hhs telemedicine hack - project echo“hhs telemedicine hack” curriculum session #1:...

HHS Telemedicine Hack

Office Hours #1

July 29, 2020

2Saving Lives. Protecting Americans.

Welcome to Telemedicine (TM) Hack!

• 10-week learning community to accelerate telemedicine implementation for ambulatory care providers

• Modeled after learning collaboratives successfully implemented by the Centers for Medicare & Medicaid Services (CMS)

Emphasis on peer-to-peer learning

• Designed as a 10-week sprint due to public health need and desire to optimize telemedicine readiness in anticipation of

COVID-19 surge in the fall

GOAL: At least 75% of participants will have conducted and billed 1 or more

video-based telemedicine visits by September 30, 2020


Welcome to Telemedicine (TM) Hack!

• 10-week learning community to accelerate telemedicine implementation for ambulatory care providers

• Modeled after learning collaboratives successfully implemented by the Centers for Medicare & Medicaid Services (CMS)

Emphasis on peer-to-peer learning

• Designed as a 10-week sprint due to public health need and desire to optimize telemedicine readiness in anticipation of

COVID-19 surge in the fall

GOAL: At least 75% of participants will have conducted and billed 1 or more

video-based telemedicine visits by September 30, 2020


“HHS Telemedicine Hack” Curriculum

Session #1: Telemedicine– Where Do I Start?

July 22nd, 12-1PM ET

Session #2: Workflows & Documentation

August 5th, 12-1PM ET

Session #3: Billing & Reimbursement– How to Do It Properly & Ensure Compliance


Session #4: Clinical Best Practices & the Art of the Tele-Physical Exam

September 2nd, 12-1PM ET

Session #5: The New Normal– Making Telemedicine Part of Your Permanent Practice

September 16th, 12-1PM ET

You are here

Office Hours # 1July 29th, 12-1PM ET

Office Hours # 2August 12th, 12-1PM ET


Office Hours # 4September 9th, 12-1PM ET

Office Hours # 5September 23rd, 12-1PM ET

GOALAt least 90% of participants will have conducted and billed 1 or more video-based telemedicine visits by

September 30, 2020


TM Hack Community—How Are You Using Telemedicine?

Have conducted ≥1 visits using video-based telemedicine in the last 30 days

52% have conducted >10 visits in last 30 days (n = 501)77%

5% Pre-COVID-19: Mean % of visits conducted by video-based telemedicine

32% Last 30 days: Mean % of visits conducted by video-based telemedicine


TM Hack Community—What Are Your Barriers to Success?

Bandwidth/connectivity issues for

patients, 61.43%

Challenges by patients in using

telemedicine technology, 68.39%

Responses

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

What Are Your Current Barriers to Implementing Video-based Telemedicine? Select All That

Apply. (n = 503)

No barriers

Malpractice/liability concerns

Scope of practice restrictions

IT costs

Bandwidth/connectivity issues for providers

Bandwidth/connectivity issues for patients

Lack of clarity on available telemedicine options

Uncertainty regarding permanence of telemedicine waivers and

regulations

Challenges by patients in using telemedicine technology

Insufficient reimbursement

1

2


Logistics

• Use Q&A function on Zoom for questions and comments for speakers

• Use Chat function on Zoom for technical/logistical issues

• This session is being recorded. Your attendance is consent to be recorded.

• CME/Continuing Professional Development (CPD) credits—Link is in today’s Project ECHO email announcement and will also

be placed in the Chat at end of session.


“HHS Telemedicine Hack” Data Use

• Project ECHO® collects registration, participation, questions/answers, chat comments, and poll responses for this program

and shares this data with HHS/ASPR. Your individual data will be kept confidential. These data may be used for reports,

maps, communications, surveys, quality assurance, evaluation, research, and to inform new initiatives


Today’s Agenda

• Case #1: Rural IHS Facility on the Navajo Nation (10 min) — Stephen Neal, PA-C, Chinle Service Unit, Indian Health Service

Q&A Follow-up (5 min)

• Ask Our Panelists Your Telemedicine Questions (35 min) – Moderated by Dr. Christian Ramers. Panelists are:

Meg Barron — VP, Digital Health Strategy, American Medical Association

Joe Brennan — Advisor, American Telemedicine Association

Marijka Grey, MD, MBA, FACP — Executive Leader for Transformation Implementation, CommonSpirit Health

Michele McComas, RN, BSN — Clinical Manager, Shepherd’s Clinic

Stephen Neal, PA-C — Chief of Staff, Chinle Service Unit, Indian Health Service

Rebecca Picasso — Program Director, California Telehealth Resource Center

John Scott, MD, MSc, FIDSA — Medical Director, Digital Health, UW Medicine

Andrew Solomon, MPH — Senior Program Manager, Northeast Telehealth Resource Center

Haley Taylor, LCPC, LGADC, ACS, NCC — Behavioral Health Director, Shepherd’s Clinic

Chinle Service Unit Approaches to Telemedicine During the COVID-

19 Pandemic

Stephen Neal, PA-C, Chief Of Staff, Chinle Service Unit (CSU), Informatics

Indian Health Service

Navajo Nation Diné Bikéyah

15

• 27,000 mi2 (~the size of West Virginia)

• Largest Reservation in USA and most populous 1

• 2010 census 160,000 living on the reservation

• 30% without running water or indoor plumbing 2

• 10%-20% lack access to power

• Geographically isolated

• High poverty index

Canyon De Chelly: Chinle

Photographer: Ansel Adams

16

• 55 bed hospital/ outpatient facility

• Federal facility in the middle of the reservation

• Approximately 120 members on the medical staff

• 40,000 outpatient visits annually

• 25,000 ER visits annually

• Main 3rd party payor is Medicaid, >2/3 of our visits

• Indian Health Services ( IHS )

Location: Chinle

Photographer: Nina Ritchie

Pink is the CSU

The Chinle Service Unit (CSU)

17

Services at the CSU

Emergency Med

OB/Gyn/Midwifery

General Surgery

Anesthesia

Pharmacy lab

Radiology

Native Medicine

Public health Dept

Cardiology

Family Medicine

Internal Medicine

Pediatrics

School-based Teen Clinic

Dental

Optometry

Physical Therapy

Occupational Therapy

Audiology

Nutrition

Infectious Disease

Psychiatry Adult/Child

Counseling Services

Integrated Behavior Health

Speech Language Pathology

Everyone practices to the full scope of their license Location: Chinle



SARS-CoV-2: Covid-19

15

Heat map of reservation July 24; 2193

cases in Chinle

Apache County 4050

per 100,000

July 24

Multiple deployments: FEMA, National Guard, and others

Lock down and curfew

1/1…

1/8…

1/1…

1/2…

1/2…

2/5…

2/1…

2/1…

2/2…

3/4…

3/1…

3/1…

3/2…

4/1…

4/8…

4/1…

4/2…

4/2…

5/6…

5/1…

5/2…

5/2…

Series1

Challenges of COVID-19

• March 6th Public Health Emergency

• Outpatient services closed

• Underserved and marginalized patient population,

many with comorbidities

• Increasing number of cases/testing

Lots of challenges, maybe we could apply

telemedicine as a solution?

19

A perfect storm… if you will

Location: Chinle


Telemedicine Set-up Pre-COVID

20

• Some telemedicine equipment had already been purchased and ready to plug in: DX80 Codec dedicated to

audiovisual, 8865(VOIP w Camera)

• Cisco call manager for VOIP communications (Phone calls over the internet)

• CSU campus has adequate internet (~25 mbps)

• Cisco Web RTC telepresence platform had been developed by HIS

Home-grown, user-friendly platform met federal security requirements

• FirstNet

Cisco IP Phone 8865 DX 80

Challenges with Telemedicine at CSU

21

• AZ is #36th State in Broadband coverage in USA 2

• The state average is 79 mbps

• Only 0.16% of Apache County residents has access to 25 mbps…

• The next lowest in AZ is la Paz 51.7%

Apache

La Paz

What is broadband?

High speed Internet access via numerous modalities (i.e. Fiber, DSL,

Cable, Fixed Wireless (Cellular))

Our patients lack access to reliable, affordable broadband

CSU Telemedicine Response to COVID-19

22

• Novel application in multiple domains:

Specialty Clinics

Primary Care high risk case management group

Respiratory Clinic

Emergency Department

• Nephrologists on the reservation generally visit several sites across

the Navajo Nation

• Concern about providers exposing patients due to multiple site visits

• Patient population is largely elderly and high risk

• Canceling clinics meant patients would have to travel off-reservation

for specialty care (>100 mi one way)

• CSU set up telemedicine for nephrology clinics to address concerns

raised by the pandemic

• Some resistant to adopting telemedicine

23

Specialty Clinics and COVID-19

Nephrology

Location: Chinle, Lukachukai, Tsaile


Yaadila = “Good Grief”

• 7 Nephrologists participated

Get VPN access for them to chart in our system (i.e. place orders, review

results etc)

Train on the telemedicine platform

Have access to IT support to troubleshoot issues

• Benefits of CSU telemedicine set-up:

One of our most high-risk patient populations was able to be seen during

pandemic while minimizing the risk of exposure to COVID-19

Operational with in 10 days

No fancy equipment, just a computer (web camera, internet, microphone) and

cisco meeting platform

Patients still must come to the facility for visit although reduced, still some

risk.

24

Specialty Clinics and COVID-19

Nephrology

TM HACK TIP:

1. Stakeholders are fundamental in the process: Nephrologists were resistant to the change. Clinic nurse supervisor and

hospital admin supported it. Currently, ALL the nephrologists love it.

2. Use what you have: Telemedicine equipment was on back order, a basic desktop worked well.

• CSU has a risk stratified group of primary care patients that have identified

as warranting more intensive case management

High-risk patients with multiple co-morbidities, low health literacy,

few resources and/or of concern to their PCPs

• Patients are often difficult to reach, lacking reliable phone or internet

access

• Phone visits are not ideal for addressing complex problems

• In-person visits less desirable given importance of protecting these high-

risk patients from exposure to COVID-19 at the hospital.

25

Primary Care Challenges Due to COVID-19

Location: Chinle, Spider Rock


Bringing Broadband to End-Users

• FirstNet

• IHS has an Enterprise Mobile Service Program with FirstNet

• Federal program established in 2012 giving First

Responders priority in communication priority access to

available cellular networks, greater security, and other

benefits

• https://firstnet.gov/about (please see website for details)

• Public private partnership with AT&T

• FirstNet is for:

26

“First responders receive access to resources first, ahead of others. And there’s no throttling

for FirstNet users anywhere in the U.S. In times of crisis, first responders within the network

get first access to necessary resources through the automatic preemption capabilities of the

network.”

Primarily:

Fire, Law Enforcement

EMS, PSAP, EMA

Extended examples:

Healthcare, utilities,

transportation

Location: Chinle


https://firstnet.gov/about

24

• IHS HQ offered the CSU 2 tablets with access to FirstNet to explore novel

uses of this technology

• PCPs were asked to pick which of their high-risk patients most needed to

be seen

• Tablets were taken to patients’ homes via Navajo Nation health promotions

staff for telemedicine visits

• Able to have multiple providers see a patient in a single visit Diabetes

educators, Behavioral Health, Podiatry, PT, OT… etc.

• Small number (n = 20) but growing and well received

• Feedback:

Patients loved having their needs met in the field and avoiding COVID-19

exposure

Providers got time with complicated patients and maintained critical primary

care bonds

Tablet Program & COVID-19

TM HACK TIP:

3. Get input: Providers “If we had vitals this would be great for CHF patients…”

4. Build on what's working: Expanding to CHF clinic

25

• Large volume of respiratory cases demanded a new approach

• Patients vitals taken roomed and have visit from a on campus via

“remote” provider.

• Benefits:

Decreased PPE burn rate

Reduced contact with patients and therefore also probability of quarantine for

providers

Able to involve higher risk providers in patient care

High throughput High testing rate and rapid triage

High volume of billable visits (5,300 since March)

Rapid provider uptake of telemedicine platform

Respiratory Clinic & COVID-191/…

1/…

1/…

1/…

1/…

1/…

1/…

1/…

1/…

1/…

1/…

2/…

2/…

2/…

2/…

2/…

2/…

2/…

2/…

2/…

3/…

3/…

3/…

3/…

3/…

3/…

3/…

3/…

3/…

3/…

3/…

4/…

4/…

4/…

4/…

4/…

4/…

RESPIRATORY CLINIC

Total Encounters >5,300 94% seen via telemedicine

Point to Point:

1. Via audio-video phone call between patient and provider

all located on campus

2. Had our telemedicine platform set up in the room and

just kept rooming patients.

26

We implemented Telemedicine in 4 environments with 2 basic

architectures:

Point to point on premises

• VOIP Phone call with Video

• Meeting space set up with

• Patients cycling through

Summary

Billing Licensure

• Arizona Medicaid already has generous reimbursement for

telemedicine visits Right now everyone does, no better time to

try innovating!

• We are federal facility; licensure is less critical (We take all)

• Medicare reimbursement structure likely to change

External

• Tablets using FirstNet

Future potential for the CSU and Telemedicine

27

Pipeline for the future Potential Growth (Ideas)

• Tele ICU

• Tele Stroke-Center (similar sized institutions have shown

return on investment, decrease in LOS, and decrease

mortality)

• Lactation (take home tablet and return)

• Hospice (take home tablet and return)

• Outfit EMS with Tablets for in the field consults

• What else…?

• Expanded use of tablets

• Field Clinic Kiosks

Chapter Houses, Senior Centers, etc.

• Additional Specialty Services:

Asynchronous Dermatology

Rheumatology

Endocrinology

Telemedicine is not a panacea, but it will be part of the future of healthcare delivery

TM Life Hacks

28

Advice

What Would I Do, If I Were You?

• Consult Telehealth Resource Centers (TRC)

Regional organization i.e. NATA

• Needs assessment, start where you need it

• I have a problem, is there a virtual solution?

• What do you really need?

Broadband Rural or city has options

Devices tablets $200-$400, vs dedicated audiovisual

equipment

Platform Large market out there, find one that meets your

needs

• If we can do it, so can you…

Use whatever internet you have

Start small and grow from there

Fail fast and frequently… reassess and adapt

Involve stakeholders

Remember Distance prevents… but Telemedicine can bridge

29

Ahéhee’ (Thank you)

Stephen Neal

928-674-7356

[email protected]

mailto:[email protected]


Your Telemedicine Questions,

Answered

Please submit your questions through the Q&A box


TRAIN is Your One-Stop Shop for TM Hack Resources

• Visit www.train.org

Login if you have an account, or create an account if you don’t have one

• To access discussion boards, including slides and archived recordings

Click on “Your Profile” (under Your Name on the top right) to access the “Manage Groups” screen

Enter “TMHACK” under “Join by Group Code”

Save your profile and then click the Discussions tab

• Other TRAIN benefits

HHS training certificate, if you complete 8/10 TM Hack sessions

Access to other public health/clinical trainings, including COVID-19 resources

http://www.train.org/

https://iecho.unm.edu/sites/unm/download.hns?i=26855


TRAIN Discussion Boards

• Discussion Boards (n=11)

8 topical boards

Getting Started in Telemedicine (Session 1)

Scaling Up & Sustainability (Session 5)

Equitable Access

Billing, Coding, and Reimbursements (Session 3)

Regulations, Compliance, and Documentation (Sessions 2 & 3)

Technology

Workflows & Integration (Session 2)

Miscellaneous

Specialty Connect

Slides, Recordings, and Session Materials

Telehealth Resource Centers (TRCs)


New Discussion Board Features

• Session Materials

Complete slide decks available same-day; Recordings available within several days

“Meet Our Panelists”—Expanded bios for Office Hours panelists

Transcripts of Q&A’s from all sessions (including some written answers solicited post-session)

Survey results

• Curated Telemedicine Resources

25 high-yield resources handpicked by Telehealth Resource Center (TRC) staff

Resources linked with corresponding discussion boards

Contact list for regional (n=12) and national coordinating (n=2) TRCs

• Developing processes for TRC staff to respond to your discussion board questions


Discussion Board Etiquette and Best Practices

• At the start of each post, please indicate the state/jurisdiction where you are from

For example, “David from MD…”

Many telemedicine issues are state-specific, and this helps ensure your questions are routed appropriately and

answered correctly

• We encourage the TM Hack community to make “Requests and Offers” of each other

Request Assistance—If you have a specific question or need help, ask the community

Offer Solutions—If you have successfully implemented telemedicine (fully or partially), go to the Discussion Board

and offer to help a peer(s)


“HHS Telemedicine Hack” Curriculum

Session #1: Telemedicine– Where Do I Start?

July 22nd, 12-1PM ET

Session #2: Workflows & Documentation


Session #3: Billing & Reimbursement– How to Do It Properly & Ensure Compliance


Session #4: Clinical Best Practices & the Art of the Tele-Physical Exam

September 2nd, 12-1PM ET

Session #5: The New Normal– Making Telemedicine Part of Your Permanent Practice

September 16th, 12-1PM ET

You are here

Office Hours # 1July 29th, 12-1PM ET



Office Hours # 4September 9th, 12-1PM ET

Office Hours # 5September 23rd, 12-1PM ET

GOALAt least 90% of participants will have conducted and billed 1 or more video-based telemedicine visits by

September 30, 2020


Happy Collaborating!

hhs telemedicine hack - project echo“hhs telemedicine hack” curriculum session #1:...

Documents