telemedicine: transforming the delivery of healthcare debbie voyles, mba hom director of...
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Telemedicine: Transforming the Delivery of Healthcare
Debbie Voyles, MBA HOMDirector of TelemedicineF. Marie Hall Institute for Rural and Community Health
June 2013
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Five Core Programs
• Telemedicine –community-based telemedicine in Texas; one of 2 correctional programs; one of longest running programs in nation; 45,000+ consultations
• TexLa Telehealth Resource Center
• Rural Research – Project FRONTIER, TARC, Alzheimer’s Disease
• Health Education – West Texas Area Health Education Center (WTAHEC), Hot Jobs, Double-T Health Service Corps, region-wide community health needs assessment
• Electronic Health Records – West Texas Health Information Technology Regional Extension Center (WTxHITREC)
Texas Tech University Health Sciences CenterF. Marie Hall Institute for Rural and Community Health
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• Unique challenges for Rural Health Care• What is Telemedicine• Benefits to using Telemedicine• Challenges/Barriers to Telemedicine• Critical Steps to Implement Telemedicine• Reimbursement • TexLa Telehealth Resource Center
Today’s Discussions:
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US 2010 Census
• Population = 308,745,538
• 9.7% increase from 2000
• 83.7% live in the nations 366 metro areas (population over 50K)
• 10.0% live in the nations 576 micro areas (population between 10K and 50K)
• 6.3% live in rural areas (population less than 10K)
US Department of Commerce Population Distribution and Change: 2000 to 2010
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Current Challenges in Rural Health Care
• Workforce shortages
• Geographic isolation – limited transportation
• Diminishing community economics
• Low healthcare margins
• Difficulty recruiting physicians
• Increasing dependence on specialty and expensive technologies
• Demand for quality
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Is this the Future of Healthcare?
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Health Professional Shortage Areas
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HPSA – Mental Health Designated Populations
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HPSA – Dental Health Designated Populations
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Ratio of Providers per 100,000 PopulationRatio of Providers per 100,000 Population
Primary Care
Doctors
Physician Assistants
Nurse Practitioners
RNs LVNs
U.S., 2010 67.4 34.4 22.8 882.5 244.0
Texas, 2011
(2005)
69.5
(68.5)
20.8
(14.7)
25.8
(17.7)
712.7 (628.6)
281.7
(269)
West Texas, 2011
60.8 18 28.5 746.4 415.4
West Texas/Border, 2011
48.0 13.4 24.82 577.54 193.18
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Family Practice Physicians in Rural Counties
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Texas Counties Without a Pharmacists
Source: Texas Department of Rural Affairs, August 2010
HoodHoward
Presidio
BrewsterVal Verde
CulbersonHudspeth
Jeff Davis
El Paso
Crane
Pecos
Reeves
Crockett
Terrell
Upton Reagan
Andrews
Ward
Loving Winkler MidlandEctor Glasscock
Martin
Bandera
Jim Hogg
La Salle
Webb
Starr
Zapata
Dimmit
ZavalaMaverick
Kinney Uvalde
Frio
Medina
Nueces
Brooks
Hidalgo
Duval
Kenedy
Willacy
Cameron
Jim Wells
Kleberg
Wilson
McMullen
Bexar
Atascosa
BeeLive Oak
San Patricio
Karnes
GuadalupeGonzales
Mason
McCulloch
Edwards
Sutton
Schleicher
Kerr
Real
Kimble
Menard
Nolan
Tom GreenIrion
Mitchell
SterlingCoke
Runnels
Concho
Coleman
Taylor Callahan
Bell
Blanco
Kendall
Comal
Gillespie
Llano
Travis
Hays
Caldwell
Burnet
Williamson
Comanche
Mills
San Saba
Brown
Eastland
Hamilton
Lampasas
Coryell
Erath
Bosque
Somervell
Swisher
Randall
Hockley
Gaines
Yoakum
Cochran
Dawson
Terry Lynn
Lubbock
Deaf Smith
Bailey
Parmer
Lamb Hale
Castro
Hartley
Oldham Potter
Moore
Dallam Sherman
Knox
Kent
ScurryBorden
Garza
Crosby Dickens
Fisher Jones
King
Stonewall Haskell
Hall
MotleyFloyd
Briscoe
Hardeman
CottleFoard
Childress
JackYoung
StephensShackelford
Throckmorton
ParkerPalo Pinto
Wise
Baylor Archer
WilbargerWichita
ClayMontague
GrayCarson
Armstrong Donley
Hutchinson Roberts
Wheeler
Collings-worth
Hemphill
OchiltreeHansford Lipscomb
Jefferson
Trinity
Brazos
Lavaca
Victoria
Goliad
Refugio
De Witt
Calhoun
Aransas
Jackson
Wharton
Milam
Bastrop
Fayette
Lee
Austin
Colorado
Burleson
Washington
Robertson
Waller
Brazoria
Matagorda
Fort Bend
Harris
Galveston
Chambers
Montgomery
Walker
Grimes
Madison
Jasper
Liberty
Hardin
Polk
San Jacinto
Tyler
Anderson
Ellis
Falls
McLennan
Hill
Freestone
Limestone
Leon
Navarro
Henderson
DallasTarrant
Johnson
Denton
Kaufman Van Zandt
Collin
Rockwall
Hunt
Smith
Cherokee
Houston
Nacogdoches
Angelina
Rusk
Shelby
Panola
Franklin
RainsWood
Hopkins
Marion
Gregg
Upshur
Harrison
Titus
Camp
Morris Cass
Newton
Orange
San AugustineSabine
FanninCooke Grayson
Delta
Lamar Red River
Bowie
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Dentists in Rural Counties
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ACCESS
Hospital:
Clinics:
Physicians:
Nurses:
P.A.s:
0
1
1
2
.5
(nearest 85mi.)
Presidio, TX
Presidio to Lubbock: 398 mi. / 7.5 hrs.
El Paso to Lubbock: 343 mi. / 7 hrs.
Population:
Medicaid Enrolled:
4167
705
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We know a need exists
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If we can dream it – we can do it!
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Could healthcare be better?
• If it were available anywhere at anytime to anyone
• Costs were reduced and outcomes improved
• Practitioners could consult with experts and each other anytime and anywhere
• Chronically ill and homebound patients could be monitored remotely 24/7/365
• Preventive care could be integrated into work, home, school, or any environment
With Telemedicine it is possible!
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What is Telemedicine?American Telemedicine Association
• It the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.
• It has evolved to telehealth to incorporate health education, prevention and anticipatory guidance that does not always involve clinical services
• It may include videoconferencing, transmission of images, e-health, m-health, patient portals, remote monitoring of clinical information, etc.
• It is not a separate medical specialty!
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Three Links to Effective Telemedicine
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How can Telehealth/Telemedicine be used?
“Shrinking the distance”
•Increasing access
•Bridging the gaps
•Serving the needs
“Care closest to home”
•Medically underserved rural areas
•Health professions shortage areas
•Saves travel time / increases convenience
•Lowers costs
•Aging & chronic conditions
•Special populations (Prisons)
•Disaster response & relief efforts
•Refocus on prevention, team-based community-centric care
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How it Works
• Video conference system (SF & RT)
• Various medical peripherals (heart rate, blood pressure, ekg, dematomes, otoscopes, etc.)
• Connectivity (High-speed T-1 phone lines, DSL, Wireless, Satellite, Cloud, etc.)
• Consultant – physician or specialists
• Presenter – in Texas any certified healthcare provider working within the scope of their license
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Telemedicine Components
• Equipment standardization
• Peripherals• Otoscope• General Exam Camera
• Dermatology
• Burn Care
• Wound Care
Stethoscope
Color Printer
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Telemedicine Components
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Digital - Electronic Stethoscope
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General Exam Camera
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Fiber Optic Otoscope
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Electrocardiogram (ECG)
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Emerging Technology Applications
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Service Lines
•Burn/Wound Care
•Dermatology
•Genetics
•Infectious Disease
•Mental Health
•Neurology
•Nutritional
•Orthopedics
•Primary Care
•Pulmonology
• Cardiology
• Endocrinology
• Geriatrics
• Internal Medicine
• Nephrology
• Oncology/Hematology
• Pharmacy
• Pulmonology
• Urology
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Telemedicine Philosophy
• Telemedicine does not alter the practice of medicine.
• It is only a tool.
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Telemedicine Access
Response to:• Fewer physicians in rural/frontier communities• Fewer specialists throughout region• Technology advancements• Changes to state rules• Services w/out taking too much time off from work/school• Reduces escalating (spiking) personal travel costs• Another way to see a health care professional; comparable to face-to-face
care…• Meeting increasing need for specialties due to increasing chronic illnesses
(diabetes, obesity, psychiatric, geriatric, cognitive…)• Expand benefits that health services bring to rural and frontier
communities• …and patients like telemedicine
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Benefits to Using Telemedicine
• Improved access to specialty services and care – “care closest to home”
• High patient satisfaction –
• improved access, • reduced travel costs (mileage and travel time)• reduced time away from home/school/work
• Improved patient outcomes – earlier interventions, reduced complications, consistent use of evidenced based medicine
• Healthy People/Healthy Communities - better relationships with rural communities – create, improve and maintain local access to appropriate high quality care
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Challenges/Barriers to Telemedicine
• Keeping up with changes in technology
• Investment in equipment and training
• Credentialing/licensing (especially across state lines)
• Limits on reimbursement from insurance companies, Medicare, Medicaid
• Connectivity issues
• Regulatory Restrictions
• Systems implementation and interoperability
• End user adoption and training
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Critical Steps to Implementation
• Community Assessment – in person
• Be clear on goals – what are you trying to achieve?
• Identify a telemedicine team – find champions
• Determine how telemedicine will fit into the organizational structure
• Develop a plan for educating and training
• Continually educate senior leadership, medical staff, community and state leaders, on performance and advances
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Treat Telemedicine The Same As Any Other Practice of Medicine
• Apply same protocols, techniques, standards and style
• Treat patient in the same manner as if they were presented in the same room
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Licensure
• State licensing – does not require a different license
• Physician must be licensed in the same state the patient is located
• Federal licensing proposal
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Telemedicine Credentialing and Privileging Requirements• If seeing patients in a hospital setting must
be credentialed with facility as if seeing the patient in person
• New CMS rule, which applies to all hospitals that participate in Medicare, and inpatients at critical access hospitals, upholds The Joint Commission's current practice of allowing the hospital or CAH to utilize information from the distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners.
Effective July 5, 2011
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Confidentiality and Consent Forms
• Employee confidentiality forms
• Patient consent to treatment form – same as if being seen face to face
• Release of medical records forms
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Telemedicine Reimbursement
•Medicare
•Medicaid
•Third-Party
•Private Pay
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MedicareEligible areas include:
• Health Professional Shortage Area (HPSA)• County that is not included in metropolitan statistical area (MSA)
Eligible sites include:
• Office of physician or practitioner• Critical access hospital (CAH)• Rural health clinic (RHC)• Federally qualified health clinic (FQHC)• Hospital• Skilled nursing facility (SNF)• Hospital-based or CAH-based Renal Dialysis Centers (including satellites)• Community mental health center (CMHC)
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MedicarePractitioner who may bill:
• Physician• Nurse practitioner (NP)• Physician assistant (PA)• Nurse midwife• Clinical nurse specialist (CNS)• Clinical psychologist (CP) and clinical social workers (CSW)
(CPs and CSWs cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90805, 90807, and 90809)
• Registered dietitians or nutrition professionals
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Medicare – Eligible Medical Services
• Office or other outpatient visits (99201-99215)• Individual psychotherapy (90804-90809)• Pharmacologic management (90862)• Psychiatric diagnostic interview examination (90801)• End stage renal disease related services included in the monthly
capitation payment (90951, 90952, 90954, 90955, 90957, 90958, 90960 and 90961)
• Individual Medical Nutritional Therapy (G0270, and 97802-97804)
• Individual and group diabetes self-management training services (G0108-G0109)
• Neurobehavioral status examination (96116)
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Medicare – Eligible Medical Services
• Individual and group health and behavior assessment and intervention (96150-96154)
• Follow-up inpatient Telehealth consultations (G0406, G0407 and G0408)
• Emergency department or initial inpatient telehealth consultations in hospitals and SNFs (G0425-G0427)
• Subsequent hospital care services (but not more frequently than once every 3 days) (99231-99233)
• Subsequent nursing facility care services (but not more frequently than once every 30 days) (99307-99310)
• Individual and group kidney disease education services (G0420-G0421)
• Smoking cessation services (99406-99407, G0436-G0437)
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Medicare – New for 2013• 7/30/12 Proposed Rule to add two codes for “alcohol
and/or substance abuse (other than tobacco) structured screening (e.g. AUDIT, DAST) and intervention services”
• (G-0396 – 15-30, • G0397 – more than 30 minutes) • (NOTE: not screening services but as part of diagnosis or treatment of an
illness or injury)
• Preventive Services added in 2012 now available. • G0442-G0443. Annual alcohol misuse screening and counseling, • G0444 Annual depression screening, • G0445 Screening for sexually transmitted infections and counseling,• G0446 Intensive behavioral therapy for cardiovascular disease• G0447 Intensive behavioral therapy for obesity
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Medicare
Distant site physicians and practitioners submit claims for Telehealth services using the appropriate CPT or HCPCS code for the professional service along with the Telehealth modifier GT, “via interactive audio and video telecommunications system.
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Medicare
Originating sites are paid an originating site facility fee HCPCS Code Q3014. The originating site facility fee is a separately billable Part B payment.
Current fee is $24.24
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Telemedicine Reimbursement Medicaid
35 States Reimburse for Telemedicine
Alabama, Alaska, Arizona, Arkansas, California, Colorado, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming
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Texas Medicaid Reimbursement
Current Texas Medicaid
• Started reimbursing in 1998
• One of the first states in the country
• Must be “face to face” interactive video, no store and forward, except for Tele-radiology
• Patient site bills for a facility fee –• Code Q3014
• Must use GT modifier, indicating it was a telemedicine visit
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Texas Medicaid Reimbursement
•Eligible areas include:•Rural county – less than 50K
•Medically Underserved Area (MUA) or Medically Underserved Population (MUP)
• Patient Site Location•State hospital•State school•Physician office•Hospital•Rural Health Clinic (RHC)•Federally Qualified Health Center (FQHC)•Intermediate care facility for persons with mental retardation (ICF/MR) that is not a state school•Community Center as defined in Health and Safety Code 534.001 or outreach site associated with a community center•Local health department
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Texas Medicaid Reimbursement
•Patient site presenter:• Licensed or certified in this state to perform health care services
• Qualified mental health professional (QMHP)
•Eligible Medical Services• Consultations• Office or other outpatient visits• Psychiatric diagnostic interview• Pharmacologic management• Psychotherapy
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Private Payers
• States with government mandated legislation
• California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas, Virginia
• All prohibit payers from excluding services solely because they are delivered via telemedicine
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Private Payers Providers
Texas Insurance Code (Chapter 1455) generally requires health care coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment.
JUST BILL THEMJUST BILL THEM
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Self Pay
Patients are billed at a discounted rate similar to what they would be billed if seen in person
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TexLa Telehealth Resource Center
Telehealth Resource Centers (TRCs) are funded by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) Office for the Advancement of Telehealth, which is part of the Office of Rural Health Policy. Nationally, there are a total of 15 TRCs which include 12 Regional Centers, all with different strengths and regional expertise, and 3 National Centers which focus on areas of technology assessment, telehealth policy and technical assistance regarding State policies affecting the use and deployment of telehealth services.
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What does a TRC do?
TRC’s provide technical assistance to health care organizations, health care networks, and health care providers in the implementation of cost-effective telehealth programs to serve rural and medically underserved areas and populations
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TexLa TRC
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Primary ObjectivesTo provide telehealth technical assistance and resources to new and existing
telehealth programs throughout Texas and Louisiana
To evaluate telehealth programs in Texas and Louisiana for effective delivery of telehealth services, efficiency, sustainability, and patient satisfaction
To develop an interactive hands-on training center to provide guidance in telehealth planning, implementation, management and sustainability
To educate policy makers about legislative and regulatory barriers to the use of telehealth in Texas and Louisiana and work to improve reimbursement for telehealth services with CMS and third party payors
To collaborate with other regional TRCs to share resources as well as lessons learned to help promote best practices in telehealth across the United States
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Project Oversight
PI – Billy U. Philips, PhD, M.P.H Executive Vice President and Director The F. Marie Hall Institute for Rural and Community Health Texas Tech University Health Sciences Center
Co-PI – John Griswold, M.D, F.A.C.S Professor and Chairman, Department of Surgery Texas Tech University Health Sciences Center
Project Director – Debbie Voyles, M.B.A, H.O.M Director of Telemedicine The F. Marie Hall Institute for Rural and Community Health
Site Coordinator, LSU – Ted Lambert Telemedicine Program Coordinator Medical Informatics and Telemedicine Louisiana State University, Health Care Services Division
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Funding for Project
This project was made possible by grant number G22RH24748 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS.
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Texas Tech Telemedicine
Q&A
Contact information:
Debbie Voyles, MBA, HOM
TTUHSC Telemedicine
806-743-4440