Telemedicine: Improving Access to Specialty Care in Wisconsin s Rural Communities David Guggenbuehl, RN, MBA, Director Jessica Miller, RN, Telemedicine Program Manager Department of Regional Services and Telemedicine 2 1
Gundersen Health System is: A comprehensive healthcare network including one of the nation's largest multispecialty group medical practices, teaching hospital, regional community clinics, affiliate hospitals and clinics, behavioral health services, vision centers, pharmacies, and air and ground ambulances. A physician led, not for profit healthcare system Located throughout western Wisconsin, northeastern Iowa and southeastern Minnesota caring for patients in 19 counties Able to meet patients' needs for primary and specialized care Comprised of more than 700 medical, dental and associate staff Supported by a staff of more than 5,500 A tertiary referral center A teaching hospital with 325 beds and a Level II Trauma and Emergency Center Gundersen Health System Statistics for 2015 Licensed Beds 325 Average Set up and Staffed Beds 268 Average Length of Stay 4.42 Average Daily Census 174 Number of Inpatient Admissions (excludes newborns) 14,384 Newborns (live births) 1,503 Inpatient Days 63,553 Newborn Days 5,346 Annual Emergency Services Visits 44,395 Annual Inpatient Surgery Cases 4,646 Annual Outpatient Surgery Cases 13,020 Number of Outpatient Visits (Clinic) 1,000,584 Number of Outpatient Visits (Hospital) 197,270 * Includes principal affiliates Gundersen Clinic, Ltd. and Gundersen Lutheran Medical Center, Inc. 2
Gundersen Health System Statistics as of February 2016 Gundersen Health System Regional Specialty Services Over 46 Specialty Services Over 188 Specialty Providers Over 65 Locations Total patients seen in 2015 46,949 3
History Great Race of Mercy 4
Alaska Kiana Selawik 5
6
7
American Telemedicine Association Defines Telemedicine Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient s clinical health status. Telemedicine includes a growing variety of applications and services using two way video, email, smart phones, wireless tools and other forms of telecommunications technology. Telehealth is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth. http://www.americantelemed.org Key Definitions Synchronous Telemedicine Real time live video interaction between a patient and their provider. 8
Key Definitions Asynchronous Telemedicine The store and forward transmission of medical images and/or clinical data from one site to another. The data transfer takes place over a period of time. The transmission typically does not take place simultaneously. This is the opposite of synchronous or real time interaction. Key Definitions Tele presenter The presenter is an individual, located at the patient site that provides support to the patient and the telemedicine consulting provider, in completing the physical examination and/or telemedicine activity. 9
Key Definitions Originating Sites An originating site is the location of an eligible Medicare beneficiary at the time the service furnished via a telecommunication systems occurs. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in: A rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or A county outside of a MSA. As a condition of payment, you must use an interactive audio and video telecommunications system that permits real time communication between the provider, at the distant site, and the beneficiary, at the originating site. Asynchronous store and forward technology is permitted only in Federal telemedicine demonstration programs in Alaska and Hawaii. Source: Department of Health and Human Services, Centers for Medicare & Medicaid Services December, 2015 Key Definitions Originating Sites Authorized by Law: The offices of physicians or practitioners Hospitals Critical Access Hospitals (CAHs) Rural Health Clinics Federally Qualified Health Centers Hospital based or CAH based Renal Dialysis Centers (including satellites) Skilled Nursing Facilities (SNFs) Community Mental Health Centers (CMHCs) Note: Independent Renal Dialysis Facilities are not eligible originating sites. 10
Key Definitions Distant Site Practitioners Practitioners at the distant site who may furnish and receive payment for covered telehealth services (subject to State law) are: Physicians Nurse Practitioners (NPs) Physician Assistants (PAs) Nurse midwives Clinical Nurse Specialists (CNSs) Certified Registered Nurse Anesthetists Clinical Psychologists (CPs) and Clinical Social Workers (CSWs). CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838; and Registered Dietitians or Nutrition Professionals Billing and Payment Distant Site Practitioners Practitioners at the distant site who may furnish and receive payment for covered telehealth services (subject to State law) are: Physicians Nurse Practitioners (NPs) Physician Assistants (PAs) Nurse midwives Clinical Nurse Specialists (CNSs) Certified Registered Nurse Anesthetists Clinical Psychologists (CPs) and Clinical Social Workers (CSWs). CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838; and Registered Dietitians or Nutrition Professionals 11
Billing and Payment Numerous CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System) Codes are approved for CMS billing Codes must include a GT modifier via interactive audio and video telecommunication systems Originating Site Facility Fee Additional HCPCS Code Q3014 is a separately billable Part B payment Wisconsin Reimbursement for Telemedicine Reimbursable Telemedicine Services The following individual providers are reimbursed for selected telemedicine based services: Physicians and Physician Clinics RHCs FQHCs Physician Assistants (PAs) Nurse Practitioners (NPs) Nurse midwives Psychiatrists in Private Practice Ph.D. Psychologists in Private Practice These providers may be reimbursed, as appropriate, for the following services provided through telemedicine: Office or other outpatient services (CPT procedure codes 99201 99205, 99211 99215) Office or other outpatient consultations (CPT codes 99241 99245) Initial inpatient consultations (CPT codes 99251 99255) Outpatient mental health services (CPT codes 90801 90849, 90862, 90875, 90876, and 90887) Health and behavior assessment/intervention (CPT codes 96150 96152, 96154 96155) ESRD related services (CPT codes 90951 90952, 90954 90958, 90960 90961) Outpatient substance abuse services (HCPCS codes H0022, H0047, T10066) Reimbursement for these services is subject to the same restrictions as face to face contacts (e.g., POS allowable providers, multiple service limitations, PA). 12
Telemedicine Parity Laws http://americantelemed.org Licensure Current state law requires that the provider be licensed in the state where the patient is located. The Interstate Collaboration in Healthcare Stakeholder Group is aggressively pursuing reciprocity between states. 13
Credentialing By Proxy Telemedicine Rules Adopted for Hospitals/CAH s: New and amended rules effective July 5, 2011 permit hospitals and CAH s to provide telemedicine services to their patients through written agreements with a distant hospital or distantsite telemedicine entity. Streamlined Credentialing & Privileging for Telemedicine Physicians & Practitioners. Hospitals and CAH s may rely, when granting telemedicine privileges, upon the privileging decisions of the distant site hospital or telemedicine entity with which they have a written agreement that meets Medicare requirements *Center for Medicaid, CHIP, and Survey & Certification/Survey & Certification Group Contracting Contracts are established with independent hospitals and clinics It is best to have agreements in place when providing services outside your own system 14
Gundersen Health System Services 15
Travel by vehicle in our region 16
Outcomes are less predictable l GUNDERSEN HEALTH SYSTEM REGIONAL AIR MILES Eau Claire 75 Miles Stanley Service Area population approximately 600,000 Marshfield Mondovi Osseo Durand Lake City BUFFALO 50 Miles Neillsville Whitehall JACKSON Wabasha Black River WABASHA Falls Arcadia TREMPEALEAU 25 Miles WINONA MONROE Rochester Winona LA CROSSE JUNEAU Friendship MINNESOTA Tomah Sparta Onalaska Mauston HOUSTON La Crosse FILLMORE Spring Valley Caledonia Hillsboro VERNON Harmony Spring Grove Viroqua Reedsburg HOWARD IOWA Cresco WINNESHIEK Decorah West Union FAYETTE RICHLAND Waukon Richland Center ALLAMAKEE CRAWFORD Postville Prairie du Chien Boscobel Madison CLAYTON GRANT WISCONSIN Elkader Minnesota Wisconsin Oelwein Guttenburg Lancaster Platteville Waterloo Iowa Dubuque Cedar Rapids S:Maps.12.2.15 Service Area Map Department of Regional Services & Telemedicine 17
GUNDERSEN HEALTH SYSTEM Stanley Eau Claire 75 Miles Greater La Crosse metro population approximately 120,000 Marshfield Mondovi Osseo Durand Lake City BUFFALO 50 Miles Neillsville Whitehall JACKSON Wabasha Black River WABASHA Falls Arcadia TREMPEALEAU 25 Miles WINONA MONROE Rochester Winona LA CROSSE JUNEAU Friendship MINNESOTA Tomah Sparta Onalaska Mauston HOUSTON La Crosse FILLMORE Spring Valley Caledonia Hillsboro VERNON Harmony Spring Grove Viroqua Reedsburg HOWARD IOWA Cresco WINNESHIEK Decorah West Union FAYETTE RICHLAND Waukon Richland Center ALLAMAKEE CRAWFORD Postville Prairie du Chien Boscobel Madison CLAYTON GRANT WISCONSIN Elkader Minnesota Wisconsin Oelwein Guttenburg Lancaster Platteville Waterloo Iowa Dubuque Cedar Rapids S:Maps.12.2.15 Service Area Map Greater LaX Pop (Dave) Department of Regional Services & Telemedicine GUNDERSEN HEALTH SYSTEM 75 Miles Eau Claire Stanley Rural population approximately 480,000 Marshfield Mondovi Osseo Durand Lake City BUFFALO 50 Miles Neillsville Whitehall JACKSON Wabasha Black River WABASHA Falls Arcadia TREMPEALEAU 25 Miles WINONA MONROE Rochester Winona LA CROSSE JUNEAU Friendship MINNESOTA Tomah Sparta Onalaska Mauston HOUSTON La Crosse FILLMORE Spring Valley Caledonia Hillsboro VERNON Harmony Spring Grove Viroqua Reedsburg HOWARD IOWA Cresco WINNESHIEK Decorah West Union FAYETTE RICHLAND Waukon Richland Center ALLAMAKEE CRAWFORD Postville Prairie du Chien Boscobel Madison CLAYTON GRANT WISCONSIN Elkader Minnesota Wisconsin Oelwein Guttenburg Lancaster Platteville Waterloo Iowa Dubuque Cedar Rapids S:Maps.12.2.15 Service Area Map Rural Population (Dave) Department of Regional Services & Telemedicine 18
Initial Phase of Infrastructure Development Develop wide geographic distribution of Telemedicine services at both Gundersen Health System and non Gundersen Health System sites 19
Initial Phase of Clinical Services Development Achieve growth in number of specialties, services, and providers offering a clinical Telemedicine option for their patients Current Active Services Bariatric Surgery Behavioral Health Cardiology Cardiovascular Surgery Dermatology Diabetes Education Endocrinology Family Medicine (Decorah/Muscoda) Fertility General Surgery Genetics Hematology Interventional Radiology Medical Oncology Nephrology Neonatology Neurology Nutrition Services Orthopedic Surgery Palliative Care Pediatric Allergy Pediatric Cardiology Pediatric Critical Care Pediatric Hematology/Oncology Pediatric Surgery Podiatry Radiation Oncology Rheumatology Telestroke Vascular Surgery 20
Advancing into Target Markets To develop service specific clinical Telemedicine Programs to improve access, extend specialty care, and enhance referral base 21
Target: Critically Ill Newborns in Critical Access Hospitals Gundersen Health System NeoNET Active Currently Active by end of 2016 Potential Sites Eau Claire Neillsville Whitehall Black River Falls MINNESOTA Winona Tomah Friendship Onalaska La Crosse Mauston Viroqua Hillsboro Reedsburg Cresco Decorah Waukon Richland Center IOWA Prairie du Chien West Union Boscobel WISCONSIN S:Regional Service/NeoNET Services/NeoNET MAP. 2015 Revised 6/9/2016 22
Utilizing Resources to Gain Efficiencies To reduce travel and costs associated with transport of inmates from Wisconsin Department of Corrections Facilities in Western Wisconsin 23
WDOC Volume Growth Wisconsin Department of Corrections Volumes GHS 3500 3000 2,949 2500 Volumes 2000 1500 1,719 1000 599 500 237 23 0 Aug Dec 2011 2012 2013 2014 2015 Series1 23 237 599 1,719 2,949 24
Achieve Market Growth To realize progressive and sustainable expansion in patient transmission volumes 25
Enhance the Patient Experience Reduce Travel/Costs Enhance Access Achieve Patient s Recommendation Patient Experience Data 2009 2015 Strongly Agree = 4, Agree = 3, Disagree = 2, Strongly Disagree = 1 Responses Average Rating Telemedicine decreased my travel time 3.65 I could clearly see the healthcare provider 3.56 I felt the care provider answered my questions thoroughly 3.56 I would recommend Telemedicine to others 3.54 I was comfortable discussing my issues/concerns with the care provider 3.54 I felt my privacy was respectedduring my telemedicine visit 3.54 My overall experience with telemedicine was excellent 3.52 I could clearly hear the healthcare provider 3.52 The quality of overall medical care met my expectations 3.50 I knew what to expect during my telemedicine visit 3.33 Telemedicine allowed me to see the care provider sooner than expected 3.28 Overall Average 3.51 **Overall, 96.1% of the responses were Strongly Agree or Agree. Strongly Disagree (1) Strongly Agree (4) Agree (3) Disagree (2) No Response % of % of % of % of Question Total Total Total % of Total Total Total Total Total Total Total I knew what to expect during my telemedicine visit 872 43.7% 963 48.3% 114 5.7% 38 1.9% 7 0.4% I felt my privacy was respected during my telemedicine visit 1,147 57.5% 806 40.4% 16 0.8% 20 1.0% 5 0.3% I could clearly hear the healthcare provider 1,141 57.2% 791 39.7% 39 2.0% 19 1.0% 4 0.2% I could clearly see the healthcare provider 1,204 60.4% 747 37.5% 18 0.9% 19 1.0% 6 0.3% I was comfortable discussing my issues/concerns with the care provider 1,157 58.0% 792 39.7% 26 1.3% 15 0.8% 4 0.2% I felt the care provider answered my questions thoroughly 1,165 58.4% 784 39.3% 20 1.0% 19 1.0% 6 0.3% Telemedicine allowed me to see the care provider sooner than expected 846 42.4% 973 48.8% 107 5.4% 50 2.5% 18 0.9% Telemedicine decreased my travel time 1,427 71.6% 792 39.7% 36 1.8% 35 1.8% 4 0.2% The quality of overall medical care met my expectations 1,111 55.7% 821 41.2% 35 1.8% 20 1.0% 7 0.4% I would recommend Telemedicine to others 1,193 59.8% 728 36.5% 44 2.2% 24 1.2% 5 0.3% My overall experience with telemedicine was excellent 1,194 59.9% 717 36.0% 47 2.4% 24 1.2% 12 0.6% Total 1,994 1,994 1,994 1,994 1,994 26
Telemedicine Patient Experience Survey January 2009 December 2015 Responses Prepared by L. Ritter, CRPD February 2016 TOTAL SURVEYS RETURNED: 1,994 Surveys ** Observations made are based on surveys returned not total Telemedicine patients. PATIENT TYPE: Established patients account for roughly 80% of those surveyed. The overall average response rating is 3.49 for 2015. Sixteen percent of Telemedicine participants are new to Gundersen Health System Age Demographics: 2009 2015 Sixty three percent of Telemedicine participants are aged 65 or older 27
Future Expansion Expand Provider and Specialty Base Add New Geography Grow Patient Participation Gain Efficiencies with New Technology Explore and Develop New Venues Enhance Patient and Provider Experience An eye on the future of telemedicine 28
29