SalinaTelehealth

Regional Telemedicine Conference Heartland TRC

GAlloway@HeartlandTRC.org

1-877-643-HTRC (4872)

http://www.HeartlandTRC.org

Gordon AllowayProject Director, HTRC

HTRC PARTNERSSince 2010

University of Oklahoma Health Sciences Center

Started 1993

Store-and-Forward expertise

University of Kansas Medical Center

Started 1991

2,000+ clinical consults/yr

University of Missouri Health System

Started 1994

Public/Private Network

Telehealth / Telemedicine:

The

Delivery of CareTechnology-Assisted

What Telemedicine is:

1. A method of delivering care that is available for use when appropriate.

2. A care delivery method with proven efficacy and insurance reimbursement, in general, equal to in-person care.

What Telemedicine is: Not:

1. Significantly different way of providing care

2. An additional level of care

3. A replacement for face-to-face care

4. A departure from clinical protocols

5. Tele-surgery or Robotic surgery

6. Virtual care / Checklist medicine

Telemedicine Benefits:

1. Increased community satisfaction– Meeting a community need– Keeping patients in community

» Additional revenue (Rx, food, gas)

2. Increased patient satisfaction– Access to specialists– Keeps patients in community

– Time is key for stroke– Family access– Reduced transp.

Telemedicine Benefits:

3. Increased Board satisfaction– Efficient addition of services at your facility

– Technology available for admin. needs

4. Increased staff satisfaction– Fill available capacity

– Available for CME & CE training

5. Enhanced Continuity of Care– Increases practitioner avail.

Terms

Relationshipof

TechnologyTerms

WhatAbout

mHealth?

Two Common Forms of Telemedicine

1. Asynchronous or “Store-and-forward”

Example: RadiologyX-ray image/CAT scan/MRI

Sent to different location

Radiologist reads image and responds to PCP/patient

Two Common Forms of Telemedicine2. Interactive or “Real Time”

Example: Clinical ConsultationScheduled appointment

Patient at clinic, hosp, CAH

“Normal” exam room

Presenter/provider remains with patient in exam roomOperates equipment, assists provider

Specialist/Provider/Practitioner on video monitor

Reimbursement

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

CPT / HCPCS Codes –

Telehealth Services

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

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

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

Kansas-Specific Reimbursement

• Included in Kansas Medical Assistance Program (KMAP) policy

• Three KanCare MCOs• Amerigroup • Sunflower• UnitedHealthCare

• Private Insurance – most major carriers

State Telehealth Mandate

• Mental/Behavioral Health – Kansas - SB 175, HB 2395 and HB 2317– Mass– Nebraska

Technology

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

1500

2000

2500

3000

Telemedicine Technology KUMC 1993 - 2010

1993

2010

Telemedicine Today

TelemedicineToday

• Smaller, less expensive equipment• High quality, high definition (HD) technology• Less expensive internet connectivity• Mobile, wireless capability

Applications

Specialty Consultation via ITV

Group Sessions and Educational Events

Telestroke / Physician-to-Physician

Intra-Oral Scope (Tele-Sleep Study)

What Tele-Sleep Presenter Sees

Electronic Otoscope for Pediatrics

Oncology Care (Hospital Exam Room)

Telemedicine on Smaller Scale

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

PROVIDER’S OFFICEw/ Desk Top Computer

TABLET

SMARTPHONE

Telehealth Peripherals

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

Digital Stethoscopes

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:

Robotics

Security

• Two Sections1. Privacy Rule2. Security Rule

Health Insurance Portability Accountability Act (HIPAA)

Privacy/Security Issues• Generally, all

videoconferencing systems are secure

• All include encryption• Log-in at both sites

• Privacy• Telemedicine room should be private just like any

other clinic room• Telemedicine patients same rights

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

Insurance & Licensure

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

Insurance & Licensing

• State Licensing Boards regulate practitioners– Physician/Practitioner must be licensed in state where

patient is located.

– No limits on practitioner location

Credentialing & Privileging

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

CMS

TELEMEDICINE WORKS BOTH WAYS

1. Bring additional services into your site. Refer to specialists not currently available Patient remains onsite

2. Extend your services to other sites. Expand outreach activities Distant sites have access to your staff’s expertise Additional outpatient activity without additional traffic

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

KUCTT • Over 60 sites interacted with KUCTT• 16 specialties provided

Total KS activity unknown

Stormont-Vail& Mayo Clinic Care Network

Funding

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.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

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

– FCC – Broadband funding (Formerly Univ. Serv. RHC Program)

• Healthcare Connect Fund – Supports broadband connectivity and networks

– Provides 65% discount on broadband services, equipment, connectivity, construction, if shown to be most cost-effective

– Requires 35% contribution

• Started January 1, 2014

• Encourages use of consortiums

• KHA is leading initiative in Kansas

• FCC website: http://www.fcc.gov/health

Telemedicine in U.S.Multiple Federal Funding Resources

Eligible to participate in Healthcare Connect Fund– Public or not-for-profit hospitals, rural health clinics, community

health centers, health centers serving migrants, community mental health centers, local health departments or agencies, post-secondary educational institutions/teaching hospitals/medical schools, or a consortia of the above

– Non-rural HCPs may participate in Healthcare Connect Fund if they belong to a consortium that has a majority rural HCPs

– The largest HCPs (400 + patient beds) are eligible, but support is capped if non-rural.

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.

http://www.HeartlandTRC.orgGAlloway@HeartlandTRC.org

1-877-643-HTRC (4872)