telemedicine, today and tomorrow for southwest clinical society
TRANSCRIPT
+
Telemedicine, Today and
Tomorrow
David Voran, MD
Southwest Clinical Society
Kansas City, 10/29-31/2015
+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
+
Where is telemedicine
today?
,,, an update
Objective 1
+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
+
Organic Growth
continues in Hub
and Spoke NetworksAvera eCare
+
Expanding
Telemedine’s reach:
In-House
TelemedicineNebraska Medical Center
+
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
+
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
Rate limiting step
Chronic condition management
Increasing range of services
+
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.
+Retail gets personal
+Really?
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
+
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
+
Legislative Updates and
Initiatives
… still struggling with “what IS is”
Objective 2
+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.
As long as it’s not recorded it’s not PHI?
Device encryption and a private internet connection are
recommended for patient security and privacy.
Most telemedicine equipment encrypts transmission.
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.
+
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
+
What’s Happening Around
Here?
…probably more than most of us realize
Local Activity
KU Center for
Telemedicine &
Telehealth
+Report Cards 2014
+2015 Grades
+
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 & TeleHealth
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
37
+
Kansas iCare
+
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
outcomesExtension 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 forewardreimbursement
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 Endocrinology
6%
Neurology4%
Other5%
2011-2012 Encounters
+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
+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
+
The Future of Telehealth
…where it becomes personal
Objective 3
+
Game Changers
Activity tracking devices + Apps
Fitbit, Fuel band, Vivofit, Gear
Biometric monitors
External
Implanted medical devices
“Quantified Self” movement
Smart implantables
+ Devices
AliveCor ECG
Cellscope
Proscope
Fitbit
Services
Fitbit
Skype and FaceTime
Patient Portals
+
iOS Health Kit
Apple Watch
Healthcare embedded into operating
systems
+Forecast: Telemedicine Potential
Operational costs of clinics and hospitals become
unsustainable
Reimbursement paradigm changes
Telemonitoring capabilities embedded in all devices
Adequate universal spectrum
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