telehealth: opportunities and challenges for home-based delivery deborah a. randall, jd &...
TRANSCRIPT
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TELEHEALTH: Opportunities and Challenges for Home-Based Delivery
Deborah A. Randall, JD & Consultant
202-257-7073
www.deborahrandallconsulting.com
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Electronically Enabled Care Delivery in 2012
HIT = Health Information Technology HIE = Health Information Exchange EHR = Electronic Health Record EMR = Electronic Medical Record PHR = Personal Health Record ONC = Office of the National
Coordinator for HIT [DHHS]
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American Telemedicine Assn
Extensive materials on-line and training. Creating standards for practice in telemedicine and telehealth. Lobbying for expansion.
Working groups in new areas. I chair palliative care and end-of-life.
www.americantelemed.org
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Survey 2010: eHealth Initiative
61% of respondents agree or strongly agree that significant progress has been made in the successful adoption and use of HIT since 2007.
BUT 54.9% disagree or strongly disagree the value of HIE is clearly understood &
66.6% disagree or strongly disagree outreach on value of EHR/HIE is effective
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eHealth Survey, cont.
55.5% of respondents disagree or strongly disagree that differences between federal and state privacy laws are not a barrier to consumer’s rights to healthcare privacy.
56% agree or strongly agree that HIT and HIE have had a positive effects on care delivery.
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Evolving Definitions
Telemedicine vs. telehealth Doctor to doctor d2d Doctor to patient d2p Distance learning Remote monitoring eCare eHealth mHealth “Smart” homes
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Developments & Trends
New Medicare Reimbursement Possibilities: Reviewed annually; patient must be in a rural or underserved area.
Devices as diagnosis-enhancers Infrastructure for Telemedicine and
Telehealth Legislation
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“Originating Sites”
office of a physician or practitioner Hospitals; Critical Access Hospitals Hospital or CAH-based Renal Dialysis
Centers (including satellites) Community Mental Health Centers
Rural Health Clinics; Skilled Nursing Facilities ;Federally
Qualified Health Centers (FQHC);
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Practitioners
Nurse practitioners NP Physician assistants PA Nurse midwives; Clinical nurse specialists Clinical psychologists & social workers (but
not billing psychotherapy that includes medical and management services under Medicare)
Registered dieticians; nutrition professionals
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Medicare Coverage Expansion
Telehealth consultations, emergency department or initial inpatient
Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs
Office or other outpatient visits Subsequent hospital care services, limited to
1 telehealth visit q 3 days
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Medicare Coverage Expansion
Individual and group health and behavior assessment and intervention
Individual psychotherapy, Pharmacologic management, and Psychiatric diagnostic interview examination
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Medicare Coverage Expansion
Individual and group Kidney Disease Education (KDE) services;
Individual and group Diabetes Self-Management Training (DSMT) services;
Group Medical Nutrition Therapy (MNT) services;
Smoking cessation
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LEGISLATION 2009-2010
HITECH ACT 2009- Stimulus Bill
HIT Policy Committee of ONC
Infrastructure got first funding
Aging Services Technology Study
PPACA – Health Reform Act 2010
Independence@Home;Medicaid Medical
Home; Chronic Care; Innovation Center
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HighTech Telehealth Impact
A. $2 billion Office of the National Coordinator– Regional health information exchange efforts and state-based “extension centers"– Health information enterprise integration- Big grants
B.Medicare and Medicaid provider and hospital incentive to adopt and use health IT through “meaningful use”
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HIGHTECH, cont.
– Indian Health Service health IT
– Community health centers for health IT acquisition
– Social Security
– $1.1 billion for comparative effectiveness research
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BEACON: $16+Million Buffalo
Western NY Info.Exchange clinical decision support –registries +
point-of-care alerts/reminders innovative telemedicine =improve
primary/specialty care for diabetics, ↓ preventable ER visits, hospitalizations re-admissions for diabetes, CHF, pneumonia; ↑immunization of diabetics
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Patient Protection and Accountable Care Act of 2010
“PPACA” --This is where the expansion will continue to be.
PPACA drives the process towards management of chronic disease.
Health information technology is finally showing, with reliable data, that telehealth can integrate with traditional care and use staffing innovations.
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PPACA
Post-hospitalization bundling pilot Independence at Home
demonstration Innovation Center at DHHS; policy
includes strong telehealth focus ACOs Medical Home-Medicaid and Pilots
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Ohio Projects from PPACA $$
Cleveland Clinic Homecare was selected for Independence at Home
Univ Hospitals of Cleveland got Innovation Award of $12.7million to transform pediatric care through health care advice, referrals, and care coordination services through telehealth and home nurse hotlines;
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Blue Cross/Blue Shield WNY
Blue Cross/Blue Shield Western New York in May 2010 initiated online physician-patient communication as a compensated service; encouraging telehealth communications and webcam visits; measuring quality of care and patient compliance factors
Hawai’I HMO doing major telehealth
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Scope and Payers
Home-based telehealth mostly chronic care management => avoid ER & re-hospitalizations. Provider funded; grants.
Medicaid pays some telehealth visits. Home as “originating site” NOT
reimbursed by Medicare. Skilled nursing home= live consultations in rural or medically underserved area
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Technology-enabled Community Care
Satellite health facilities In situ care w medical devices Remote monitoring and sensors Awareness and acceptance European efforts in ambient care The VA system –the Vanguard
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Telehealth Expansion
Care coordination and Chronic Disease
Patient self-management Ambulatory care and safety Palliative care Rehabilitative services Behavioral & mental health services
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CMS Comprehensive Primary Care Initiative
4 yr program represents > 2000 primary care doctors and nurse practitioners in seven markets
care management fee supports enhanced, coordinated bene services
participating commercial, state, other federal insurance plans offering enhanced payment
This
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designed to test a model of improved access to quality health care at lower costs. The 500 practices were selected through a competitive application process and will start delivering enhanced health care services this fall.
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OHIO AND KENTUCKY
the Ohio counties of Adams, Brown, Butler, Champaign, Clark, Clermont, Clinton, Greene, Hamilton, Highland, Miami, Montgomery, Preble, Warren and the Kentucky counties of Boone, Campbell, Grant, Kenton
75 primary care practices; 261 providers; Ohio Medicaid and others
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VA Chronic Care Coordination Telehealth Report 12/08
CONDITION # % DECREASE UTILIZATION
Diabetes 8,954 20.4
Hypertension 7,447 30.3
CHF 4,089 25.9
[congestive heart failure]
COPD 1,963 20.7
[chronic pulmonary obstruction]
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VA Chronic Care Coordination via Telehealth Study, cont.
Posttraumatic stress disorder 45.1% Depression 56.4% Other mental health condition 40.9% Single condition 10,885 patients;24.8% Multiple “ “ 6,140 patients;26.0% Interventions “just in time”; “air traffic
control”
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VA Chronic Care Coordination via Telehealth Study
The cost ($1,600.24 pp/yr compares favorably)
direct cost of VHA’s home-based primary care services of $13,121.25 per annum and
market nursing home care rates that average $77,745.26 per patient per annum”.
Conclusion: a flexible and cost-effective adjunct to VHA’s existing services. Darkins et al., Telemedicine & EHealth, 12/2008.
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Telehealth: Dementia Patients
Residential facilities designed to allow movement of individuals through facility and grounds; Families can track on computer/internet based systems
Sensoring systems; Intel research; TRILL; diagnostic sensoring for fall prevention yielding data on Alzheimer specific movement differentials
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Telehealth:Dementia Patients
AlarmTouch GPS is a personal safety phone with GPS location in Europe. The telecare device includes a ‘Geofencing’ feature, enabling accurate location of users in need. When the wearer wanders outside a specified zone – such as home or school area - the system can send a short message (SMS) alert to a monitoring centre or to a relative or caregiver.
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Ambient Assisted Living Programme - EU
23 EU member states with support of European Community [EC]
-Enhance quality of life of older people-Strengthen industrial base by use of Information and
Communication Technologies [ICT]-Aging well at home, community and work-Coherent framework for research into solutions which
are compatible with varying social preferenceswww.aal-europe.eu
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What are the New Directions?
Tele-rehabilitation; Falls prevention Tele-mental and behavioral health Continuous monitoring: diabetes;
cardiac Impaired; Alzheimer’s & dementias “Wellness”
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Telehealth and Rehabilitation
Distanced assessments Robots in SNFs Telestroke => telerehab Wii units in senior living facilities Remote monitoring for falls anticipation Traumatic brain injury;wounded warrior
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Behavioral & Mental telehealth
On-going research Post traumatic stress disorder Tele-psychiatry Distanced mental health services
under new Medicare reimbursement provisions for community mental health centers
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VA Rapidly Expanding Behavioral Health Outreach
Major projects to help with PTSD and other mental and behavioral concerns of wounded warriors
Use of local centers and distanced mental health specialists
Use of internet-based programs along with Skype-type live sessions
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Palliative Care
Pain and symptom management Outreach and crisis management Triage without transporting to facility Psychological pain and suffering Diagnostic opportunities; family
interactions Ethical principles= autonomy enhanced
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Advanced Illness –Is there a Role for Telehealth
Using an existing model. Kaiser’s Advanced Illness Coordinated Care Program (AICCP) included health counseling
developed for patients with advanced illness (congestive heart failure, end-stage pulmonary disease, end-stage renal disease, and cancer) in 3 settings of a multistate health plan.
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Expanding a model, cont’d.
Improved communication about discomfort, support for decision making;
Advance directives (5.5 mo.);problem resolution; attention to caregiver needs.
more agreement to do-not-resuscitate or intubate orders; <inpatient admits with no difference in survival.
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Opportunities and Challenges
Medical Director and other physicians Demonstrating cost savings, &/or
quality of care/life improvements- to justify expense of equipment and staff
Training and staffing. Maintenance of depth of field/bench so turnover is not a problem. Need for a "champion".
Leading nurses to embrace technology
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Telehealth: Impediments
Medicare Reimbursement and Coding Medicaid Grants Outcomes, cost savings and Disease
Management concerns Licensure and interstate barriers Standards; Interoperability among
devices/software/infrastructure
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Compliance Concerns
Licensure and Credentialing Under-serving patients; Liability Consent Reimbursement and Documentation Management of the Case Privacy and confidentiality Security of Communication Fraud and Abuse
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Licensure
Many states –New York is one--bar physicians from practicing via telehealth without a full or partial new license => quality; control as issues
Some states licensing the entity which arranges for/participates in telehealth
Therapy associations “waking up” Nurses more sane but States not
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Credentialing
HHS concessions on no need for physicians and other health professionals to have admitting privileges at “receiving” institution where patient is located who gets telehealth.
Next steps for Compliance Officer
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HHS Concessions in Rules
76 Fed Reg 65891,65893 (10/24/11) c HHS wants to “provide hospitals the clarity and flexibility they need under federal law to maximize their staffing opportunities for all practitioners,.. particularly for non-physician [s].. under ..States’ laws.”
Final Rule satisfied most but still costly.
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AMA --Conservative Stand
AMA has issued practice code guidance suggesting all physicians must see a patient in-person to establish a physician relationship
AMA has raised ethical issues AMA opposed to Rx on-line AMA self-interest?
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Health Insurers More Positive
Move to use telehealth for patient management and reduction of cost
States requiring insurers to cover on a parity basis with regular health care
Rates of payment do not vary in Medicare, so why should they in private insurance.....or should they?
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Liability-Consent-Management
Medical device or simply a conduit of information
Manufacturer; Software vendors will seek total immunity from exposure
Patients need to hear from physicians and health entity about conditions, errors and backup response
Malpractice Insurers may be ignorant
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“Under-Serving” a Patient in Need? Not likely but.....
Civil Money Penalties Act concerns Loss of Provider Arrangement If telehealth is not a Medicare-covered
home visit, is it still a “visit”, an “encounter”, a service or an accessory? Is it a patient inducement? –OIG Advisory Opinion from 2000 suggests not (when not advertised.....)
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Impediments to Data Exchange
State privacy laws HIPAA Congressional focus HITECH and other HIT bills
resulted in Strong language extending privacy protections including business associates.
Telemedicine and telehealth raise HIPAA issues on transmission, storage, security, “use” and authorizations grounds, at least
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HIPAA Case $1 million fine....
Massachusetts Eye and Ear “failed to take necessary steps to comply with certain” Security Rule requirements: ensuring data maintained on portable devices, such as laptops computers, were protected & procedures in place for identifying and reporting data security incidents.
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Meaningful Use Regulations
The developments around electronic health records have concentrated on privacy and encryption.
First stages will be ePharmacy transmissions; see MLN Matters Number: SE1107 and version 5010 coding [began Jan 2012, with enforcement delay.]
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Texting? mHealth?
The UK’s NHS on tablet/iPad security:
“We have developed interim guidance these devices are currently not as secure as more traditional IT equipment. They should therefore not be used to store sensitive patient data and should, as with all mobile devices, be encrypted as necessary.”
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Texting? Joint Commission:
Not acceptable for physicians or licensed independent practitioners to text orders for patients to the hospital or other healthcare setting... no ability to verify the identity of the person sending the text .. no way to keep the original message as validation of what is entered into the medical record.
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Contracting Issues
When private pay, family members are the contracting parties
When you are subcontracted to another organization
When the HIT vendor writes the contract….Indemnification concerns and insurance issues
When the State intervenes
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Fraud and Abuse
Coordination of telehealth services vs.Impermissible incentive to referral source, including patient herself. -Limited OIG safe harbor
-OIG advisory opinions -Stark law :physician financial
interests - ACO guidances HHS and FTC
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RESOURCES
Final ACO regulations 76 Federal Register 67802 November 2, 2011
Final OIG waivers for ACOs, same Fed Reg, at page 67992.
OIG Advisory Opn 11-12, oig.hhs.gov/compliance/advisory-opinion and OIG e-prescribing safe harbor oig.hhs.gov/authorities/docs/06
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OIG Advisory Opinion 11-12
Advisory opinion regarding a health system’s proposal to enter into arrangements to provide neuro emergency clinical protocols and immediate consultations with stroke neurologists via telemedicine technology to certain community hospitals --Approved with caveats
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Discussion – Are you involved
Audience experience in telehealth Reluctance….and reasons Board reactions…have they been
educated about telemedicine and telehealth?
Can our society afford not to bring telehealth into our healthcare management situations?
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Thank You!
Deborah Randall, JD
Health Law Attorney
Telehealth Consultant
202-257-7073
www.deborahrandallconsulting.com
©2012 deborah randall