NM DEPARTMENT OF HEALTH

NM DEPARTMENT OF HEALTH TELEHEALTH SERVICES PROJECT DELIVERABLE 4: COMPREHENSIVE PROJECT REPORT AND ACTION PLAN PREPARED FOR: HEALTH SYSTEMS BUREAU OF THE PUBLIC HEALTH DIVISION PREPARED BY: RICK DRAKER LAWRENCE JOHNSON JON KING JEAN VOSBURG Prepared by: June 24th, 2015 5971 Jefferson NE, Suite 101 Albuquerque, NM 87109 Phone 505.243.2287 FAX 505.243.4677 Providing solutions for the development, integration and support of information systems

TABLE OF CONTENTS 1 EXECUTIVE SUMMARY ---------------------------------------------------------------------------- 4 1.1 Purpose of Project --------------------------------------------------------------------------------------------------------------------- 4 1.2 Methodology ---------------------------------------------------------------------------------------------------------------------------- 4 1.3 Definitions of Telehealth and Telemedicine ----------------------------------------------------------------------------------- 5 1.4 Project Summary ----------------------------------------------------------------------------------------------------------------------- 5 1.4.1 Stakeholder Identification Summary ------------------------------------------------------------------------------------------ 5 1.4.2 Gap Analysis Summary ------------------------------------------------------------------------------------------------------------ 6 1.4.3 SWOT Analysis Summary --------------------------------------------------------------------------------------------------------- 7 1.4.4 Recommended Actions Summary ---------------------------------------------------------------------------------------------- 9 1.4.5 Action Plan-------------------------------------------------------------------------------------------------------------------------- 16 2 INTRODUCTION ----------------------------------------------------------------------------------- 17 2.1 Scope of Document------------------------------------------------------------------------------------------------------------------ 17 2.2 Methodology -------------------------------------------------------------------------------------------------------------------------- 17 2.3 Definitions, Acronyms, Abbreviations ----------------------------------------------------------------------------------------- 18 3 COMPREHENSIVE PROJECT REPORT -------------------------------------------------------- 19 3.1 Deliverable 1: Stakeholder Identification ------------------------------------------------------------------------------------- 19 3.1.1 Identification Methodology and Results ----------------------------------------------------------------------------------- 19 3.1.2 Current Telehealth Usage ------------------------------------------------------------------------------------------------------ 19 3.1.3 Current and Potential NMDOH Collaborations --------------------------------------------------------------------------- 20 3.1.4 Current Non-NMDOH Collaborations --------------------------------------------------------------------------------------- 21 3.2 Deliverable 2: Gap Analysis ------------------------------------------------------------------------------------------------------- 21 3.2.1 Gap Analysis Methodology and Results ------------------------------------------------------------------------------------ 21 3.2.2 Telehealth Utilization Gaps ---------------------------------------------------------------------------------------------------- 21 3.2.3 Telehealth Communication Gaps --------------------------------------------------------------------------------------------- 24 3.3 Deliverable 3: SWOT Analysis ---------------------------------------------------------------------------------------------------- 27 3.3.1 SWOT Analysis Methodology and Results---------------------------------------------------------------------------------- 27 3.3.2 Primary SWOT Areas Identified ----------------------------------------------------------------------------------------------- 28 3.3.3 SWOT Focus Group Summary ------------------------------------------------------------------------------------------------- 30 3.4 Telehealth Summit Review ------------------------------------------------------------------------------------------------------- 30 4 FINAL RECOMMENDATIONS ------------------------------------------------------------------- 32 Deliverable 4 NMDOH Telehealth Project Page 2 Table of Contents

5 ACTION PLAN -------------------------------------------------------------------------------------- 42 APPENDIX 1: STAKEHOLDER DIRECTORY ------------------------------------------------------- 58 APPENDIX 2: ACRONYMS, ABBREVIATIONS, DEFINITIONS --------------------------------- 61 Deliverable 4 NMDOH Telehealth Project Page 3 Table of Contents

1 EXECUTIVE SUMMARY 1.1 PURPOSE OF PROJECT Based upon the Governor s initiative, the New Mexico Department of Health (NMDOH) Public Health Division s (PHD) Health Systems Bureau (HSB) has been tasked with the administration of funds (recurring) awarded to the Department in the 2014 legislative session to expand telehealth services throughout the state. NMDOH HSB believes it to be in the best interest of New Mexico communities and residents to include telehealth stakeholders in discussions concerning the expansion of telehealth practices. To this end, DOH HSB has determined that it should first identify potential telehealth stakeholders, their current roles and responsibilities in the use of telehealth, and with whom NMDOH should collaborate or partner. A significant part of this effort is to identify current collaborations between the NMDOH and various stakeholders, as well as collaborations among the stakeholders themselves, to identify gaps and issues in current telehealth utilization, and finally, to evaluate strengths, weaknesses, opportunities and threats in the utilization of telehealth practices and technologies to improve access to healthcare for the residents of New Mexico. This project also includes the basics of a strategic plan for the NMDOH to move forward with a collaborative effort to initiate and implement the best use of telehealth in New Mexico. As a major part of this project, NMDOH HSB required a summit be held for the identified stakeholders to present the findings of this project, and to discuss with the stakeholders potential collaborations, the future role of NMDOH in the telehealth field and how best to tackle some of the issues and gaps identified in this study. NMDOH engaged POD, Inc. to undertake the work. POD, Inc. subcontracted with Draker-Cody Inc. to help with the project. 1.2 METHODOLOGY This document represents a comprehensive project report including summaries of the three previously submitted project deliverables. Most importantly, it contains a set of final recommendations together with an action plan outlining next steps for the NMDOH. The summaries of the three previous deliverables include: 1. An extensive telehealth stakeholder analysis ascertaining stakeholder roles and responsibilities, and the identification of logical entities with which the NMDOH might partner. 2. A Gap Analysis, from the perspective of current telehealth stakeholders, examining gaps in the utilization and communication/collaboration of telehealth and telemedicine. 3. A SWOT (Strengths-Weaknesses-Opportunities-Threats) analysis, as articulated by current telehealth stakeholders during individual interviews, and a summary of two focus groups organized by the consultant team to discuss the major SWOTs identified. Lastly, this document puts forth final recommendations for consideration by the NMDOH, as well as an action plan, based upon those recommendations, setting out next steps to help the NMDOH to move Deliverable 4 NMDOH Telehealth Project Page 4 Executive Summary

forward to establish a collaborative effort to address how best to initiate and implement the practice of telehealth in New Mexico. 1.3 DEFINITIONS OF TELEHEALTH AND TELEMEDICINE For our purposes, the New Mexico state legislature has defined telemedicine as follows: Telemedicine is the use of interactive simultaneous audio and video or store-and-forward technology using information and telecommunications technologies by a healthcare provider to deliver healthcare services at a site other than the site where the patient is located, including the use of electronic media for consultation relating to the healthcare diagnosis or treatment of the patient in real-time or through the use of store-and-forward technology. (New Mexico State Statute: SB 69, 2013). The Health and Human Services Department definition of telehealth will serve for this project: Telehealth is the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health related education, public health and health administration. 1.4 PROJECT SUMMARY 1.4.1 Stakeholder Identification Summary The discovery process portion of this project, which utilized interviews with potential stakeholders, provides information concerning a number of areas in which the NMDOH could play a major role in telehealth in New Mexico. The interviews also provide a snapshot of those stakeholders with whom NMDOH is now collaborating, and those stakeholders with whom NMDOH could collaborate. Also described is the nature of those collaborations, existing and potential. Less than 50% of the stakeholders interviewed collaborate with the NMDOH and most of these collaborations are not telehealth related. Principal collaborations that involve telehealth practice by stakeholder include Project ECHO, UNM Center for Rural and Community Behavioral Health and Envision New Mexico. Collaborations sought after by these stakeholders, for the most part, center on education and training directed at the value of telehealth to the healthcare industry. Other partnerships desired include access to data that the NMDOH collects. There are those stakeholders that want to see the NMDOH play a facilitator role in telehealth. Just over 50% of the stakeholders interviewed do not currently collaborate with the NMDOH. However, many of these stakeholders would like a collaboration with the NMDOH in the area of education and training related to the value of telehealth. Some stakeholders want specific programs. The NMDOH is in a position to collaborate with virtually any stakeholder it wishes. Deliverable 1 clearly describes the existing collaborations and the nature of those collaborations. Deliverable 4 NMDOH Telehealth Project Page 5 Executive Summary

The collaborations between and among the stakeholders, excluding the NMDOH, are also described in detail in Deliverable 1. The strongest collaborations, in terms of telehealth practice, occur between and among five stakeholders (Project ECHO, Indian Health Services, Envision New Mexico, UNM Center for Telehealth and Cybermedicine Research, and UNM Center for Rural and Community Behavioral Health). These five are common denominators among the list of stakeholders, and these might well form the nucleus of a set of collaborations for the NMDOH. 1.4.2 Gap Analysis Summary Throughout the course of the Gap Analysis, three specific gaps were mentioned in over 50% of interviews conducted. The most frequently mentioned gap is the lack of stakeholder coordination/collaboration and the need for a statewide coordinating body or blueprint to help guild and build telehealth programs and systems in a collaborative and sustainable way. Nearly 75% of all stakeholders mentioned this to be a major gap with a need for action. This is also the most frequently mentioned weakness in, or threat to, the advancement of telehealth in New Mexico. The second most frequently mentioned gap was the lack of consistent and useful educational programs targeting healthcare providers and consumers alike and was mentioned by nearly 65% of stakeholders. This lack of education also contributes to the lack of buy-in by healthcare providers, specifically in rural and frontier communities, to design and build sustainable telehealth programs. Without a centralized, reliable, and unbiased agency providing best practice advice and a centralized planning and coordination role, many physicians and healthcare professionals do not understand the applications of telehealth and may find it easier to ignore or resist telehealth rather than explore and exploit its benefits. The third most common gap mentioned by over 50% of stakeholders interviewed pertained to the last mile of connectivity and speaks to a fundamental issue of balancing adequate system functionality and financial sustainability in smaller and rural healthcare providers to include broadband bandwidth and poor or no phone service. The second and third most frequently mentioned gaps are also major weaknesses and/or threats to the telehealth system. Gaps in Communication/Collaborations Less than 50% of the stakeholders interviewed currently collaborate with the NMDOH with respect to telehealth. An even smaller percentage have established programs and initiatives with other stakeholders in order to build or sustain telehealth programs and initiatives The following five statements represent the most critical communication/collaboration gaps in telehealth currently: 1. A lack of a centralized telehealth coordinating body or blueprint for the state to take a holistic approach to creating a viable and sustainable interoperable telehealth system. 2. Various medical professional certification and credentialing issues that create bottle necks when attempting to connect with providers and provide telehealth services at a distance. Deliverable 4 NMDOH Telehealth Project Page 6 Executive Summary

3. A general lack of pilot programs & resources utilization studies to better manage risk, provide quantitative and measurable results and better understand the most impactful health disorders effecting the New Mexico population. 4. A mixed set of understandings about the functionality of NMHIC and the overall lack of telehealth system interoperability. 5. A general stakeholder concern regarding over-regulation and excessive bureaucracy with regards to telehealth that may damage or hinder future efforts to advance and utilize telehealth in the state. Gaps in Utilization Utilization of telehealth equipment and services in the state of New Mexico is very low. This is notable in the context of the very liberal atmosphere of regulations regarding the licensing, development and use of telehealth in New Mexico, as well as an ideal and fertile landscape of rural and frontier communities with centralized primary healthcare facilities. The following gaps represent the most pressing utilization issues regarding telehealth in New Mexico and will be discussed throughout the remainder of this report. 1. There appears to be a large void in stakeholder understanding of the benefits and possibilities telehealth offers. Many stakeholders believe the lack of educational programs and incentives in which to participate to be the cause. 2. Provider connectivity and various issues that arise with respect to technical assistance seem to plague telehealth. 3. Long-term and sustainable funding issues, as well as budget constraints, are hampering the build-out of potentially beneficial programs. 4. A lack of expertise and equipment, as well as a limited understanding of telehealth technology is creating unforeseen problems for both providers and patients when attempting to implement and utilize telehealth services. 5. Uncertainty around provider liability and the lack of a defined telehealth standard of care is preventing some providers from joining the movement towards telehealth. 1.4.3 SWOT Analysis Summary Five major SWOTs are identified in Deliverable 3. These are briefly described below. 1. Need for Coordination of Telehealth Efforts by A Single Group This SWOT begins with a statement of current telehealth strengths: current, excellent telehealth programs; telehealth champions in the state; and, the NMDOH support for various programs. It then moves to a set of opportunities for coordinating existing programs, and facilitating new programs, as well as establishing a single organization to do this. Then, the related weaknesses and threats are described: programs that are too siloed; the piece-meal approach to telehealth practices; the need to utilize scarce resources more effectively; the absence of a single entity to help organize and facilitate telehealth practices in this state; and, finally, the lack of an overall blueprint for the promotion and advancement of telehealth practices in New Mexico. Deliverable 4 NMDOH Telehealth Project Page 7 Executive Summary

2. Need To Promote Telehealth to Healthcare Providers And The Public The importance of this SWOT lies with the threat to telehealth as seen by many stakeholders. This is the negative attitude healthcare providers have towards telehealth. The consultant team was told that this negativity has several roots: a belief that telehealth is not a good way to practice medicine; a fear of a loss of revenue or not being paid for the service; the cost of equipment; and, an unwillingness to participate in training programs because it takes time away from tending to paying patients in the office setting. Mostly, the negativity comes from a real lack of understanding of the value of telehealth in providing access to good healthcare. The strengths and opportunities stated in this issue involve the University of New Mexico s Project ECHO (Extension for Community Healthcare Outcomes) as an excellent example of a teaching program, and the opportunity to provide in depth training and education to healthcare providers with an emphasis on the value of increased access to healthcare for New Mexico residents and the cost savings that can result from the introduction of telehealth into a healthcare facility. 3. Infrastructure, Equipment and Cost In terms of stated weaknesses and threats, this is the most frequently stated issue by the stakeholders. With respect to strengths and opportunities, it is generally believed by the stakeholders that the necessary infrastructure, for the most part, is in place in New Mexico. It is also believed that telehealth technology has become simpler, more available, and less expensive. The opportunity to cut healthcare costs and to improve access to healthcare for New Mexico s residents is now a huge opportunity. However, the major weakness cited by almost 50% of the stakeholders interviewed is the cost of that last mile of connectivity. In addition, several areas of the state do not have sufficient broadband bandwidth. Fortunately, there are programs such as the Federal Communications Commission (FCC) National Broadband Program and the New Mexico Broadband Program, to help pay the cost of increased broadband width and connectivity. It is suggested by several stakeholders that the NMDOH might make some portion of its annual telehealth allocation available to local healthcare providers in order to help finance their share of the cost of these programs. 4. Healthcare Records and Health Information Exchange Of the five major SWOT areas, this issue was not mentioned as often as the others, but the frequency is significant compared to many other SWOTs. It is an issue that received significant discussion at the two stakeholder focus group sessions held at the end of April, 2015. This is the one issue for which no one mentioned that the availability of healthcare records or the operation of the Health Information Exchange (HIE) is a strength. However, several stakeholders held that the opportunity is significant for better coordination in the storage and access to health records, and the standardization of systems through the New Mexico Health Information Collaborative (NMHIC). The related weaknesses mentioned were: inadequate availability of health records as well as information systems that do not talk to each other. Threats included the aforementioned weaknesses as well as the lack of a standardized electronic health records system. Some concern about the security of health records was also expressed. Deliverable 4 NMDOH Telehealth Project Page 8 Executive Summary

5. New Mexico has Many Telehealth Positives - so What is the Problem The last major SWOT, as expressed by over 50% of the stakeholders interviewed, has only strengths and opportunities; there are no threats or weaknesses noted. The premise is this: New Mexico is a largely rural state with low population density making it an ideal setting for telehealth practices. Telehealth is, to some extent, filling the gap created by a dearth of healthcare providers in rural areas. So with the opportunities available and the pluses that are currently in place, why isn t telehealth more widely utilized in New Mexico and why is it not at a more advanced stage? 1.4.4 Recommended Actions Summary a. Create or Designate an NMDOH Employee Position Responsible for Telehealth Throughout the course of this project, many stakeholders cited the fact that NMDOH should take a more active role in telehealth because of the benefits and advantages it can provide to New Mexico residents. They also cited the fact they have no knowledge about the NMDOHs current actions in telehealth, nor who to contact within the NMDOH when issues or opportunities arise. Sometimes, stakeholders have a need for some assistance or perhaps questions about regulatory issues or a need for some training. The availability of one point of contact for telehealth matters within the NMDOH would improve relationships with stakeholders as well as help implement telehealth practices across the state. Recommendation: It is recommended that the NMDOH designate an individual within the Public Health Division of the NMDOH as the point of contact for all NMDOH telehealth initiatives and actions. This individual shall be the liaison and coordinator for telehealth efforts within the NMDOH. This position should be responsible for the following, but not limited to: 1. Act as the NMDOH telehealth liaison for other organizations and entities involved in the statewide telehealth body. 2. Establish a working relationship with NMHSD and NMDoIT. 3. Act as the NMDOH telehealth liaison for the general public to contact. 4. Evaluation and organization of NMDOH telehealth initiatives and the relay of that information to telehealth stakeholders and the general public, as appropriate. 5. Maintaining and updating a contact list of telehealth stakeholders and other organizations. 6. Evaluating potential partnerships with other entities to ensure any partnership NMDOH enters into concerning telehealth meet specific goals and outcomes outlined by the NMDOH. 7. Provision of reports and status updates regularly to senior NMDOH leadership on telehealth projects and initiatives. 8. Assisting the general public with questions or referring them to organizations and entities that can assist them. 9. Working directly with various healthcare professional recruitment and retention entities to address the staffing needs of various organizations and stakeholders. New Mexico Health Resources is one agency that the NMDOH currently funds, but others may exist around the state. 10. Ensuring any proposed NMDOH legislative changes take into account the needs of telehealth practice. 11. Coordination with various membership organizations to ensure the greatest measure of stakeholder interests are taken into account when making decisions. Some membership organizations to consider including are: Deliverable 4 NMDOH Telehealth Project Page 9 Executive Summary

a) New Mexico Primary Care Association b) New Mexico Hospital Association c) New Mexico Telehealth Alliance 12. Evaluating the benefit of making the 2015 NMDOH Telehealth Summit a yearly event, or if the organizing of this type of event should be the responsibility of the single, centralized coordinating body. 13. Outlining eligibility requirements, underwriting grants, and supporting programs that can prove financial practicality and health improvement effectiveness. Finally, the consultant team believes that the NMDOH and the New Mexico Human Services Department (NMHSD) should cooperate on and coordinate their respective telehealth efforts to achieve a more organized and effective approach to telehealth practices, and to achieve a more efficient expenditure of public funds. The two agencies have common interests and missions that telehealth may help to address. The NMDOH should consider partnering and cooperating with NMHSD a top priority. This partnership may be able to promote a more holistic representation of stakeholders for a centralized body (as discussed in the next sub-section), as well eliminate resource redundancy. b. Need For Coordination of Telehealth Efforts by A Single Group Telehealth programs tend to be single-purpose and siloed. Programs or initiatives for programs that may have similar purpose and intent are not coordinated or integrated in a single cohesive effort to the benefit of the greatest number. Competition for scarce funds is sharp and the results are not always cost efficient. While there is some coordination of effort between organizations, the overall result is a somewhat piecemeal approach to telehealth practice that does not serve healthcare providers or patients well. A single centralized body responsible for the coordination and advancement of telehealth in New Mexico will be able to address many of the gaps outlined earlier in this report.in previous deliverables. One such gap that can be addressed is the lack of pilot programs and resource utilization studies across the state. With appropriate authority and funding this single group could organize studies to evaluate resource utilization and the effectiveness of programs in order to identify how programs and other telehealth efforts can be made better in terms of the services offered and in terms of the resources utilized. Placing a major emphasis on, and giving priority to, studies that can provide quantitative and measurable outcomes may shed light on opportunities to better leverage current assets in telehealth to address major health problems New Mexico residents are facing. Recommendation: The Identification of Telehealth Gaps report set out three possible scenarios for a single organization: 1. Reactivate the existing Telehealth Commission created by the Governor s Office and ensure its board membership is broad enough to accommodate a full range of interests in telehealth and to accomplish the goals laid out in the Act. Authority to take specific actions and funding must be part of the reactivation in order that this commission be effective. 2. Merge the duties of the Telehealth Commission with an existing organization, such as the New Mexico Telehealth Alliance, and provide the necessary authority and resources to ensure that the goals outlined in the Act or by subsequent regulation are met. 3. Whether scenario 1 or 2 (above) is selected, the organization must be a public-private partnership. The duties, roles responsibilities and expectations for this organization must be Deliverable 4 NMDOH Telehealth Project Page 10 Executive Summary

clearly spelled out. This includes a clear definition of the meaning of coordination and facilitation. The consultant team believes that either item 1 or 2 can work in practice; however, scenario 2 is likely the more practical approach given current circumstances surrounding the state commission. At a minimum the organization should be responsible for: a) Preparing a blueprint for telehealth practice across the state and an implementation plan for that blueprint. b) Actively working with organizations to coordinate and facilitate existing and new telehealth initiatives. c) Providing oversight and administrative services for various pilot or seed programs and resource utilizations studies. d) Working with various healthcare organizations to obtain funding for programs. e) Working with NMDOH to offer training and education programs in telehealth. f) Helping healthcare organizations network with one another. g) Working with NMHIC to help create more comprehensive and more accessible health records. h) Alleviating stakeholder concern of unfair or burdensome regulations and legislation. i) Providing a platform for all stakeholders to express their concerns and give voice to the needs of all is vital to ensuring fair regulatory and legislative change are implemented. The NMDOH should be a major player in any such organization. One major role it can certainly play, depending on available assets, is providing training to providers through this organization. c. Facilitate the Adoption of a More Technological and Streamlined Approach to Certification and Credentialing The process of certifying and credentialing medical professionals is a major gap in the current state of telehealth in New Mexico. The major problem is that it often takes months, if not longer, for a physician to become certified and credentialed in a hospital in order that he/she may offer specialized services to the members of that community. This problem is multiplied when attempting to set up a network of medical professionals that would serve multiple medical facilities around the state. Technology is providing groundbreaking solutions in the field of healthcare and the New Mexico healthcare professional credentialing system needs to utilize recent technological advancements to eliminate the gap associated with verifying medical professional qualifications. The consultant was informed through the Telehealth Summit discussions (see Section 3.4 of this report) that the NMDOH does have policy available regarding credentialing. The policy as the consultant team understands it applicable only to NMDOH facilities. Even in this process a physician, medical specialist, or other healthcare provider must make application and be vetted by a NMDOH facilities credentialing committee. The team also understands that this is a relatively fast process. Also available through the NMDOH are sample agreements and contracts for telemedicine and telestroke services between clinics and hospitals, and between hospitals. Deliverable 4 NMDOH Telehealth Project Page 11 Executive Summary

Given all of this, it still appears appropriate for the NMDOH and the telehealth coordinating body to review the NMDOH policy in the light of the FCVS verification system to recommend and implement a comprehensive policy that applies to all medical facilities in the state, private and public. Recommendation: It is recommended that the NMDOH develop working partnerships with the various organizations responsible for overseeing and updating various certification and credentialing regulations for clinics, hospitals, pharmacies and other healthcare organizations around the state. There may be opportunities for the regulations and policies to be standardized throughout the state in an attempt to facilitate acceptance of pre-checked medical professional qualifications. In doing so, patient safety and system reliability need to be primary concerns. Inasmuch as there is in place a NMDOH policy regarding its own facilities, this policy ought to be reviewed in the light of the FCVS guidelines to create a comprehensive credentialing policy for all medical facilities in New Mexico. The following primary attributes are ones that the NMDOH should consider when transitioning towards a more technological and efficient credential verification system: a) Identity b) Medical education c) Postgraduate training d) Licensure examination history e) Board action history f) ABMS (American Board of Medical Specialties) Certifications g) Additional medical aspects as necessary and appropriate d. Facilitate and Support the Advancement of the New Mexico Health Information Collaborative and Overall System Interoperability A major issue identified in previous deliverables is the need for the storage and the sharing of patient health records. The New Mexico Health Information Collaborative Health Information Exchange (NMHIC- HIE) is the state body tasked with this function. Despite some difficulties with the previous electronic platform, the NMHIC is up and running with a new platform, however, the general feeling expressed by some stakeholders is that the Health Information Exchange projects need to develop more quickly than it has to date. Many stakeholders noted the need for the current state of health information technology to complement any efforts to collaborate and create a more fully integrated healthcare system. Recommendation: It is recommended that the NMDOH develop a strong working partnership with the NMHIC to better understand what resources are needed and what resources the NMDOH has available to provide. This partnership should focus on working towards a more transparent and integrated Health Information Exchange. One way the NMDOH may approach this is to meet with the NMHIC and evaluate the practicality of implementing a minimum reportable information requirement. The consultant team believes the meaningful use objectives outlined in previous deliverables may be the best starting point for such discussions. These meaningful use objectives include a bare minimum set of fields such as: patient name sex date of birth Deliverable 4 NMDOH Telehealth Project Page 12 Executive Summary

current medications medication allergies procedure history and more The main benefit of having this information centrally stored by a New Mexico entity is that this information can be pulled directly from the NMHIC by various medical entities around the state in the event of an emergency if the patient was unable to provide the information himself/herself. Although, strictly speaking, this might not constitute a telehealth practice the consultant team believes it would be a great foundation upon which to promote telehealth and use its fundamental technological capabilities in order to create a more integrated statewide healthcare system. Finally, to complement this effort, the NMDOH should include the NMHIC in its initial evaluation and actions towards the creation of a central body for telehealth coordination. Doing so will allow the standardization of advice and assistance given to providers seeking guidance in terms of systems and software to house and store patient health information. This standardized advice may have compound benefits in the long run because of decreased variety of systems being implemented by healthcare entities, and additional interoperability of information systems. e. Creation and Provision of Telehealth Seminars and Learning Programs The current lack of telehealth educational programs, and the lack of incentives to healthcare providers to participate in educational programs are mentioned as one of the largest barriers to the development and utilization of telehealth in New Mexico. Nearly 65% of the stakeholders spoke of this issue in the interviews. Educating healthcare providers on the benefits of telehealth is one of the surest ways to expand the understanding and adoption of telehealth services. According to multiple stakeholders, many existing healthcare providers believe telehealth does not offer an adequate level of healthcare, but are unwilling to learn about the various applications offered and the statistically supported outcomes telehealth creates. Recommendation: It is recommended that the NMDOH evaluate the practicality and cost of building and sustaining and on-going program of educational telehealth seminars and training sessions that highlight the benefits of telehealth practices, provide information on the latest technology, offer training in the use of the latest technology, and provide information on best practices in telehealth. One example cited by Project ECHO is a program the State of California has created that compensates providers for joining into select ECHO clinics. There are a variety of ways the NMDOH could go about increasing attendance to these events including: 1. Allocating a set amount of funding to promote provider participation in educational programs that are already in place and functioning. Some entities providing educational opportunities include, but are not limited to: a) UNM Project ECHO b) Envision New Mexico c) UNM Center for Telehealth and Cybermedicine Research d) New Mexico Human Services Division Deliverable 4 NMDOH Telehealth Project Page 13 Executive Summary

2. Investigating the practicality of mandating or offering a small portion of healthcare professionals yearly Continuing Education Credits (CEUs) to focus on telehealth programs and services in an attempt to expand awareness at the provider level. The NMDOH should look to form partnerships with the above mentioned organizations to efficiently and effectively share expertise and resources. f. Review Telehealth Service Providers Liability Exposure Provider liability was not a frequently mentioned issue, but the consultant team believes it important enough to highlight the concern and to suggest the NMDOH consider the possible implications, if any, on the advancement of telehealth in the state. Some stakeholders expressed concern regarding the issue of liability to individual doctors and organizations as a whole when telehealth is used to provide services. One of the stakeholders explained that when a healthcare provider is part of an overarching or integrated healthcare system, this issue is somewhat minimized because of various insurance options and the economies of scale associated with these organizations. When the provider is a small rural clinic, those benefits may not apply and the risk to these entities is significant when providing medical advice or prescribing medications to a patient via telehealth. Recommendation: It is recommended that the NMDOH establish a collaboration with a few stakeholders to look at the possible implications of liability to healthcare practitioners in the utilization of telehealth to treat patients. If it appears that the concern around liability in the utilization of telehealth might be mitigated by better defining and establishing particular standards of care that would apply specifically to telehealth encounters, the NMDOH should initiate legislation to effect such standards. g. Review and Support Change in Regulations for CHW/CHR and Remote Monitoring Telehealth Applications and Technology NMDOH provides funding for various health initiatives around the state, including some Project ECHO programs and many others that have beneficial missions and outcomes. Most recently, funds were provided to Project ECHO to develop curriculum for certification programs stemming from SB 58, Community Health Workers Act from the 2014 regular session. These certification programs provide training to Community Health Workers (CHW) and Community Health Representatives (CHR) and seek to address many health issues, specifically prevention and reduction of pediatric and adult obesity, and, to train rural providers, primary care providers and school-based health center providers in Screening and Brief Intervention and Referral to Treatment (SBIRT) to increase the number of trained SBIRT providers. This is one instance in which NMDOH is providing short term funding solutions to ensure a vital need is filled in New Mexico. It is also an instance of an unassured funding stream that may change yearly. Project ECHO and other stakeholders informed the consultant team that the CHW program will have exponential positive effects for the community because they are a powerful interface between individuals in the community and the healthcare system as a whole. The CHW s are focusing on broad public health programs and initiatives and are, overall, very aligned with the mission and responsibilities of NMDOH. The issue is that Project ECHO, select New Mexico MCO s and a small group of other stakeholders from around the state have had to come together to contribute resources to ensure these CHW programs are funded and can continue operations. A main reason this is occurring is that CHW s and CHR s currently cannot bill CMS for services provided. Another reason may include the infancy of this project and the time it takes for changes to be made. Deliverable 4 NMDOH Telehealth Project Page 14 Executive Summary

Telehealth offers great advantages to healthcare professionals when it comes to monitoring high risk individuals at a distance. Currently, remote telehealth monitoring is not reimbursed under CMS regulations in New Mexico. This problem, further detailed in prior deliverables, is in some cases preventing healthcare professionals from providing these services to patients who would benefit from this type of care. In other instances, it is forcing larger organizations to provide these services without the possibility of being reimbursed because of the improvement in the outcomes of patients in need of remote monitoring. Recommendation: It is recommended that the NMDOH review the legislation regarding Community Health Workers (CHWs) and determine what is needed to ensure that the work provided to patients by the CHW can be reimbursed through the Centennial Care program. During this review, the NMDOH should examine the possibilities of tying the CHW training programs into a telehealth initiative, or even expanding the enrollment in these programs utilizing telehealth infrastructure at the federally Qualified Health Clinics (FQHCs) around the state. If the NMDOH feels this is a good initiative to support and if it could play a vital role in creating and supporting telehealth programs in rural parts of the state, reimbursement and further support to Project ECHO in this effort should be considered a high priority. Also, it is recommended that NMDOH review the various capabilities of remote patient health monitoring systems and determine what actions, partnerships, and changes are required in order to ensure these services being provided around the state are reimbursed for and promoted. These types of systems provide organizations major advantages in closely monitoring patient health and having the capabilities and data needed to react faster to patient s needs. NMDOH needs to examine the health home option, Created by the Affordable Care Act (ACA) to better coordinate primary, acute, behavioral, and long-term and social service needs for high-need, high-cost beneficiaries. These types of programs, already in use by states near New Mexico such as Colorado and Texas, complement the rural and remote nature of New Mexico by eliminating the need for long drives by high-need, high-cost beneficiaries and providing major cost savings to both the patient and organizations attempting to care for those individuals. h. Infrastructure, Equipment and Cost With respect to strengths and opportunities, it is generally believed by the stakeholders that the necessary infrastructure, for the most part, is in place in New Mexico. It is also believed that telehealth technology has become simpler, more available, and less expensive. The opportunity to cut healthcare costs and to provide increased access to healthcare for New Mexico s residents is now a huge opportunity. However, the major weakness, cited by almost 50% of the stakeholders interviewed, is the cost of that last mile of connectivity. In addition, several areas of the state do not have sufficient broadband bandwidth. Fortunately, there are programs such as the Federal Communications Commission National Broadband Program and the New Mexico Broadband Program to help pay the cost of increased broadband width and connectivity. It is suggested by several stakeholders that the NMDOH make some portion of its annual telehealth allocation available to local healthcare providers in order to help finance their share of the cost of these programs. Also needed is an inventory of what is available in terms of broadband width in the state, where are the gaps, and how do we close these gaps? Related to this item is the determination of where patients in rural areas can go when they need access to the internet or some web site for healthcare. A look at NMDOH clinics as well as federally qualified health clinics are possibilities for the location of facilities for these patients. Deliverable 4 NMDOH Telehealth Project Page 15 Executive Summary

Recommendation: It is recommended that: Recommendation: It is recommended that: 1. The NMDOH with the New Mexico Department of Information Technology to initiate a survey of infrastructure available across the state and to identify where the gaps are and where they may be an issue with the last mile of connectivity. 2. Along with the survey outlined in 1. above an inventory of broadband availability across the state should be undertaken, site by site. 3. The NMDOH in conjunction with other state agencies such as the NMHSD and the NMDoIT establish a fund to help local healthcare providers pay for the last mile of connectivity. 1.4.5 Action Plan Please see Section 5 of the report for a full description of the Action Plan. Deliverable 4 NMDOH Telehealth Project Page 16 Executive Summary

2 INTRODUCTION 2.1 SCOPE OF DOCUMENT This document provides a comprehensive project report, including summaries of three earlier deliverables. It includes final recommendations together with an action plan outlining next steps for the NMDOH. The summaries of previous deliverables include: 1. An extensive telehealth stakeholder analysis ascertaining stakeholder roles and responsibilities and the identification of logical entities with which the NMDOH might partner. 2. A Gap Analysis, from the perspective of current telehealth stakeholders, examining gaps in the utilization and communication/collaboration of telehealth and telemedicine. 3. A SWOT analysis, as expressed by current telehealth stakeholders during individual interviews and two focus groups organized by the contractors to discuss the major SWOTs identified. Finally, this document puts forth final recommendations for consideration by the NMDOH. It details an action plan, based upon the recommendations outlining next steps for the NMDOH to consider to move forward in creating a collaborative effort to address how best to initiate and implement the use of telehealth in New Mexico. 2.2 METHODOLOGY This comprehensive project summary is based upon an interview with each stakeholder utilizing a script of questions designed to elicit the information necessary to fulfill the requirements of the scope of work. Specific to the script were questions designed to elicit the following information: 1. Current roles and responsibilities of each stakeholder for health care provisions, education and the use of telehealth. 2. Current and past experience of gaps in the utilization and collaboration of telehealth programs. 3. Strengths, weaknesses, opportunities, and threats experience by current stakeholders in the practice of telehealth in New Mexico that could impact the advancement of telehealth practice in the state. 4. Current telehealth technology utilized, including internet access capabilities and systems (hardware and software) used to securely acquire, store, and share telehealth data. This information gleaned was used to develop three project deliverables and one comprehensive project summary. These documents are intended to provide the NMDOH with a comprehensive understanding of the current situation of telehealth stakeholders, activities, and gaps in New Mexico. This information can be used by the NMDOH to evaluate and develop sustainable and effective partnerships to promote the use of telehealth and best utilize precious resources. Deliverable 4 NMDOH Telehealth Project Page 17 Introduction

2.3 DEFINITIONS, ACRONYMS, ABBREVIATIONS This document includes acronyms and abbreviations that should be understood according to specific definitions. An expansion of an acronym or abbreviation is presented when a term is first used in this report. Appendix 1, an integral part of this document, presents a list of acronyms and definitions. However, at this juncture for purposes of understanding and clarity, some discussion of the terms telehealth and telemedicine is useful. These two terms are often used interchangeably; the American Telemedicine Association, a national advocate and repository of telehealth practice and technology does this. However, the two terms are not necessarily the same and should not be viewed as interchangeable. While both terms are broad in scope in their own right, telehealth seems to be the umbrella term which encompasses telemedicine. Telemedicine is a practice of healthcare that includes other tele disciplines such as: teleneurology, teleobstetrics, teledermatology, telewounds and telepsychiatry. Telemedicine normally includes clinical applications; that is, healthcare provider to healthcare provider, or healthcare provider to patient or hospital to hospital. It can also include transmission of records and images. Telehealth encompasses all of telemedicine practices and more. It includes healthcare mentoring, education and training. It also includes administration of health records and remote monitoring of patients. For our purposes, the New Mexico state legislature has defined telemedicine as follows: Telemedicine is the use of interactive simultaneous audio and video or store-and-forward technology using information and telecommunications technologies by a healthcare provider to deliver healthcare services at a site other than the site where the patient is located, including the use of electronic media for consultation relating to the healthcare diagnosis or treatment of the patient in real-time or through the use of store-and-forward technology. (New Mexico State Statute: SB 69, 2013). The Health and Human Services Department definition of telehealth will serve for this project: Telehealth is the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional health related education, public health and health administration. It is not intended that a lot of time be spent distinguishing between the two terms. Telehealth as used in this report is used in its broadest meaning and includes telemedicine. Deliverable 4 NMDOH Telehealth Project Page 18 Introduction