telemedicine sw clinical society
TRANSCRIPT
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Telemedicine, Today and TomorrowDavid Voran, MDSouthwest Clinical Society Kansas City, 10/29-31/2015
http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
+Agenda and Objectives
Review the status of telemedicine globally and locally Legislative, reimbursement initiatives, interstate
licensing and ACA effect Examine newer technologies and services available to
clinicians Make some projections
http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
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Where is telemedicine today?… an update of sorts
Objective 1
http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
+Growth Types in Telemedicine
Traditional hub and spoke telemedicine encounters increasing organically Over 200 networks with 3,500
service sites in US Over half of US hospitals
using some form of telemedicine
Adding more spokes Specialty driven telemedicine
expanding primarily in ED’s Provider-to-Provider
consultation
Retail telemedicine pilots are expanding and gaining traction
Portal-based telehealth services are normal part of practice
Direct to consumer services popping up spurred by ACA
Organic – Logarithmic Inorganic - Exponential
+Telehealth Growth Curve
HIS Telehealth Report 2014
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Organic Growth continues in Hub and Spoke NetworksAvera eCare
+Expanding Telemedine’s reach:In-House TelemedicineNebraska Medical Center
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eVisits Booming“Almost one in six doctor visits will be virtual this year”
Up 400% since 2012
eVisits have … saved UPMC an average of $86.80 per member visit compared with the cost of an office visit
This year [2014] in the U.S. and Canada, 75 million of 600 million appointments with general practitioners will involve electronic visits, or eVisits
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Medical Centers Jumping In
+ Mid-Level Telemed “Load Balancing”
CVS Minute Clinic Experience California
Off loading volume to remote APRNs Lower level LPN performs registration and
hands on Remote APRNs are MC providers in the same
state who are in-between live patients Over 4,000 visits in last year Reimbursement same as face-to-face Survey results (1,700 patients)
33% prefer video to face-to-face, 50% liked it about the same and 10% found it worse
+Retail Telemedicine Expansion
Collaborative Coverage Physician shortages Rate limiting steps
Chronic condition management Cooperation with IDN CCM reimbursement not
dependent on face-to-face visits
Increasing range of services Beyond APRN scope of
practice Clinic expansions
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Kicking it up a notchLooking at where telemedicine industry is really heading
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Telemedicine Studio in your Pocket
Nearly every smart phone owner has more resolution, bandwidth and capability than all telemedicine facilities built in the 1990’s.
How many of you do
telemedicine?
+Daily “telemedicine”
Phone messages Patient Portal eVisits Retail direct-to-consumer
Low cost answers to questions
Phone conversations Peer based
videoconferencing Face Time Skype
Retail direct-to-consumer Most by phone Maybe 10% video
Asynchronous Synchronous
+My own experience with e-Visits using Vgo Robot Inexpensive, ad-hoc use of
mobile systems
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Dabbling in Retail VisitsSigned up with HealthTap
+Other developments
75% of large employers would be offering telemedicine benefits for employees within the next year
57% of broadband households access at least one portal per month
ACA health plans are or will be offering telehealth coverage in most plans
Health insurers offering their own telehealth or video consults for enrollees
mHealth use expanding Most new devices capable
of measuring some health parameters
+Telemedicine Savings
Would require all employees and dependents to use technology-enabled interactions in lieu of face-to-face visits
37% employers will offer telemedicine consultations in 2015
> 80% of insurance providers to offer telemedicine reimbursement by 2019
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Legislative Updates and Initiatives… still struggling with “what IS is”
Objective 2
Legislative Arena
+Medicaid.gov
Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.
Means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.
Asynchronous or “store and forward” applications would NOT be considered telemedicine but may be utilized to deliver services.
+HIPAA
Does NOT consider an interactive video consultation to be protected health information, so it does not govern telemedicine encounters.
Not considered PHI unless it’s recorded.
Device encryption and a private internet connection are recommended for patient security and privacy.
Most videoconferencing tools are encrypted.
Other types of telehealth, such as the transmission of patient data or images, ARE considered protected health information and must be managed according to HIPAA requirements.
Fine line between real-time video transmission and the same interaction that is being stored.
+Medicare Reimbursement
Performed By Physician Nurse Midwife Clinical Psychologist Registered Dietitian Clinical Social Worker
Originating Site (Patient) Office (Physician/NPA) Hospital Critical Access Hospital Renal Dialysis Federal qualified health
center Skilled Nursing Facility Community Mental Health
Center
Charges E&M + Facility ($24.24)
HCPCS Q3014 Type of Service “9, other
items and services”
+Legislative Action
Fostering Independence Through Technology Act Sens. Amy Klobuchar (D-Minn), John Thune (R-S.D.)
TELEhealth for MEDicare (TELE-MED) Act of 2013 Reps. Devin Nunes (R-Calif) and Frank Pallone (D-N.J) HR 3077
H.R. 5380 creates a phased approach over four years to expand coverage of telemedicine-provided services and remove arbitrary barriers that limit access to services for Medicare beneficiaries. Included in these provisions are the gradual removal of geographic restrictions to patient care, and the addition of coverage for healthcare services that take place in other locations such as the home and walk-in retail health clinics
+Federation of State Medical Boards Interstate Medical Licensure Compact
Expedited license Recognized by all member states Compliments, does not replace existing State
licensure
Interstate Medical Licensure Compact Commission Administrate physicians applying for this type
of license
Spearheaded by Wyoming State Board of Medicine Requires a minimum of 7 states to participate Looking to form in 2016
+Available Guidelines
Formal Policies and Procedures Guidelines and Consensus
Documents Operational Procedures Foundation for formal deployment
American Telemedicine Association
+Telehealth Grades for States
+States with Telemedicine Parity
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What’s Happening Around Here?…probably more than most of us realize
Local Activity
KU Center for Telemedicine &
Telehealth
+Report Cards 2014
+2015 Grades
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KU Med Telemedicine Overview
Eve-Lynn Nelson, PhDDirector, Center for Telemedicine & TelehealthProfessor, Pediatrics(913) [email protected]
+Kansas
Medicaid covered some TM services since 2004 Physician, Psychotherapy,
Pharmacological management – GT modifiers
Requires patient to be present at originating site
Requires State Licensure
Kansas Center for TeleMedicine & T
eleHealth Kansas Medical Center 60 nodes 4,500 (1,500 unique pts)
Become more research oriented Dependent on grants
Exploring using system to provide urgent care for whole state
+KU Center for Telemedicine and Telehealth Approximately 4,000
consults per year across 40 providers
Behavioral consults most common
Traditional model in supervised settings
Team-based services with trainee participation
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Kansas iCare
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Project Echo MissionTo expand the capacity to provide the best practice care for common and complex diseases in rural and underserved areas and to monitor outcomes
Extension for Community Health Outcomes
+Missouri
HB 986 – prohibits plans from denying telehealth coverage and reimbursement (7/2013)
Covers services that would have been delivered in-person
Mo-Healthnet requires 2-way interactive video
No restrictions on type of technology being used No store and foreward
reimbursement Require prior face-to-face physical
exam
Defined clinical locations Hospital, CAH Rural Health Clinic Federally Qualified HC Nursing Home Dialysis Center Mo State Rehab Center Community Mental Health
Requires State Licensure Missouri Telehealth Network
University of Missouri, Columbia 202 node MOREnet 2 gigabit
backbone
Missouri
+Missouri Telehealth Network
Psychiatry47%
Dermatology19%
Autism19%
Ped En-docrinology
5%
Neurology4%
Other5%
2011-2012 Encounters
+Why Isn’t Telemedicine the Norm?
TM visits reimbursed at lower rates than face-to-face visits
RVU based productivity Parochial nature of
medicine Site-specific credentialing State licensing
requirements
Store-and-forward prohibition
Scheduling issues Culture of convenience
E-mail, texting favored over synchronous communication
Regulatory and Reimbursement Logistics and Culture
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The Future of Telehealth…where it becomes personal
Objective 3
+ Activity tracking devices + Apps Fitbit, Fuel band, Vivofit, Gear
Biometric monitors External
Implanted medical devices
Quantified Self Movement
+Game Changers
Devices (moving out of the exam room) AliveCor ECG Cellscope Proscope Fitbit
Services Cloud based storage and sharing Multimedia Patient Portals Embedded video conferencing Communities (Fitbit)
FDA approved mobile apps and devices.Selling to patients directly.
Allowing them to record and share with physicians, family and friends…pushing cost and control to patients (Consumer Directed Care)
+iOS Health KitApple WatchHealthcare embedded into operating systemsEnhancing real time researchOpenning door to real-time clinical population monitoring and intervention
Will the exam room survive?
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+Convenience +Coverage+Consumerism
Time Magazine, November 9, 2015
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+Convenience +Coverage+Consumerism
Time Magazine, November 9, 2015
+Forecast: Telemedicine Potential
Operational costs of clinics and hospitals become unsustainable
Reimbursement paradigm reaches inflection point Telemonitoring capabilities embedded in all devices Adequate universal spectrum
When…
…we’re close
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Will we be ready?