How Telemedicine Can Change How You Practice. Edward I. Galaid, MD, MPH ABIM, ABPM Medical Director, Occupational Health Partners Roper St.

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1 How Telemedicine Can Change How You Practice Edward I. Galaid, MD, MPH ABIM, ABPM Medical Director, Occupational Health Partners Roper St.Francis

2 Dr. Galaid has no conflicts of interest to declare.

3 Top Three Questions/Concerns 1. Can telemed change the way I practice for the good or is it just going to make my life complicated and affect the bottom line? 2. What kinds of clinical encounters can we do with telemed? 3. Oh, and by the way how do we get paid?

4 Agenda Survey of Attendees Top Three Questions/Concerns (1) Basics of Telemed: Scope, Concepts, Technology Form Follows Finance South Carolina Telemedicine Act (2016) Review of the literature Top Three Questions/Concerns (2) What s the future for telemed and primary care?

5 Scope for Primary Care Episodic Visit for care of acute illness Office Visit Equivalent for medical management of active diagnoses Record of Visit Integrated in EMR vs Isolated Encounter

6 Concepts for Primary Care Full Price DTC Retail vs Health Plan Benefit Pricing Issues: ERISA, Fair Market Value Synchronous vs Asynchronous Voice, Video, /Text Location where services provided

7 Technology Hardware generally not an issue Can do it inexpensively Can do it with generic equipment Can supplement with diagnostic instruments Software platforms may require specific hardware configurations or be agnostic

8 Examples of Hardware and Software Platforms

9 Littman TeleSteth CellScope OTO Cisco Jabber

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14 Direct-to-Consumer (DTC)

15 Direct-to-Consumer (DTC)

16 Direct-to-Consumer (2) Examples: Teladoc; American Well Cloud-based; frequently smart phone; but typically is hardware agnostic Retail price typically $49 Providers may or may not be affiliated with patient s primary care practice or system

17 Direct-to-Consumer (3) Some use APPs as well as physicians Providers typically do not have access to the EMR for read-only or to record visit Providers typically do not have access to diagnostic instruments Some vendors do forward summary of visit to patient s regular primary care clinician

18 Direct-to-Consumer Quality Issues Fragmentation of care is inevitable without access to the medical record. One informed corporate client has made its concerns known. Will DTC promote overutilization of services?

19 Investors appeared to be more interested in integrated programs rather than DTC.

20 South Carolina Telemedicine Act

21 SC Telemedicine Act (1) Doesn t explicitly require synchronous interactive audio-video communications technology but licensees must use technology sufficient to accurately diagnose and treat the patient in conformity with the applicable standard of care Licensee can establish a patient-physician relationship solely via telemedicine

22 SC Telemedicine Act (2) Physician can use a licensed HCP as a patient-side telepresenter to provide the physical findings that the physician may need to complete an adequate assessment. Must ensure the availability of appropriate follow-up care.

23 SC Telemedicine Act (3) Schedule II and III Drugs: Can t prescribe. Lifestyle medications (including ED drugs): Not permitted unless authorized by the Board Abortion-inducing drugs: Can t prescribe Earlier version of bill prohibited HRT, but it was deleted in the version that was voted on.

24 Form Follows Finance

25 Form Follows Finance 1. How could telemed affect my productivity and how much I make? 2. How does telemed relate to the finances of a healthcare system? 3. Is anyone making any money doing this?

26 Inconvenient Truth (1) As long as you ve taken call, and responded to patient phone calls after hours You ve been doing telemed. You probably haven t been paid to do it.

27 Inconvenient Truth (2)? NOW

28 Insurance and Telemed No true parity yet with the OV CPT Codes S.C. BCBS has a telemed CPT code. Pays $34 Medicare has the GT Modifier.? Only accepted in defined geographic areas

29 Q: Will a system like Roper evolve to this?

30 A: Probably, but when? While critics have said telehealth won t take off until payment models are realigned to reimburse providers

31 aspects of value-based care, including accountable care organizations and bundled payment programs are shifting risk to providers and compelling them to look at new platforms for care.

32 When you re given a specific amount of money to achieve a certain clinical outcome, there s a strong incentive to use telehealth. Bernard J. Tyson CEO, Kaiser Permanente

33 Review of the Literature

34 Bashsur RL, Howell JD, Krupinski EA, et al. Telemedicine and e-health 22:5, 2016 Cosmic Review of the Literature Focused specifically on primary care Initial search yield 2,308 articles 86 met inclusion criteria

35 Bashsur RL, Howell JD, Krupinski EA, et al. Telemedicine and e-health 22:5, 2016 Are studies from Western European healthcare systems generalizable to the U.S. Some studies occurred in high-performing populations making benefits difficult to detect, compared to control groups

36 Telemed Characteristics Reviewed Flexibility and Acceptance Health Outcomes Intermediate Outcomes Attendance Adherence Use of Service Cost

37 Examples of Studies Looking at Intermediate Outcomes #1 Adherence with protocols for URI and sinusitis improved antibiotic choices #2 Office visits reduced in Kaiser population by 11%; specialty care visits reduced by 6%; lab and radiology use unchanged #3 Discharge to a multidisciplinary telemed virtual ward team did not change readmit rates at 30, 60, 90, 180 days or at one year (Canadian RCT)

38 Examples of Studies Looking At Health Outcomes #1 Remote behavioral intervention/weight loss #2 Phone based optimized analgesic use among patients with risky drug use #3 Internet based educational program improved adherence in HTN medication, exercise, Na + control

39 Top Three Questions/Concerns 1. Can telemed change the way I practice for the good or is it just going to make my life complicated and affect the bottom line? 2. What kinds of clinical encounters can we do with telemed? 3. Oh, and by the way how do we get paid?

40 Integrating Telemed into Your Practice Acute illness vs chronic disease management Time requirements to do an telemed visit Transitioning between in-person and telemed during a routine work day Reimbursement parity

41 What s the Future for Telemed and Primary Care?

42 System-based primary care telemed will be driven by: Where we are on VBR vs FFS curve Parity with OV reimbursement Shared-risk relationships Integration with telemed services provided elsewhere in the organization

43 Some last thoughts Many who could benefit most from telemed have limited resources to access it Telemed is a potentially inexpensive way to triage Telemed can improve primary care by improving access to other services

44 Workplace School

45 Cancer Patient Education Diabetes Education

46 Behavioral Health Medical Nutrition Therapy

47 From The Jetsons first aired January 25, 1962

48 Science and Invention Magazine, 1925

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