Dale C. Alverson, MDMedical Director, Center for Telehealth

University of New MexicoCMIO, New Mexico Health Information Collaborative

Telehealth in New Mexico: Need for Coordination and Collaboration

in the New Age of Healthcare Transformation

June 16, 2015

NMDOH TELEHEALTH PROJECT-SUMMIT

Health Care Reform/PPACA

Economic Downturn

Critical Shortage of Healthcare Providers

Emerging Enabling Information Communication Technologies

Need for more Access to Care

A Time for Telemedicine & e-Health

An Aging Population/Baby Boomers

EHR Adoption/HIE

PCMH

ACOs

Meaningful Use

ICD10/11

Telemedicine and eHealth:

The General Concept

Defining Telemedicine and Telehealth

“Tele-” comes from the Greek root word meaning “distant or remote”/ “at a distance”.

• Tele-phone• Tele-vision• Tele-graph• Tele-gram• Tele-scope• Tele-Etc, etc, etc

a combining form meaning “distant,” especially “transmission over a distance,” used in the formation of compound words

So What is Telemedicine/Telehealth?• The use of advanced telecommunications technologies to

exchange health information and provide healthcare services across geographic, time, social and cultural barriers (J. Reid)

• Telehealth is more than just video-conferencing and encompasses health information exchange and a spectrum of health information technologies

• It is simply the delivery of health services at a distance (A. Darkins)

“Back to the Future”

So What is e-Health?

• Healthcare practice supported by electronic processes and communication

• Includes Electronic Health Records (EHR), Computerized Physician Order Entry, and e-Prescribing

• Health Information Exchange (HIE)

• “Digital Health”

Health Information Exchange and Telemedicine :

A Complimentary Piece of the Puzzle

Telemedicine and Health Information Exchange (HIE)

• Telemedicine creates the “virtual” consultation and provision of service between providers and patients

= access to care

• HIE creates the consolidated “virtual” medical record about the patient from a variety of electronic health records and sources

= access to the patient’s health information

How is Telehealth & e-Health used?

• Clinical (“Telemedicine”): Direct Patient Care and Consultation, Case Reviews

• Educational: Providers, Students, and Patients

• Research: Community-based Participatory, Outcomes driven

• Public Health

• Administrative: Strategic planning, Operations

• Sharing Health Information

• Enhanced Disaster Response

• Becoming a Standard of Care/Part of Work Flow• Avoiding Unnecessary Variations in Care• Part of Patient protection and Affordable Care Act (PPACA)• The “Triple Aim”: Patient Centered, Improved Outcomes,

Reducing Costs• Prevention: Avoiding ED visits and Hospitalization• Pay For Performance (P4P)• Accountable Care Organizations (ACOs)• Impacting Ambulatory Sensitive Conditions• Patient Centered Medical Home (PCMH)

Telehealth as an Integral Part of Our Healthcare System

Telehealth and Health Information Technologies:

Part of the Solution in Creating the Medical Home and Enhancing Access

Hitting the Targets: “The Triple AIM”

ImprovePatient Access

Improve Health

Outcomes

Reduce Costs

Telehealth

Involving the Patient

Telehealth NetworksRural/Remote Health Providers Can Access Expert Medical Opinions, Knowledge, Education via Telehealth

Rural or Remote Location

Local HealthProvider

Patient

Specialty Medical Center

Medical Specialty

Teams

AudioHigh-Resolution Images & Video

Telehealth Network

ConsultationDirect Patient CareCase ReviewsEducationTrainingHealth Information ExchangeCommunity-Based Research

Student

Telehealth in New Mexico

Brief History of Telehealth Milestones in NM

• UNM Center for Telehealth founded through state legislation and started in 1995

• Other HealthCare providers becoming involved in Telehealth Activities 2000

• The ECHO project launched in 2003 as a Hepatitis C educational, case-review model

• NM Telehealth Alliance, non-profit 501c3 founded in 2004

• NM Telehealth Act passed into law 2004• Medicaid established Telemedicine rules in 2007• NM Telehealth and HIT Commission formed in 2007• FCC Southwest Telehealth Access Grid Proposal

approved 2007; Brings in $15.4 million federal funds for broadband connectivity

Brief History of Telehealth Milestones in NM (cont.)

• Parity telemedicine reimbursement laws passed in 2013

• Broadband Assessment and Recommendations: Education, Healthcare, and Economic Development; Report released 2013

• Medicaid updated Telemedicine Rules in 2014• Removed rural requirements for originating sites• No longer required a certified health professional be with

the patient at the originating site• Allows use of store and forward applications

• Telehealth Fund created at NM DOH July 2014• Neurosurgery Tele-stroke CMS ACCESS Grant funded

$15 million 2014• New Mexico receives very high grades from the

American Telemedicine Association (ATA) on a national level when compared to other states 2015

New Mexico Telehealth Act Passed and Signed

into Law 2004

Introduced by: Rep. Danice Picraux(D)

andSupported by

Sen. Susan Wilson-Beffort (R)

HOUSE BILL 581

46TH LEGISLATURE - STATE OF NEW MEXICO

Introduced by: Sen. Jerry Ortiz y Pino (D)

and Rep. Stephen Easley (D)

SENATE BILL 69

HOUSE BILL 171

Insurance Coverage for Telemedicine Services

Passed and Signed into Law 2013

ECHO: Treatment Outcomes

Outcome ECHO UNMH P-value

N=261 N=146

Minority 68% 49% P<0.01

SVR (Cure) Genotype 1/4 50% 46% NS

SVR (Cure) Genotype 2/3 70% 71% NS

SVR=sustained viral response

NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G, et.al.

Direct Patient Care

Maternal Fetal Medicine-High Risk PregnancyGenetic Counseling

School Based Health Centers

24

Telehealth assistants at the school or child care center provide the link to examine the eyes, ears, throat, lungs and skin.

Videoconferencing provides the “face to face” interaction.

“Getting providers to think of their desktop computer as an exam room is the trick.” Dr. Neil Herendeen

Family Visitation

“Store and Forward”• Capturing an image and storing it to then be forwarded for review by

a medical specialists• Examples include teleradiology, telepathology and teledermatology,

tele-ophthalmology (retinal scans)• “Telemedicine” or HIE?/It’s about connecting patients and providers

to achieve better care

Teleradiology and Image Transfer Web-Based Portals

Diabetic RetinopathyRetinal Scans:

Trauma Triage

Moya M, Valdez J, Yonas H, Alverson DC. The Impact of a Telehealth Web-based Solution on and Consultation. Telemedicine and eHealth, 2010; 16:945-949 

44% Transfer Avoidance

27% Management Recommendation Changes

Access to Critical Cerebral Emergency Support Services (ACCESS):Expanding New Mexico's telehealth network to include all 30 hospitals statewide. CMS Innovation Grant$15 million

http://hsc.unm.edu/emermed/PED/ChildReady/CR.shtml

Behavioral HealthCenter for Rural and Community

Behavioral Health (CRCBH)Psych Emergency Services (PES)

http://psychiatry.unm.edu/centers/crcbh/index.html

Behavioral Health Services – PTSD/TBISuicide Prevention

IRA HAYES

Teledermatology (Store and Forward)

ENVISIONhttp://www.envisionnm.org/index.php/telehealth/comm-tc/

CYBER CF (Cystic Fibrosis)Support Groups

Transitions of Care Consultative Clinic

Pediatric Intensive CarePediatric CardiologyPediatric Oncology

Southwest Telehealth Access Grid (SWTAG): a “Network of Networks” that can support both Telehealth and HIE

Awarded $15.5 million to cover 85% of build-out and operations of broadband networks for healthcare

FCC RHCPP

Navajo Rural Health Project

Community Health Representative (C.H.R.)

C.H.R.Broadband Connection

Navajo HomesChapter House

Hospital

Telehealth: Dynamic Emerging

Technologies

• H.323 Video Conferencing Systems (e.g. Polycom, Tandberg and use of IP addresses)

• H.324 Video phones (analog)

• Video SIP Client (e.g. Jabber, federated MS Lync etc.)

• Cloud based video conferencing (e.g. Vidyo,

Zoom): hosted or non-hosted, BYOD

• “WebRTC” (Real Time Communications): Secure Web browser access

Video Options

Videophone (H.324)

Skype

Software IP Based (H.323)Desktop IP Based (H.323)

Small Conference Room IP Based (H.323)

Telehealth Toolkit

SaaS (SIP&the Cloud)

Hand Held Devices- “mHealth”

Smart Phones and Tablets

iPhone

iPhone

Droid

Remote Monitoring

The “Smart Band-Aid”

Smart Phone “Snap-Ons”or Blue Tooth to Mobile Devices

TytoCare

Eye exams via your Smart Phone

“Google Glass”(A Passing Fad?)

Rafael Grossmann, MD, FACS at Google Glass's first surgical

appearance

Tele-mentoring, Tele-Supervision, Teaching &Training

Telehealth Resources

The New Mexico Telehealth Alliance

Telehealth Alliance

• Represents a consortium of public and private health care stakeholders: “Neutral Territory” (501c3)

• Reflects the diversity of our health

care delivery system in New Mexico

• Enables collaboration

“Networks of Networks” Providers

Consumers

Telehealth Expertise

Communication Networks

Social Networks

The 4 “C’s”CooperationCoordinationCollaborationCommunication

ATA Interstate Telehealth DG

http://www.telehealthresourcecenter.org/

http://www.americantelemed.org

Interstate Telehealth Discussion Group

http://ctel.org/

The Future and Next Steps

Telehealth Planning:Keys to successful implementation

• Feasibility and Needs Assessment• Technology Planning: Platforms for both consulting and

originating sites, connectivity, security• Operations Planning: Workflow, workforce, C/P, Licensure,

Documentation/Integration with EHR, scheduling vs. 24/7-emergencies, reimbursement (parity legislation)

• Business Planning: Integration with strategic direction, Sustainability, ROI

• Evaluation Planning: data collection, metrics of success• CQI

Legal and Regulatory Ramifications

• HIPAA/HITECH

• FDA/FCC

• Liability and Malpractice Insurance/Risk Reduction

• Standards of Care

• Credentialing/Privileging and Licensure

Telehealth: Next Steps (7) and Strategic Path Forward in New

Mexico1. Coordination and Collaboration

2. Meeting Healthcare Needs

3. Overcoming Barriers

4. Connectivity and Technical Support Services

5. Network of Telemedicine Clinic Originating Sites

6. HIE Integration

7. Research and Evaluation, ROI, Value Based Accountability (VBA)

1. Need for Centralized NM Telehealth Resource

Center• Enhance coordination of telehealth services and provide

platform for collaboration• Provide a listing and contacts (Data Base/“Catalogue”) for

specific available telehealth services• Answer question regarding provision and receiving of

telehealth services• Provide telehealth education and training as needed• Follow established guidelines and standards of care• Evaluate the impact and provide CQI• Serve as a single point of contact for other entities

interested in telehealth

2. Ongoing Needs Assessment

• Telehealth services should be implemented that address define healthcare needs of communities, providers, and patients throughout NM

• Develop ongoing periodic surveys for needs assessments

3. Identify Issues and Barriers Affecting

Telehealth Services• Work with the Legislature, Governor’s office, and

State Departments, along with Governing and Regulatory Bodies to address those barriers and find solutions

4. Develop Affordable Appropriate Broad-band and Technical Support

Services

• Develop “Cash Match Fund” for Federal Programs (FCC HCF, USDA DLT Grants)

• Work with DoIT• Work with telecommunication industry• Provide support services for the FCC and USDA

related healthcare programs and subsidies• Contract for secure, reliable NOC services

5. Develop Network of Telemedicine Clinic Originating

Sites

6. Integrate with Health Information Exchange (HIE)

initiatives

• Patient healthcare information, medical history, and documentation should go hand-in-hand with telemedicine services, similar to in-person services

7. Continued Quality Improvement• Research and Evaluation

• Value-Based Accountability

• Return on Investment

• Meeting the Triple Aim

• Ongoing Assessment

Promoting Adoption and Overcoming Barriers

• It takes a Transdisciplinary Team and Collaboration

• Belief in the Value

• Demonstrating the Value

• Dedication

• Persistence

Questions & Comments?