Telemedicine SW Clinical Society

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Telemedicine, Today and TomorrowDavid Voran, MDSouthwest Clinical Society Kansas City, 10/29-31/2015

http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society

+Agenda and Objectives

Review the status of telemedicine globally and locally Legislative, reimbursement initiatives, interstate

licensing and ACA effect Examine newer technologies and services available to

clinicians Make some projections

http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society

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Where is telemedicine today?… an update of sorts

Objective 1

http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society

+Growth Types in Telemedicine

Traditional hub and spoke telemedicine encounters increasing organically Over 200 networks with 3,500

service sites in US Over half of US hospitals

using some form of telemedicine

Adding more spokes Specialty driven telemedicine

expanding primarily in ED’s Provider-to-Provider

consultation

Retail telemedicine pilots are expanding and gaining traction

Portal-based telehealth services are normal part of practice

Direct to consumer services popping up spurred by ACA

Organic – Logarithmic Inorganic - Exponential

+Telehealth Growth Curve

HIS Telehealth Report 2014

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Organic Growth continues in Hub and Spoke NetworksAvera eCare

+Expanding Telemedine’s reach:In-House TelemedicineNebraska Medical Center

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eVisits Booming“Almost one in six doctor visits will be virtual this year”

Up 400% since 2012

eVisits have … saved UPMC an average of $86.80 per member visit compared with the cost of an office visit

This year [2014] in the U.S. and Canada, 75 million of 600 million appointments with general practitioners will involve electronic visits, or eVisits

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Medical Centers Jumping In

+ Mid-Level Telemed “Load Balancing”

CVS Minute Clinic Experience California

Off loading volume to remote APRNs Lower level LPN performs registration and

hands on Remote APRNs are MC providers in the same

state who are in-between live patients Over 4,000 visits in last year Reimbursement same as face-to-face Survey results (1,700 patients)

33% prefer video to face-to-face, 50% liked it about the same and 10% found it worse

+Retail Telemedicine Expansion

Collaborative Coverage Physician shortages Rate limiting steps

Chronic condition management Cooperation with IDN CCM reimbursement not

dependent on face-to-face visits

Increasing range of services Beyond APRN scope of

practice Clinic expansions

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Kicking it up a notchLooking at where telemedicine industry is really heading

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Telemedicine Studio in your Pocket

Nearly every smart phone owner has more resolution, bandwidth and capability than all telemedicine facilities built in the 1990’s.

How many of you do

telemedicine?

+Daily “telemedicine”

Phone messages Patient Portal eVisits Retail direct-to-consumer

Low cost answers to questions

Phone conversations Peer based

videoconferencing Face Time Skype

Retail direct-to-consumer Most by phone Maybe 10% video

Asynchronous Synchronous

+My own experience with e-Visits using Vgo Robot Inexpensive, ad-hoc use of

mobile systems

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Dabbling in Retail VisitsSigned up with HealthTap

+Other developments

75% of large employers would be offering telemedicine benefits for employees within the next year

57% of broadband households access at least one portal per month

ACA health plans are or will be offering telehealth coverage in most plans

Health insurers offering their own telehealth or video consults for enrollees

mHealth use expanding Most new devices capable

of measuring some health parameters

+Telemedicine Savings

Would require all employees and dependents to use technology-enabled interactions in lieu of face-to-face visits

37% employers will offer telemedicine consultations in 2015

> 80% of insurance providers to offer telemedicine reimbursement by 2019

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Legislative Updates and Initiatives… still struggling with “what IS is”

Objective 2

Legislative Arena

+Medicaid.gov

Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.

Means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.

Asynchronous or “store and forward” applications would NOT be considered telemedicine but may be utilized to deliver services.

+HIPAA

Does NOT consider an interactive video consultation to be protected health information, so it does not govern telemedicine encounters.

Not considered PHI unless it’s recorded.

Device encryption and a private internet connection are recommended for patient security and privacy.

Most videoconferencing tools are encrypted.

Other types of telehealth, such as the transmission of patient data or images, ARE considered protected health information and must be managed according to HIPAA requirements.

Fine line between real-time video transmission and the same interaction that is being stored.

+Medicare Reimbursement

Performed By Physician Nurse Midwife Clinical Psychologist Registered Dietitian Clinical Social Worker

Originating Site (Patient) Office (Physician/NPA) Hospital Critical Access Hospital Renal Dialysis Federal qualified health

center Skilled Nursing Facility Community Mental Health

Center

Charges E&M + Facility ($24.24)

HCPCS Q3014 Type of Service “9, other

items and services”

+Legislative Action

Fostering Independence Through Technology Act Sens. Amy Klobuchar (D-Minn), John Thune (R-S.D.)

TELEhealth for MEDicare (TELE-MED) Act of 2013 Reps. Devin Nunes (R-Calif) and Frank Pallone (D-N.J) HR 3077

H.R. 5380 creates a phased approach over four years to expand coverage of telemedicine-provided services and remove arbitrary barriers that limit access to services for Medicare beneficiaries. Included in these provisions are the gradual removal of geographic restrictions to patient care, and the addition of coverage for healthcare services that take place in other locations such as the home and walk-in retail health clinics

+Federation of State Medical Boards Interstate Medical Licensure Compact

Expedited license Recognized by all member states Compliments, does not replace existing State

licensure

Interstate Medical Licensure Compact Commission Administrate physicians applying for this type

of license

Spearheaded by Wyoming State Board of Medicine Requires a minimum of 7 states to participate Looking to form in 2016

+Available Guidelines

Formal Policies and Procedures Guidelines and Consensus

Documents Operational Procedures Foundation for formal deployment

American Telemedicine Association

+Telehealth Grades for States

+States with Telemedicine Parity

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What’s Happening Around Here?…probably more than most of us realize

Local Activity

KU Center for Telemedicine &

Telehealth

+Report Cards 2014

+2015 Grades

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KU Med Telemedicine Overview

Eve-Lynn Nelson, PhDDirector, Center for Telemedicine & TelehealthProfessor, Pediatrics(913) 588-2413enelson2@kumc.edu

+Kansas

Medicaid covered some TM services since 2004 Physician, Psychotherapy,

Pharmacological management – GT modifiers

Requires patient to be present at originating site

Requires State Licensure

Kansas Center for TeleMedicine & T

eleHealth Kansas Medical Center 60 nodes 4,500 (1,500 unique pts)

Become more research oriented Dependent on grants

Exploring using system to provide urgent care for whole state

+KU Center for Telemedicine and Telehealth Approximately 4,000

consults per year across 40 providers

Behavioral consults most common

Traditional model in supervised settings

Team-based services with trainee participation

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Kansas iCare

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Project Echo MissionTo expand the capacity to provide the best practice care for common and complex diseases in rural and underserved areas and to monitor outcomes

Extension for Community Health Outcomes

+Missouri

HB 986 – prohibits plans from denying telehealth coverage and reimbursement (7/2013)

Covers services that would have been delivered in-person

Mo-Healthnet requires 2-way interactive video

No restrictions on type of technology being used No store and foreward

reimbursement Require prior face-to-face physical

exam

Defined clinical locations Hospital, CAH Rural Health Clinic Federally Qualified HC Nursing Home Dialysis Center Mo State Rehab Center Community Mental Health

Requires State Licensure Missouri Telehealth Network

University of Missouri, Columbia 202 node MOREnet 2 gigabit

backbone

Missouri

+Missouri Telehealth Network

Psychiatry47%

Dermatology19%

Autism19%

Ped En-docrinology

5%

Neurology4%

Other5%

2011-2012 Encounters

+Why Isn’t Telemedicine the Norm?

TM visits reimbursed at lower rates than face-to-face visits

RVU based productivity Parochial nature of

medicine Site-specific credentialing State licensing

requirements

Store-and-forward prohibition

Scheduling issues Culture of convenience

E-mail, texting favored over synchronous communication

Regulatory and Reimbursement Logistics and Culture

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The Future of Telehealth…where it becomes personal

Objective 3

+ Activity tracking devices + Apps Fitbit, Fuel band, Vivofit, Gear

Biometric monitors External

Implanted medical devices

Quantified Self Movement

+Game Changers

Devices (moving out of the exam room) AliveCor ECG Cellscope Proscope Fitbit

Services Cloud based storage and sharing Multimedia Patient Portals Embedded video conferencing Communities (Fitbit)

FDA approved mobile apps and devices.Selling to patients directly.

Allowing them to record and share with physicians, family and friends…pushing cost and control to patients (Consumer Directed Care)

+iOS Health KitApple WatchHealthcare embedded into operating systemsEnhancing real time researchOpenning door to real-time clinical population monitoring and intervention

Will the exam room survive?

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+Convenience +Coverage+Consumerism

Time Magazine, November 9, 2015

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+Convenience +Coverage+Consumerism

Time Magazine, November 9, 2015

+Forecast: Telemedicine Potential

Operational costs of clinics and hospitals become unsustainable

Reimbursement paradigm reaches inflection point Telemonitoring capabilities embedded in all devices Adequate universal spectrum

When…

…we’re close

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Will we be ready?

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