Phone: 1.877.643.HTRC (4872)

Email: Questions@HeartlandTRC.org

Video IP: 169.147.3.125 ext. 7010109

Gordon AllowayProject Director, HTRC