Telemedicine: Transforming the Delivery of Healthcare

Debbie Voyles, MBA HOMDirector of TelemedicineF. Marie Hall Institute for Rural and Community Health

June 2013

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

• 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:

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

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

Is this the Future of Healthcare?

Health Professional Shortage Areas

HPSA – Mental Health Designated Populations

HPSA – Dental Health Designated Populations

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

Family Practice Physicians in Rural Counties

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

Dentists in Rural Counties

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

We know a need exists

If we can dream it – we can do it!

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!

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!

Three Links to Effective Telemedicine

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

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

Telemedicine Components

• Equipment standardization

• Peripherals• Otoscope• General Exam Camera

• Dermatology

• Burn Care

• Wound Care

Stethoscope

Color Printer

Telemedicine Components

Digital - Electronic Stethoscope

General Exam Camera

Fiber Optic Otoscope

Electrocardiogram (ECG)

Emerging Technology Applications

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

Telemedicine Philosophy

• Telemedicine does not alter the practice of medicine.

• It is only a tool.

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

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

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

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

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

Licensure

• State licensing – does not require a different license

• Physician must be licensed in the same state the patient is located

• Federal licensing proposal

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

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

Telemedicine Reimbursement

•Medicare

•Medicaid

•Third-Party

•Private Pay

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)

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

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)

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)

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

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.

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

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

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

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

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

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

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

Self Pay

Patients are billed at a discounted rate similar to what they would be billed if seen in person

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.

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

TexLa TRC

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

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

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.

Texas Tech Telemedicine

Q&A

Contact information:

Debbie Voyles, MBA, HOM

TTUHSC Telemedicine

debbie.voyles@ttuhsc.edu

806-743-4440