Quality Issues in Telepractice

Ad Hoc Committee on Telepractice in SLP

Session 1612November 20, 2009

100%QUALITY

Janet BrownASHA

jbrown@asha.org

What is Telepractice?

Telepractice is the application of telecommunications technology at a distance by linking clinician to client, or clinician to clinician for assessment, intervention, and/or consultation.

ASHA 2004 position statementwww.asha.org/telepractice.htm

A Rose By Any Other Name– Profession Specific

TelespeechTeleaudiologyTelenursing, teleradiology, etc.

– More GenericTelerehabilitation (American Telemedicine Assoc.)

– Even More GenericTelehealth, telemedicine

What Telepractice Is Not

– Distance supervision or mentoringClinical Fellows (allowed by CFCC)

Students (up to university)

Assistants (no guidance from ASHA; check with state)

– Distance education

Necessary Clarifications– Does it assume audio and visual

connection?– Are there specific standards?– What service is being provided, e.g.:

Synchronous (real time) connection with qualified provider?Access to online materials?Self-paced programs?Clinician-monitored programs?

ASHA Resources–ASHA Web page

http://www.asha.org/practice/telepractice/2004-2005 policy documentsLeader articlesVideo clip

–2008-2009 Ad Hoc Committee: Professional Issues document

–Advocacy for Medicare pilot for stroke rehab

Other Resources

– American Telemedicine AssociationTelerehab Special Interest Group

– Center for Telehealth and E-health law– Association of Telehealth Service

Providers

Pauline MashimaTripler Army Medical Center

Pauline.mashima@us.army.mil

The views expressed in this presentation are those of the author and do not reflect the officialpolicy or position of the Department of Army, Department of Defense, or the U.S. government.

Past“Telepractice will undoubtedly help our members fulfill their

obligation to improve access to clinical services.”

Telepractice and ASHA: Report of the Telepractices Team(2001)

“Only 11% are now using telepractice in delivering services to their patients…it is striking that 43% of the survey respondents expressed interest in using telepractice in the future.”

Survey Report on Telepractice Use Among Audiologistsand Speech-Language Pathologists

(2002)

Past– Barriers to Telepractice:

CostLack of professional standardsLack of data on efficacy and cost-effectivenessReimbursement policiesConcern about malpractice liabilityConcern about patient confidentialityLicensure laws that affect interstate practiceOther factors

Survey Report on Telepractice Use Among Audiologistsand Speech-Language Pathologists

(2002)

Present– Lessons learned to facilitate success:

Organizational readinessTechnological conditionsUser trainingClinical protocolsOutcomesClient and clinician satisfaction

– Quality issues in telepractice:Developing proposals for telepracticeOverview of current practice settings and modelsTechnology considerations and their impact on service deliveryLegal and ethical issues

Potential Initiative– Clinical intervention through telehealth will play an important

role in care for Wounded WarriorsIncreasing need for TBI assessment, treatment, and surveillanceShortage of TBI specialists to meet this need

– Telehealth delivery can improve TBI services and extendclinical activities across the continuum of care and recovery

Heterogeneous nature of TBI requires cooperation of many disciplinesServices need to be coordinated among military, VA, and community programs

Girard (2007). Military and VA telemedicine systems for patients with TBI.Journal of Rehabilitation Research & Development, 44(7): 1017-1026.

Future– Research is needed to:

Develop evidence-based guidelines for telepracticeProvide clinical outcomes data to substantiate reimbursement for services delivered remotelyPromote widespread acceptance of telepractice through positive scientific evidence to support its use

– Areas in which research is needed:TechnicalClinicalHuman factors and ergonomicsEconomic analyses

American Telemedicine Association(2006)

Developing Proposals For Quality Telepractice Programs

Vickie PullinsLinguaCare Associates, Inc.

vpullins@hotmail.com

USED THE EMAIL ADDRESS FROM WHAT’S IN NET FORUM?????

StakeholdersWho are the stakeholders?

State Department of EducationAdministrators and Teachers Chief Operating Officer of Medical FacilityMedical Support StaffIT Personnel of FacilityClinicians on staff

Why Telepractice?

IDEALimited access to servicesPersonnel shortagesRemote geographic areasTime limitationsCost effectiveClinical outcomes

Technology To Be Utilized

Specific equipment to be utilized and modes of deliveryDiscuss the necessary telecommunications and network links needed for the delivery of the programDiscuss the necessary environmental elements of care

Provider Qualifications

ASHA Certification

State Licensure

Liability/Malpractice Insurance

Telepractice Training

Client Selection

Discuss necessary pre-requisites for clients to be eligible for telepractice

Discuss obtaining consent for telepractice

Discuss clinical protocols

Use of Facilitators

Responsibilities of the facilitator

Utilization of current staff when selecting the facilitator

Facilitator training

Evaluation of Effectiveness and OutcomesDocumentation of clinical encounterDocumentation of client’s performanceEvaluation by student/client, physician, parent, teacher, administrator– Access to care– Timeliness of care– Continuity of care– Coordination and comprehensiveness of

care– Acceptability of care

Privacy/Security

Software and hardware applications with encryption

Virtual Private Network (VPN) software, including downloading and configuring VPN software for a modem backbone and satellite connections

Firewall applications

ReimbursementDiscuss Medicaid issues– Evaluations– Treatment– Care Coordination– Facility fee to the originating site (i.e.

school)

Discuss fees for service – Fees for SLP providing the services at the

distant site

Telepractice References

Share with the stakeholders the success stories of telepractice.

Include references with names and statements from the references regarding the success and satisfaction of the telepractice service.

Quotes

Parent - “My son really loves going to speech this year. He is disappointed when he cannot work with the speech therapist on the t.v. screen.”Teacher - “Telepractice has been amazing just to watch my students be more alert not only in seeing another person talk to them on t.v. but also enable them to improve their speech skills.”

Administrator’s Quote

“We have been very satisfied with the telepractice services. We will use telepractice again next year. Great job!”

Melissa O’BrienSpecial Education Director

Diana ChristianaClinical Communications

dianac@clinicalcom.com

SchoolsPrivate PracticeHome HealthClinicsMedical FacilitiesMilitary FacilitiesUniversitiesDay Care Centers

NeurogenicFluencyAlaryngeal SpeechVoiceDysphagiaChildhood Speech-LanguageHearing ImpairedAAC trainingAccent Training

Assessment

Intervention

Consultation

SHOULD THE WORDS ASSESSMENT, INTEVENTION, CONSULIOANLN .BE AT WITH THE BOX WITHIN A BOX?..

Mentoring

Family Education/Support

Team meetings

SHOULD THE WORDS ASSESSMENT, INTEVENTION, CONSULIOANLN .BE AT WITH THE BOX WITHIN A BOX?..

What is important? What do you need to be able to do to deliver quality service?

Audio and visual requirements

Sharing of materials

Modifications

Facilitator’s role

(281) 275-4242

DELETE THIS SLIDE SINCE INFO IS ON THE FIRST SLIDE???

David Brennan National Rehabilitation Hospital

david.m.brennan@medstar.net

• 1924 cover of Radio News• Radio still in its infancy• 3 years before first

experimental television transmission

Bonfires Telegraph Telephone Radio TV Digital Transmission Internet ???

“Telemedicine is the use of medical information exchanged from one site to another…”Live:

Participants are in simultaneous contact, typically using video and audio (and/or other signals)Real-time, synchronous

Store and Forward:Images, text, and other information are transmitted now for examination laterAsynchronous

Both methods can be used together

Technology makes telemedicine a realityThree roles for technology

Capture – Transmit – Display Information

CaptureInformation

DisplayInformation

Camera(s)MicrophoneMouse/keyboardSensorsRoboticsEtc.

Transmit

ConnectionsT1/T3Cable/DSLISDNPOTS

Computer ScreenVideoconf Equip Data LoggerWeb ServerEtc.

During a telemedicine interaction information is transmitted across a connection between participants at different sitesBandwidth is the measure of how fast information flows, i.e. the speed of a connectionYou can think of Bandwidth as a “pipe”

The bigger the bandwidth – thebigger the pipe – and the moreinformation that can flowthrough it

High Bandwidth connectionmore information can travel between sites in a given amount of time

Low Bandwidth connectionless information can travel between sites in a given amount of time

High BandwidthHigher Quality Audio/video

Faster, sharper video and smoother audio

Low BandwidthLower Quality Audio/video

Slower, fuzzier video and choppier audio

T1/T3Very high bandwidth, digital carrier technologies used for transmitting high volume voice, data, video

ISDN (Integrated Services Digital Network)high bandwidth, all-digital replacement for POTS

Cable modem servicehigh bandwidth, uses cable television coaxial wiring

DSL (Digital Subscriber Lines)high bandwidth, uses analog phone lines

POTS (Plain Old Telephone Service)uses standard analog telephone service

Firewalls

Hardware

Software

VPN

HIPAA

Technology must facilitate and promoteclient-clinician interaction

In some cases, technology may offer the opportunity to enhance and expand interaction

Face-to-Face Interaction

=Telerehab

Interaction

Telemedicine lies at the intersection of humans and technology

Environment

Organization

Telemedicine TechnologyPersonnel

Personnel are involved in all stages of telemedicine planning, training, implementationTelemedicine “users” are broad and varied

Therapists, nurses, aides, doctors, patients, caregivers, IT, support staff, administrators etc.

Each user’s response to telemedicine will be affected by his or her own level of technical expertise, physical capabilities, expectations, and organizational cultures

Clinical need MUST drive technologyAVOID “Technology Push”

Service to deliver• Assessment, treatment, monitoring

Information to transmit• Images, video, documents, EMRs, sensors,

etc.

Technology to implement• Type/format/size of data• Speed of transmission (bandwidth)

Features (“bells and whistles”) alone don’t make a specific technology the right choice…Essential considerations:

Clinical functionalityUsability (learnability, usage, error tolerance, etc.)Economic feasibility (start up and maintenance costs)

Telemedicine “users”:Clients, family members, caregivers, clinicians, assistants/aides, researchers, support staff, etc…

“Off-the-shelf” technology is powerful, but might not be exactly what is needed

e.g. modifications may be neededDocument cameras, fax machines, etc…

There’s no section in the User Manual for “How to conduct a telehealth session”Most Important…

Technology shouldn’t get in the way!

As technology improves…opportunities to deliver a wider range of services at a distancePotential clinical advantages:

Rehab in the “natural” environment is the goalMonitor transfer of trainingEnhance compliance with protocolsPatient-driven proactive healthcare

Clients will expect (and demand) high quality, technology-enabled healthcare

David Brennan, MBESenior Research EngineerCenter for Applied Biomechanics and

Rehabilitation ResearchNational Rehabilitation HospitalWashington, DCdavid.m.brennan@medstar.net202.877.1963

DELETE THIS SCREEN SINCE CONTACT INFO IS ON SLIDE 8???????????????

Diana Christiana

TeamAdministrationIT Support SLPFacilitator

EquipmentTrainingCaseload Management (individual and groups)

Helper

Escort

Behavior Manager

Liaison

Troubleshooter

Lesson on citrus fruit-School Setting

Student’s view-School Setting

• Allows for Picture in Picture

• Therapist can control camera on the school’s side with the remote control

• Zoom in on a particular student when needed

• ELMO, document camera (pictured on theleft)

The school speech therapy room requires a minimum of a 32” monitor to support groups.A document camera encourages spontaneousmaterial sharing.Far end camera control is a benefit in managing groups and for “close-ups”.Using technology that the school is familiar with is beneficial.Kids love technology!

David Brennan

TeamSLPCoordinator/SchedulerIT (Tech Support)SLPFacilitator

EquipmentVideoconferencing with integrated data sharing“Virtual Desktop”

Training

Diana ChristianaClinical Communications

dianac@clinicalcom.com

David Brennan

TeamSLPCoordinator/SchedulerIT (Tech Support)SLPFacilitator

EquipmentVideoconferencing with integrated data sharing“Virtual Desktop”

Training

Mr. F.51 year-old maleLCVA (5 months post-onset)Mild-mod aphasia, mod apraxia of speechAttorneyProficient computer userDischarged from SLPfollowing inpatient stay dueto lack of insurance coverage

Service Delivery ModelsHub-SpokeHome TelehealthResearch

Each space/location must be appropriate for service delivery

SoundLightingPrivacy

AV OnlyAudio-Visual Interaction

Only

AV + DataAudio-Visual with Shared

Data Interaction

Mr. Y.68 year-old maleLCVA (21 months post-onset)Mod-severe apraxia, mod non-fluent aphasia, mod dysarthriaRetired grocerNo prior computerexperience

Mr. F.51 year-old maleLCVA (5 months post-onset)Mild-mod aphasia, mod apraxia of speechAttorneyProficient computer userDischarged from SLPfollowing inpatient stay dueto lack of insurance coverage

Legal and Ethical Issues  in Telepractice

Michael CampbellThe University of North Carolina 

M_campbe@uncg.edu

Regulation of Telepractice

State Licensure• State Authority• Current Status of State Licensure Laws and Regulations 

• License in Telemedicine– Full license– Special license/certificate 

Regulation of Telepractice (cont.)

State Licensure (cont.)• Alternative License Possibilities

– Negotiated reciprocity – Mutual recognition – Registration – Limited licensure – National licensure 

Regulation of Telepractice (cont.)

Credentialing• Providers

– The Joint Commission:                                               Telemedicine Credentialing Standards

– Specialty Credentialing Standards• Telemedicine Sites

Telepractice Malpractice Liability

• Jurisdiction• The Practice of Telehealth

– The Clinician‐to‐Patient Relationship– The Clinician‐to‐Clinician Consultations

Telepractice Malpractice Liability(cont.)

Standard(s) of Care• Suitability of telepractice • Clinical standards specific to telepractice• Voluntary standards for telepractice practitioners

Telepractice Malpractice Liability(cont.)

• Informed Consent• Apportionment of Liability• Insurance• Telepractice Equipment• Risk Reduction

Privacy of Electronic Health Information

• Concepts of Privacy, Confidentiality and Security

•Health Insurance Portability and Accountability Act of 1996

•Other Federal Restrictions• International Restrictions• Application of Privacy Restrictions to Telemedicine

E-Health and Antitrust

• The Antitrust Laws

• Issues in Application to E‐Health

Fraud and Abuse

• Kickbacks and Financial Inducements for Referrals

• Exclusion Remedies• Stark Act• Potential E‐Health Fraud and Abuse Issues

References

Fleisher, L.D., & Dechene. J.C.(2009). Telemedicine and E‐Health Law. New York, N.Y: Law Journal Press.

The revised standards, effective January 1, 2004, are contained in the “Medical Staff” chapter of JCAHO’s 2004 Comprehensive Accreditation Manual for Hospitals.