3/27/2017. Historical Perspective. Innovative Model of Healthcare Delivery Using Telemedicine

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1 Innovative Model of Healthcare Delivery Using Telemedicine Vinita Kamath MS RDN MHA Clinical Director, Nutrition Therapy Cincinnati Children s Hospital Medical Center CNM Conference March 20, 2017 Outline Historical perspective Evolution of Telemedicine Basic concepts/definitions Licensure requirements and reimbursements HIPAA Reasons for considering telemedicine at Cincinnati Children s Steps to implementation Monitoring customer and provider satisfaction Future plans Historical Perspective First reference to Telemedicine was in 1950 Transmission of radiology images by telephone Major technology advances in have contributed to dramatic growth Increased number of people who embraced technology s integration with healthcare as they became more tech savvy by regularly using the internet 1

2 Evolution of Telehealth Information and Communication Technology Internet Telephone Face to Face Mobile Health Time Telehealth Telehealth is the use of electronic information and telecommunications technologies To support long distance clinical health care, patient and professional health related education, public health and health administration Telehealth includes The use of interactive, specialized equipment, for such purposes as health promotion, disease prevention, diagnosis, consultation, therapy and or nutrition intervention/plan of care, Non interactive (or passive) communications over the internet, or fax lines, video conferencing and other methods of distance communications for broad based nutrition information Academy of Nutrition and Dietetics Telehealth resources Telehealth Patient Cart Multiple Ways To Connect Desktop Unit Mobile Solutions 2

3 Telenutrition Involves the interactive use, by a RDN, of electronic information and telecommunications technologies to implement the Nutrition Care Process (nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care and nutrition monitoring and evaluation) with patients or clients at a remote location, within the provision of their state licensure as applicable. Academy of Nutrition and Dietetics Telehealth Resources Telemedicine and Telehealth Terms Used Interchangeably The American Telemedicine Association defines Telemedicine as the use of medical information exchange from one site to another via electronic communication to improve a patient s clinical health status Telehealth refers to broader definition of remote healthcare that does not always involve clinical services Telehealth Startup Resource Guide 2014 Two Types of Technology that Facilitate Telenutrition Real time communication Primary method of telenutrition when patient and provider are present at the same time but in different locations (3) Store and forward s and text messages 3

4 Licensing What You Need to Know Need to have a license in the state you are providing telenutrition Practicing across state lines? The originating site (the location of the patient) is considered place of service. If the current license is with a state of equal or higher standards, some state laws provide for reciprocity. Reciprocity may facilitate obtaining licensure but we are required to fill the form and pay the fee Licensure is required in the state the patient is located and in the state provider is located State Licensure Requirements Red: It is illegal to perform individualized nutrition counseling unless licensed or exempt. Effectively only RDs are eligible for licensure. Orange: It is illegal to perform individualized nutrition counseling unless licensed or exempt. There is a non RD pathway for licensure. Check for exemptions. Yellow: It is legal for all to perform individualized nutrition counseling. Effectively, only RDs are eligible for state recognition. Green: It is legal for all to perform individualized nutrition counseling. Center for Nutrition Advocacy State Map of Current Laws, 2017 Accreditation Standards Center for Medicare and Medicaid Services (CMS) conditions of participation (CoP s) Credentialed RDN s need to have telehealth added to the delineation of privileges document Interpretive Guidelines from (c) in hospital CoP When telemedicine is used when RDN and patient are in different states, the RDN must be licensed or meet the other applicable standards that are required by state or local laws in both states (where practitioner is located and the state where the patient is located) Practice Tips: Telehealth Challenges and Opportunities 2016 AND Telehealth Resources 4

5 Protection of Patient Information Compliance to Health Insurance Portability and Accountability Act (HIPAA), state, federal and facility regulations RDN s as a covered entity are required to adopt and maintain appropriate technical, administrative and physical safeguards to protect the confidentiality, integrity and security of Protected Health Information (PHI) Suitable systems in place to protect PHI from anticipated security threats Private practitioners using third party organizations or software platforms (business associates) must have a formal written agreement with them Standard operating procedures are needed for telemedicine services (5) Standard operating Procedures Logistic aspects of appointment scheduling, service payment, and reimbursement need to be considered Informed consent prior to delivering services HIPAA compliant web based booking and payment systems need to be used Workflow planning such as process for patients who arrive early or late and collection of fees before or after consultation Documentation of nutrition care (5) Technical Requirements The hardware such as webcam, microphone and speakers will influence the quality of video stream Physical space of the video consultation has implications for experience for the patient and practitioner Privacy and security of room for preventing unexpected access, background noise, lighting, colors Poor quality of video stream including disconnections can negatively impact the experience of both parties (5) 5

6 Telehealth Reimbursement Currently healthcare costs are paid by the following Private Insurers Medicare Medicaid Telehealth Reimbursement Private Insurance Varies significantly by insurance company and specific products/plan No federal legislation requiring private payer reimbursement of telemedicine services states are left to determine if and how they will regulate telehealth practice and reimbursement Twenty nine states have telemedicine parity laws that require private insurers to cover telemedicine provided services comparable to in person (4) Some private insurers value telemedicine and will reimburse wide variety of services Medicare Part B Allows Reimbursement for the Following Services Through Telehealth Medical Nutrition Therapy, Individual and group Diabetes self management training, Individual and group Intensive behavioral therapy for cardiovascular disease (must be billed by the primary care provider) Behavioral counseling for obesity (must be billed by the primary care provider) Annual wellness visit (must be billed by the primary care provider) Telehealth Services at and Guidance/Guidance/Manuals/downloads/bp102c15.pdf 6

7 Medicare Reimbursement For Medicare payment to occur, interactive audio and video telecommunication must be used, permitting real time communication between the distant site practitioner and the Medicare beneficiary. Originating site must be a medical facility not patient home As a condition of payment, the patient must be present and participating in the telehealth visit Medicaid Reimbursement Forty eight state Medicaid programs have some type of reimbursement for telemedicine (4) Must be first covered service by the state Medicaid program before the Medicaid program will reimburse when delivered via Telemedicine Practice of restricting service to rural or under served areas is decreasing Covering and Reimbursing Telehealth Services, January

8 Types of Services Reimbursed Service Facility Fee Live Video conferencing Originating site fee Transmission fee Remote patient monitoring , Fax or phone Reimbursement Fee paid to the originating site to compensate for the cost of facilitating a telemedicine visit The most frequently reimbursed service Fee paid to compensate for the cost of facilitating telemedicine visit Fee paid to telemedicine providers for the cost of telecommunications transmission Store and forward reimbursement most common restrictions include reimbursement to home health agencies, limit to patients with specific clinical conditions Rarely acceptable forms of delivery unless in conjunction with some other type of system (6) Current Procedural Terminology (CPT) Codes Each payer determines CPT codes they will recognize for reimbursement Medicare requires an addition of GT modifier code to indicate that the procedure was delivered via telemedicine Trends Shaping Telehealth Telehealth increasing access to care for population for which care was not available, providing convenience and eventually reducing cost Expansion of telemedicine from addressing acute conditions to also managing chronic conditions Migration of telehealth from hospitals and satellite clinics to the home and mobile device Impact on 140 million persons with chronic conditions that account for 80% of healthcare expenditures N Eng J Med 2016;375:

9 Cincinnati Children s CCHMC Licensed for 598 beds Employees Subspecialty clinics 32 Inpatient Short stay days 170,000 Outpatient including ED and urgent care 1.2 M visits CCHMC Network Eastgate Lindner Center Anderson Liberty Outpt Inpt Green Township College Hill Northern Kentucky Green Township The Start of our Journey Telemedicine Full time dietitian assigned to clinics at Green Township Productivity data indicated 20 30% utilization over one year Attempts at increasing referrals were not successful Decision made to bring the full time dietitian to fill a vacant position at base Eliminate dietitian position at Green Township Aware of the gap to fulfil intermittent dietitian consults at Green Township Partial Day Hospitalization Program Gastroenterology and Allergy clinic 9

10 Turned to Telemedicine to Fill the Gap Team organized consisting of staff from Center for Telehealth, patient services project manager and dietitians Designed work flow Pilot at Partial Health Program with Director of the unit at Green Township acting as a patient Trained dietitians and medical assistant at Green Township (one 45 minute session conducted by Center for Telehealth staff) to use Telehealth cart as well as laptop uploaded with Jabber software (remotely done) Work Plan Project goals and Objectives To improve the health and provide care for patients who are part of the Green Township Partial Day Hospital Program and GI Clinic by offering nutrition therapy consultations to enable them to obtain timely nutrition assessment/counseling through properly designed Telehealth interventions. For Implementation Time and Resources Needed Nutrition Therapy team met bi monthly from Oct 2015 Feb 2016 to plan/execute pilots Resources that need to be involved: Telehealth cart or laptops Information System's staff from Center for Telehealth to test connectivity to Green Township EPIC Informatics staff to create Telemedicine documentation template modified inpatient Epic template Med Staff champion 10

11 Telemedicine workflow Workflow Similar To In Person Nutrition Therapy Consults Consent obtained to do counseling through Telehealth Communication not face to face but sharing the same information Our Business Model The business model is cost savings by eliminating the need for a dietitian to travel to Green Township from another site for NT consults. Separate billing for nutrition therapy in partial hospital day program and gastroenterology/allergy clinic does not occur at this time, therefore in person services do not generate additional revenue. Saved RD salary 1.0 FTE Saved on travel cost 11

12 Lessons Learned Telehealth cart provides far superior picture and sound quality over a laptop Laptops with wired connection may work satisfactorily Need for a medical assistant to set up the patient at the clinic site Reimbursement not guaranteed as yet Printing capability needed for educational handouts being shared with the patient/family member at the clinic location Monitoring Patient/family and Provider Satisfaction Patient satisfaction surveys are administered as patient exits Provider satisfaction survey physician or health professional at the end of the counseling session Future Plans Track provider and customer satisfaction Expand Telemedicine Anderson Mason Liberty Township 12

13 Advantages of Telemedicine Take care of few and far between consults from a remote location Save on labor dollars Provide prompt service Patient convenience Forty percent of patients at University of Pittsburgh Medical Center (UPMC) would have foregone care rather than travel for a face to face visit Patient satisfaction scores at UPMC are 4.8 on a 5 point scale Butcher L Limitations of Telehealth and Potential Solutions Limitation Potential Solution Limited and fragmented reimbursement, Potential for excess healthcare utilization Lower quality patient provider relationship Fragmentation of care among multiple providers Social issues differential access to telecommunication s technologies Increase evidence base and show decreased utilization of expensive in person services Combine remote care with in person care, provide high definition telehealth carts Create integrated delivery systems facilitating information sharing among providers Provide underserved persons with smart phones or related technologies to increase access to care N Eng J Med 2016;375: Digital Divide Older population only 58 % of persons older than 65 use internetone of the lowest percentages of any single group Patients with lower income Less education Burden of chronic medical conditions among older US residents undermines the fundamental aim of telehealth to increase access to care N Eng J Med 2016;375:

14 Financial Implications At Oregon Health and Science University two way video consultation for 970 patients provided access to academic specialists Of the above 45% were able to stay in their home communities saving $ 6.4 million in transport costs to the Portland Medical Center At UPMC primary and urgent care provided on line saves $ every time a patient receives care compared to face to face, ED or urgent care clinic Butcher L Clinical Implications The Carolina Health Center successfully reduced hospital readmissions over 6 months covering 60 patients involving 165 virtual encounters from 19.4% in 2010 to 9.8% in 2013 Telehealth Start up Resource Guide version 1.1, October 2014 Why is Telemedicine Important Telemedicine can help achieve health care s triple aim developed by the Institute for Healthcare Improvement Of improving patient outcomes Improved access to care Cost savings As we move to population management, telemedicine makes a lot of sense financially! Telehealth Start up Resource Guide version 1.1, October

15 A new Opportunity for Dietetics Practitioner Telemedicine will allow us as dietetics practitioners to interact with patients virtually a new opportunity that is growing along with expanding mobile app market into the emerging practice area of remote nutrition counseling. Stein, K. JAND 2015: References 1. Academy of Nutrition and Dietetics. Definition of Terms. of practice. Accessed February The Role of Telehealth in an evolving Health care environment, Workshop summary, Institute of Medicine, Practice Tips : Telehealth Challenges and Opportunities AND 4. Dorsey at al. The state of Telemedicine. N Eng J Med 2016;375: Video Consultations and Virtual Nutrition Care for Weight Management. JAND 2015; 115: State Telehealth Laws and Medicaid Program Policies A Comprehensive Scan of the 50 States and District of Columbia March Butcher L. Telehealth and Telemedicine Today. Telemedicine 2015; May/June Blackman K, Covering and Reimbursing Telehealth Services. Legisbrief 2016; 24(4) Questions? 15