The Role of Telehealth Resource Centers and Telemedicine Outcomes/Collaborations/Successes March 24, 2014

1. The Role of Telehealth Resource Centers and Telemedicine Outcomes/Collaborations/SuccessesMarch 24, 2014 Becky Sanders Program Director Upper Midwest Telehealth Resource Center

2. Agenda • Telehealth Resource Centers • Upper Midwest Telehealth Resource Center • Overview of National Telehealth Landscape • Outcomes/Collaborations/Successes • Illinois Legislative Resources • Upcoming UMTRC activities

4. telehealthresourcecenters.org • Links to all TRCs • National Webinar Series • Reimbursement, Marketing, and Training Tools

8. Definitions and Concepts • Telehealth and Telemedicine • Sometimes used interchangeably • Two types of distinctions - • Telemedicine = billable interactive clinical services • Telehealth = • Broader field of distance health activities (CME, etc.) • Clinical remote monitoring (usually at home)

9. Service vs. Delivery Mechanism TH is not a service, but a delivery mechanism for health care services Most TH services duplicate in-person care Some are made better or possible with TH Reimbursement equal to “in-person” care

10. Three Basic “Types” or Domains • Hospitals & Specialties • Specialists see and manage patients remotely • Integrated Care • Mental health and other specialists work in primary care settings (e.g., PCMHs, ACOs) • Transitions & Monitoring • Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care

11. Federal Telemedicine Law & Policy • Professionals are regulated at the state level (doctors, nurses, counselors, etc.) • Medicare: Pays for certain outpatient professional services (CPT codes) for patients accessing care in rural counties and HPSAsin rural census tracts. • *No regs; only conditions of payment. • Medicaid: Telemedicine is “a cost-effective alternative to the more traditional face-to-face way of providing medical care…that states can choose to cover.”

12. Federal Updates • Effective 1/1/2014 Medicare expanded telehealth eligibility to include authorized originating sites located in rural Health Professional Shortage Areas (HPSAs) • Refer to the Office of Rural Health Policy’s (ORHP’s) rural definition. • All non-MSA counties continue to be eligible.  In addition, sites in designated HPSAs located in rural census tracts within urban (MSA) counties are also eligible originating sites.  

13. Federal Updates • Eligibility will be determined annually based on an authorized originating site’s status on December 31 of the previous year. • New web tool for authorized Medicare telehealth originating sites to check their geographic eligibility, as well as to update rural areas using 2010 Census data.   • http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

14. National Landscape • National Focus on Outcomes • Especially for HRSA Grantees • Triple Aim* • Improve Patient Experience • Improve Population Health • Reduce Costs • Diabetes, CHF, COPD • CMS National Health Expenditure Data projects healthcare costs in the US at 19.9% of the GPD by 2022 • * Developed by the Institute for Healthcare Improvement

15. Collaborations • What are your current referral patterns? • Could they become your partners for providing better patient care? • Do you have standardized processes and procedures? • Do you have a physician champion?

16. Collaborate - Think LEAN • LEAN • Maximize customer value while minimizing waste • Toyota Production System • Critical Access Hospital CEO Perspective • Telehealth Director Perspective • In Healthcare Speak • Improve patient experience (and health) while reducing costs • Focus on workflow • How can technology (telehealth) be used further improve workflow

17. Collaborate - Program Development • Assess & Define • Step 1: Assess Service Needs & Environment • Asses service needs • Identify potential telehealth opportunities • Assess organizational readiness • Step 2: Define Program Model • Consider the type of program that will meet needs • Step 3: Develop Business Case • Determine that impact of the proposed telehealth program • *CTEC Telehealth Program Developer Kit

18. Collaborate - Program Development • Develop & Plan • Two steps support fully defining the activities necessary for program implementation • Step 4: Develop and Plan Program & Technology • Create a detailed project plan • Step 5: Develop Performance Monitoring Plan • Define monitoring and evaluation mechanisms and program improvement process

19. Collaborate - Program Development • Implement & Monitor • The final two steps support implementation and ongoing monitoring • Step 6: Implement Telemedicine Program • Perform all the work required to implement the program • Step 7: Monitor and Improve Program (ongoing) • Collect data • Monitor performance

20. Successes • Hospitals & Specialties • Specialists see and manage patients remotely • Teleradiology – is often just called radiology • Telepharmacy – often evening and weekend care • Telestroke • Telecardiology • Tele-ICU • Maternal & Fetal Medicine • Sleep studies • Video Therapy in group homes

21. Successes • Integrated Care • Mental health and other specialists work in primary care settings (e.g., PCMHs, ACOs) • Telepsychiatry

22. Successes • Transitions & Monitoring • Patients access care (or care accesses patients) where and when needed to avoid complications and higher levels of care • Population Health • Health Coaching • Iowa Chronic Care Consortium • 200 rural Iowa Medicaid members with high risk diabetes

23. Successes • Patient Monitoring Methods • Patient enters data • Integrated Voice Response Systems • Web based systems • Smart Phone/Tablet Apps • Smart device collects data & sends it to central database • Vital sign monitoring • Blood pressure, oxygen saturation, pulse, weight, glucose levels, temperature, and electrocardiogram data

24. Outcomes • From an urban hospital perspective • Specialist is more productive • From a physician perspective • Especially one who has been doing rural rotations • Reduced windshield time • More productive

25. Outcomes • From a rural hospital perspective • Retains ancillary labs, x-rays, etc. • From a patient perspective • Remember the Triple Aim (better patient experience)! • Less time off work • Less drive time • More convenient

26. In The News • American Well • See a doctor anytime, anywhere from your phone or tablet • Healthspot • Private Pods with digital monitoring devices • New Hampshire bill would offer patients financial incentives for choosing telemedicine • $25 or 25%, whichever is higher • Florida TaxWatch • Telemedicine Can Save Florida $1 Billion Annually

31. National Legislative Overview • Medicaid has some sort of telemedicine reimbursement in 45 states • The 5 that do not are Iowa, Massachusetts, New Hampshire, New Jersey, Rhode Island • 15 states are reconsidering legislation that was introduced in 2013 • Telehealth Parity Bills • Florida, Illinois, Massachusetts, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Washington • National Telehealth Policy Resource Center • http://telehealthpolicy.us/state-laws-and-reimbursement-policies

33. Illinois Legislation • House Bill 5315/Senate Bill 3319 • Telehealth Act • The act provides that telehealth services consist of (1) the provision of services and the mode of delivering health care services, and (2) as it relates to the delivery of health care, mental health care, or substance use disorder treatment.  It also amends the Illinois Insurance Code and sets forth requirements concerning the coverage of telehealth services.

34. Illinois Licensure Law • Licensure Requirements: Temporary, visiting professor, visiting physician, visiting resident, or full medical license required. • Reciprocity: The Illinois Licensure Statute does allowreciprocity with states where the licensure requirements are substantially equivalent. • Exceptions allowed for emergencies and purely consultative services. • “Internet Prescribing” – History of revoked licenses due to prescribing via online form only.

35. Illinois Telemedicine Definition - I • Telemedicine means the performance of any of the activities listed in Section 49, including but not limited to rendering written or oral opinions concerning diagnosis or treatment of a patient in Illinois by a person located outside the state as a result of transmission of individual patient data by telephonic, electronic, or other means of communication from within this State. • 225 ILL. COMP. STAT. ANN. 60/49.5(c).

36. Illinois Telemedicine Definition - II • “Telemedicine” is the use of a telecommunication system to provide medical services for the purpose of evaluation and treatment when the patient is at one medical provider location and the rendering provider is at another location. • IL Admin. Code, Title 89 ,140.403 (2012).

37. Illinois Medicaid Policy • Telehealth is defined as the use of a telecommunication system to provide medical services…for the purpose of evaluation and treatment. Medical data exchanged can take the form of…text, graphics, still images, audio and video. The information or data exchanged can occur in real time (synchronous) through interactive video…or in near real time (asynchronous) through “store and forward” applications. • HFS Informational Notice, Expansion of Telehealth Services, January 12, 2010.

38. Illinois Medicaid Reimbursement • Medicaid Reimbursement (January 29, 2010) • Hospitals, physicians, APNs, podiatrists, FQHCs, RHCs, and Encounter Rate Clinics can participate. • Telepsychiatry(after completed residency) with form HFS 3882 on file. Group treatment not covered. • Originating site paid $25 (service code Q3014) • Distant site paid per CPT or encounter rate (HCPCS Code T1015) with “GT” modifier • Encounter rate clinic is payee whenever it is involved in a telemedicine encounter • http://www.hfs.illinois.gov/html/011210n2.html

39. Illinois Medicaid Reimbursement • Originating Site Requirements • For telemedicine services, a physician or other licensed healthcare professional must be present at all times with the patient at the Originating Site. • For telepsychiatry services, a physician, licensed healthcare professional or other licensed clinician, mental health professional (MHP), or qualified mental health professional (QMHP), as defined in 59 IL Admin Code 132.25, must be present at all times with the patient at the Originating Site. • Reimbursable sites:physician’s office, podiatrist’s office, local health departments, community mental health centers and outpatient hospitals.

40. Illinois Medicaid Reimbursement • Other Factors • Only enrolled providers can be reimbursed • Non-enrolled providers may be reimbursed by originating sites (though not by HFS) • Originating sites that reimburse providers must ensure and document that requirements are met for Distant Site providers • No telemedicine reimbursement for non-medical mental health providers

41. Home Health Care Certification Section 140.471  Description of Home Health Care Services d)         Effective July 1, 2012, to be eligible for reimbursement by the Department, initial certification of intermittent skilled nursing services or therapy services must have documentation that a face-to-face encounter was conducted by the practitioner requesting services.  • 1)         The physician responsible for performing the initial certification must document that the face-to-face patient encounter…has occurred no more than 90 days prior to the home health start of care date or within 30 days after the start of the home health care… 2)         The face-to-face encounter must be performed by the certifying physician, a nurse practitioner, etc. • C)        The face-to-face patient encounter may occur through telehealth, in compliance with Section 140.403.

42. Telemedicine Privileging for Hospitals IL Administrative Code 250.310 The medical staff shall be organized in accordance with written bylaws, rules and regulations approved by the governing board. The bylaws, rules and regulations shall specifically provide but not be limited to: 17) establishing a procedure for granting telemedicine privileges, based upon the privileging decisions of a distant-site hospital or telemedicine entity that has a written agreement that meets Medicare requirements;

43. Occupational Therapy Tele-practice • HB 2996 – Public Act 098-0264 “Occupational therapy may be provided via technology or telecommunication methods, also known as telehealth, however the standard of care shall be the samewhether a patient is seen in person, through telehealth, or other method of electronically enabled health care.” http://www.ilga.gov/legislation/publicacts/98/PDF/098-0264.pdf

45. UMTRC Resources • IL Telemedicine Reimbursement Summary: • http://www.umtrc.org/resources/payers-reimbursement/2013-illinois-telemedicine-reimbursement-summary/?back=Resources

46. UMTRC Services • Presentations & Trainings • Consultation • Technical Assistance • Connections with other programs • Program Design and Evaluation • Information on current legislative and policy developments • www.umtrc.org/events

48. Certificate Training • ATA Annual Conference • Full day pre-meeting course • Telemedicine 101 • National School of Applied Telehealth • Certified Telemedicine Clinical Presenter • Certified Telehealth Coordinator • Certified Telehealth Liaison

50. Contact Information • Becky Sanders • (812) 478-3919, ext. 232 • bsanders@indianarha.org