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Comprehensive Telemedicine: A Practical Approach

Thursday, October 16, 2014(8:00AM HST,  10:00AM AKDT, 11:00AM PDT,  12:00PM MDT,  1:00PM CDT, 2:00PM EDT)

Presented by: TexLa TRCSpeaker: Kim Dunn, M.D., Ph.D.

Your Doctor Program, L.P.Houston, Texas

Comprehensive Telemedicine: A Practical Approach

Kim Dunn, MD, Ph.D.

DrDunn@YourDoctorProgram.com

Talk overview

» What are the standards of care today?

» Medical home

» Comprehensive telemedicine

» Leadership development for value based care

Current reality

FINANCIAL / REGULATORY PATIENT OWNERSHIP QUALITY MANAGEMENT AND SERVICE

Current reality cont.

Current information management

Clinical Documentation Patient Outcomes PaymentSubjective Objective Assessment Plan Variables

Doctors paid on

what document in

subjective and

objective, not

assessment, plan.

Current EMRs

follow the money

and also do not

incorporate

outcomes nor

telemedicine.

Disjointed

Used as a

surrogate

for quality

So the most

important

is…….

Not

automated

Not integrated

outside of

doctor office

Data

not easily

obtained

Not

actionable

Genetics

Social

Environ

Value based service

Quality

CostValue =

Quality Population health• Ambulatory: Age, sex, disease

specific PQRS/measures adjusted for social / clinical factors / adherence

• Inpatient: Required regulatory

Patient experience• Satisfaction / patient education• Improve access via telemedicine

Cost / Payment• Payment for telemedicine• Real time claims management• Point of service payment via

quality attestation

Quality attestation

Patient

KDunn and Associates, PAValue based contracting for patient centered,

telemedicine based care. We assure

The Physician Quality Standard TM is met via peer review and practice-based CME-CNE.

Schull Institute, a 501 C 3De-identified data analysis

Your Doctor Program, L.P.Training and support for telemedicine, medical home,

population management, and clinical integration.

PartnersCME: Texas Medical Association

CNE: Care Track, LLC, State of California

Value-based Care

StrategySave lives and money

through engaging

physicians in

telemedicine and quality

and patients in their care.

PayersPrimary: BusinessInsist on The Physician

Quality Standard TM

Secondary

• Payers: What does

The Physician Quality

Standard TM mean?

• Consumers: How we

assure your care is

coordinated, safe, and

effective if you do your

part.

Quality

Service Cost

Patient

» Saved lives with two pilots in

high risk populations (dual

eligible) and homeless (1.5%

mortality reduction

» Established program for quality

that overcomes physician

barriers for engagement

» Eliminate ED visits

for primary care

» Reduced

readmissions 75%

» Comprehensive

reimbursable

telemedicine model

» Feedback from

patients to improve

service and

decrease liability

Accomplishments since commercialization

• Defined CME / CNE Program

• Defined market for employer community

Our value summary

KDunn and Associates, Standards for Value Based Care

Quality attestation for point of service payment for Value

Based Care

Total quality management

Use of The Physician Quality

Standard TM by practitioners

meeting standards

Patient centered, telemedicine based

service delivery

Your Doctor Program for

Accountable Communications

Service Products

Healthcare in Your Hands

Medical Home in a Box

Accountable Care in a Box

Technical integration to standards

BenefitsProviders

Leadership development for quality, service, and effectiveness

Paid for telemedicine

Paid faster via quality attestation model

Save money via medmal reductions

Board Re-Certification

Patients / Payers

Save money

Care is coordinated, safe, and effective

Engagement for prevention and disease management

Improved access and save time / money via

telemedicine

* KDunn and Associates, P.A., dba HealthQuilt, is a practice association for value based care contracting. We use a patented

process for total quality management via peer reviewed program for standards of practice for a patient centered, telemedicine based

care delivery model.

Value improvement via total quality management

Ongoing value improvement

» Quarterly value improvement peer comparison reports» Population health: Top five clinical quality adjusted for patient

adherence and patient social / clinical risk factors.

» Patient experience: Service and patient engagement

» Cost: Total cost with emphasis on devices, total costs, readmissions

» Annual value improvement» Population health: Top five clinical quality metrics adjusted for patient

adherence and patient social / clinical risk factors.

» Patient experience: Service and patient engagement

» Cost: Total cost with emphasis on devices, total costs, readmissions

HEALTH HOME

Medical home

Consumer Centered Model

Encounter Type Key actions Billing Event

In Person

Sign MH / Info mgt agreements X

Credit card on file X

Training on tool / download application X

Establish pt's doctor network X

Establish / update care plan /allergies X

Select one prevention goal: Need Smoking Cessation / Weight

Reduction? xxxx: Prevention X

Disease specific goals / contracts xxxx: Patient teaching X

Health Risk Assessment xxxx: HRA X

Update living will / mpoa X

Preparedness plan given X

Patient card sent X

Upload encounter note / labs / imaging xxxx: Encounter note

Patient Take Care plan, doctor instructions, and card to

annual visit. Request care plan update and encounter data

faxed / uploaded

Define tasks X

Send encounter survey X

Trip claim X

Update care plan

Upload encounter note / labs / imaging xxxx: Encounter note

Patient Take Care plan, doctor instructions, and card to

visit. Request care plan update and encounter data faxed /

uploaded

Define tasks X

Send encounter survey X

Trip claim X

Care plan updated and all patient records updated X

Messaage / fax referral request X

Order X

Patient take care plan with them with request X

Care plan recommendations updated X

Note / data uploaded vs. faxed back to medical home xxxx: PMPM or PCO

Patient Take Care plan, doctor instructions, and card to

visit. Request care plan update and encounter data faxed /

uploaded

Care plan updated X

Define tasks X

Send encounter survey X

Trip claim X

Care plan updated

Message / fax referral request

Patient take care plan / card with them xxxx: DME/Pharmacy

Patient Take Care plan, instructions, and card to visit.

Request care plan update and encounter data faxed /

uploaded

Define tasks X

Send encounter survey X

Patient take care plan / card with them

Note /data uploaded vs. faxed back to medical home xxxx: PMPM or PCO

Care plan updated

Patient Take Care plan, instructions, and card to visit.

Request care plan update and encounter data faxed /

uploaded

Define tasks X

Send encounter survey X

Hospital / Nursing facility based

Patient take care plan / card with them / Care plan managed by

nurse as inpatient and attending physician assumes medical

home care oversight role

1. Attending / staff

Note / data uploaded vs. faxed back to medical home xxxx: PMPM or PCO

Patient Take Care plan, instructions, and card to visit.

Request care plan update and encounter data faxed /

uploaded

2. Consultant / staff Care plan updated X

3. DME / Meds Define tasks X

Send encounter survey

Home HealthPatient care plan managed by home health with oversight from

medical home xxxx: PCO

Messaging Part of care plan for administrative purposes

Update care plan

Document telemed encounter note / labs / imaging xxxx: Encounter note

Define tasks

Send encounter survey

Trip claim or credit card payment

Update care plan

Document telemed encounter note / labs / imaging xxxx: Encounter note

Define tasks

Send encounter survey

Trip claim or credit card payment

Update care plan

Message request

Phone conversation

Specialist document encounter recommendation xxxx: Encounter note

MH Update care plan xxxx: PMPM or PCO

Define tasks

Send encounter survey

Trip claim or credit card payment

Update care plan

Message request

Video call in system

Specialist documentation encounter in system xxxx: Encounter note

MH Update care plan xxxx: PMPM or PCO

Define tasks

Send encounter survey

Trip claim or credit card payment

If patient does not have FOR A, gets daily message to enter their

data per the disease protocol

If can get FORA

Training on tool

Sync with mobile app

Uploads daily

Threshold established for patient

Above threshold triggers alert to clinical support to call the

patient xxxx: PMPM or PCO

Care plan updated

Define tasks

Send encounter survey

If not already PMPM, trip claim for PCO

Done inside the Care Plan Management, documentation,

billing at the point of service delivery completion or per

contract

Biomonitoring: Patient-Medical Home

LIV: Patient-MH or Specialist

In Person

Clinical Centered Model

Med Home: In person / episodic

In Person External Referral Specialist /

Lab

Med Home: Telephone during Office

Hours

Telemedicine

Curbside: Med Home-Specialist

Referral for DME / Pharmacy

Emergency / Urgent Care

Med Home: Telephone after Office

Hours / Oncall

Annual visit with medical home

Annual /

Population

healthdata

Ongoing:

Eight

in

person

Ongoing:

Six telemed

in care plan

* documentation

inside the care

plan

Point of

Service

Payment /

via Quality

Attestation

1. Care

Plan /

Tasks

2. Upload

data

3. Send

Survey

4. Ongoing

CME/

CNE

Trip claim to

rendering

physician

* Patent pnd

Healthcare in Your Hands TM

Patient centered care automation

Comprehensive telemedicine

» Care plan (all records available and translated into an integrated care plan)

» Messaging for administrative tasks(prescription refills, schedule appointments, call center support)

» Biomonitoring for patient engagement

» HTN: Blood pressure, weight

» Diabetes: Glucose, exercise, diet

» Weight loss

» Smoking cessation

» Telephonic / live interactive visits » Medical home / primary care

» Specialists

Medical home / specialists for clinical integration

Physician Care Oversight

Outpatient: Medical Home

Inpatient: Attending as

“Temporary Med Home”

Specialists

Outpatient : Defined by medical home

Inpatient: Defined by attending physician

Methodology• Base standard• CME / CNE to customize

treatment preferences• Primary care manage

care plan including risk factors and patient tasks

• Curbside from specialist to primary / attending

• Population health via Annual Health Risk Assessment

• Defines patient engagement tasks

• Quarterly feedback

What it means for a patient

» One phone call

» 24 / 7 access to a doctor via telemedicine

» Care coordinated via care plan and telemedicine, working with home health

» Care transitions eliminated

» Service follow up all encounters

» Care coordinated, safe, and effective

Telemed: care plan / messaging

Population health

» Prevention Visit: Annual age, sex, disease specific health risk assessment that attributes physician ownership / risk adjustment

» Disease management tracking

Health risk assessment

Disease Tracking / Biomonitoring

Patient agreementPatient tracking, many devices

for electronic tracking

Telephonic / Live interactive

» Primary care: $50 if established care

» Specialist “curbsides”: $75, applies to deductible if need in-person, part of clinical integration program

» Live interactive

» Per doctor for second opinion

» Hospital care transitions using care plan management process and home visits for telemedicine via physician care oversight

Encounter Documentation

» 15 encounter type templates

» Linked to CPT / transaction codes

» Survey follow up 3 days after service delivery with provider attribution

YDP card and Secure online access

Front of card» Identifies your primary doctor

contact for information

» Access for your doctors to your care plan through the Quick Response (QR) code

» HIPAA compliant QR reader

Back of card» Your name

» Instructions to your doctors to follow information management standards

» Financial strip

Smartphone Application

Personal QR reader

takes you and a doctor

to your care plan

Supports communication

and biomonitoring

Medical Home in a Box TM

Train the trainer model

» Teach medical home, telemedicine, clinical integration

» Policies / procedures

» Training manuals

» Online training

» Patient contract reviews

» Branded card printing

» License of Healthcare in Your Hands integrated into care delivery

» Marketing plan for The Physician Quality Standard TM

90 Day Team for Value Based Contracting to The Physician Quality Standard TM

» Kim Dunn, MD, Ph.D.: Physician leadership development, telemedicine, medical home, preparedness and disaster response

» Sandra Petersen, DNP, Ph.D.: Nurse leadership development, patient engagement for self management, hospice, policies/ procedures

» Karen Garmin: Policies / procedures

» Jay Stowers: Liability management

» Justice Kennedy: Financial management

» Kevin Dunn: Marketing with The Physician Quality Standard TM

» Adi Kadapa, MD, MS: Technical integration lead

90 day initiation

Month 1

» Initiate physician leadership / business plan

» Policies and procedures for value based contracting to The Physician Quality Standard TM

» Network / Leadership Development

» Video production for specialist “baseline protocols” for primary care / patient education

» Primary care / Emergency / Hospital physician agreements for Peer Review with KDA

» Co-branding / Marketing plan for cards / employers / MCOs

» Initiate technical integration roadmap via YDP care plan framework

» Initiate FTC Letter of Determination for Clinical Integration based on policies and procedures

Month 2

» Medical Home in a Box TM: Physician Care Oversight for Patient Centered Care / Quality

» Outpatient

» 2 day onsite consulting, workflows, tasks, go-live with HIYH Info Kiosks, NCQA application / 90 day reporting period

» Inpatient (Temporary medical home)

» 2 day onsite consulting, workflows, tasks, go-live with HIYH Info Kiosks, clinical integration

» Initiate employer marketing campaign

Month 3

» Finalize technical integration

» Initiate peer comparison report program

» Expand employer marketing campaign

Initiation

PHYSICIAN LEADERSHIP DEVELOPMENT

» Content» Standards for information management

» Clinical integration / Accountable care

» Medical home

» Telemedicine

» Liability reduction

» Patient engagement

» Care plan / regulatory management

» Care transitions

» Activities onsite with nursing staff» Practice assessment- clinical, business

» Document treatment preferences

» Telemedicine training

» Takehomes» Clinical quality improvement plan

» Secure IT / Risk infrastructure

» Quarterly reviews

» Annual PDCA

STAFF TRAINING

» Content» Policies / procedures

» Workflows / tasks

» Communication / telemed standards

» Preparedness

» Activities» Workflows / tasks

» Takehomes» Checklists for workflows / task lists

» Policies / procedures

» Ready for reporting

» Satisfaction / Education improvement plan

90 day timeline

Wk1 Wk 2 Wk 3 Wk 4 Wk1 Wk 2 Wk 3 Wk 4 Wk1 Wk 2 Wk 3 Wk 4

Telespecialists Agreements Film, edit

Peer review agreements

with all doctors in pilot

Online customized CME /

CNE training program

XXX Physician

/ Nursing

Leadership

Training

Rapid medical home to

NCQA Level 3 / FTC Clin Int

Assessment, evaluate Proposed changes Complete customized policies

Technical integration planTechnical

assessment

Co-branding / marketing

program

Marketing to SIE

Financial/ regulatory modelsCodes defined

Staff Leadership Policies TrainingTechnical

assessmentBranding

Marketing to

Employers

Financial /

regulatoryHours

Dr. Kim Dunn ** * * * * * 480

Dr. Sandi Petersen * * ** 130

Jay Stowers * * ** 120

Kevin Dunn * * * * ** * * 480

Justice Kennedy ** * 480

Sean Harkins * * 480

Karen Garmin ** * 150

Dr. Adi Kadapa * ** 480

Total for Initiation 2800 hours

Consulting Team for 3 Month Clinical Integration / Licensing Initiation

Proposed changesPhase 1 implementation: Data

submission / presentation layer

Ongoing Support: Card field

printers, patient application

ReviewMaterials developed:

website, card, printed

Co-marketing to SIE/ Business communityID Targets

FTC Clinical Integration

Letter / Value based care

DeliverablesMonth One Month Two Month Three

Physician leadership development for clinical integration, medical home, telemedicine

YDP baseline protocols

customized to XXXX

Disease management /

telemedicine established

Train the

Trainer Medical

Home Program

for 90 day

reporting

period

Ongoing Practice based CME /

CNE

Peer review agreements

Customize training platform / content with XXXX

Customized to XXXX

Policies and Procedures: Clinical integration, medical home, telemedicine, quality, risk management

Transition

Training and Support Manuals for patients, doctors, staff, specialists, nursing

Example business proforma

• $2.8 M annual revenue

• 6 physicians

• Active patients: 34750

• Average pts / doctor / day: 18

Daily Monthly

Annual

visits

not

covered

Comprehensive

Annual YDP new

wellness / disease

management /

preparedness

model for service

delivery model

with increase of

$100

Physician care

plan oversight:

Info / Quality

management /

Biomonitoring:

2.5/5/12.5 PMPM

Telephone visit

payment during

day 2/ doctor

plus on call 4,

total daily is 16 /

day $30

Clinically

Integrated

Specialists:

$50

Average per day per doctor 18

Number of doctors 6

Total Visits 108 2160 8830

Acuity Level of patients

INCREASED

ANNUAL

Level 1 26,461 2.5 883000 2646100 793830 793830

Level 2 6289 5 628900 377340 188670

Level 3 2000 12.5 200000 300000 60000

P4P 883,000 3,475,000 1,471,170 1,042,500 6,871,670

Current

model

YDP

model

Annual 200 300

1 visit 100 100

Telemedicine

2 telephonic / day / practitioner

/ 5 oncall 0 60

PCO/ QM / Biomonitoring

(50/50 split) 0 60

NP extender for annual visits home

/ office

Phone calls

and wellness

visits

300 520

Actual New Revenue by Population Health / Value Based Contracting

Definition of a computer

One who computes…….

The patient……

And their doctors…

Lifelong patient ownership 365 / 24, all situations

Self management• Education • Accountability• Wellness• Biomonitoring• Social support• Disaster

preparedness

Engaging physicians in quality

Framework transition

YDP model

» Model: Quality based, patient centered, data integration

» Communication: Care plan, telemedicine

» Documentation: Care plan, outcomes, tasks

» Payment: Paid for telemedicine / point of service completion

Current model

» Model: Episode based, financial based, not patient accountable

» Communication: Fax, voice mail, no follow up

» Documentation: Review of Systems / Exam

» Payment: Episode of care with challenges of denials, lack data

How we work with employers» Insist on

» standards for information and quality management

» Telemedicine

» point of service payment via quality attestation

» Meetings with all contracted insurers / managed care

» Define target populations

» Pre-adjudicate claims

» Pay for comprehensive telemedicine / in person

» Pre-post impact on quality, service, cost for shared savings programs

BenefitsProviders: Physicians / Hospitals / Nurses

» Rapid clinical integration

» Rapid medical home

» Payment at point of service completion via quality attestation starting with telemedicine

» Get in charge of quality, service, and efficiency for all required CME / CNE and Board Re-certification

» Clinical integration

» Hospitals: Reduce 30 day readmissions, regulatory information management, liability

» Ambulatory: Pay for wellness, telemedicine, improve revenue cycle management, reduce regulatory information management, liability, all P4P

» Technical integration to support current technology

Employees / Consumers / Patients

» Improve access via telemedicine

» Remove hassles for administrative requests

» Frustration of duplication of data to different doctors

» Improve safety of healthcare system

» Ownership of their wellness and care

» Emergency management service and travel medicine support

Employers Save 3-7 % on healthcare costs with no new cost outlays

» Patient knowledge of their responsibilities to own care

» Practitioner ownership of quality and cost reductions

» Emergency workers have access to core patient data

» Decreased costs via telemedicine

» Improved worker compensation

» Eliminate fraud

Next steps

» Enroll in “Train the trainer” program for leadership development

» Identify physician, nursing, pharma, IT, financial, marketing leaders for initiation

» Approve project plan

» Initiate 90 day project to value based contracting via medical home, comprehensive telemedicine and total quality management

Contact

» Kim Dunn, MD, Ph.D.

» drdunn@yourdoctorprogram.com

» 713-981-6125 (o)

» 832-752-1635 (c)

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