Jonathan neufeld nuts and bolts

The Nuts and Bolts of Building a Telehealth Program

Jonathan Neufeld, PhD

Georgia Partnership for Telehealth Conference

Savannah, Georgia

March 26, 2015

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This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of

Health and Human Services (HHS) under grant number G22RH24745-03-00 under the Telehealth Resource Center

Grant Program for $325,000. This information or content and conclusions are those of the author and should not be

construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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Bureau of Primary Care

Maternal and Child Health Bureau

Bureau of Health Workforce

Office of Rural Health Policy

Healthcare Systems Bureau

HIV/AIDS Bureau

HRSAOffice of the

Administrator

Office of the Deputy Administrator

Health Resourcesand Services

Administration (HRSA)

telehealthresourcecenters.org

• Links to all TRCs

• National Webinar

Series

• Reimbursement,

Marketing, and

Training Tools

UMTRC Services

• Presentations & Trainings

• Individual and Group Consultation

• Technical Assistance

• Connections with other programs

• Program Design and Evaluation

• Information on current legislative and policy developments

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Introduction to Telehealth

• Telehealth refers to a set of methods for delivering health care services

– NOT the services themselves or a specific type of service

• For example, “tele-radiology” is just radiology performed from a remote site

• The provider would do the same thing if they were on site, the patient would receive the same care

– NOT all health care technologies

• EMRs, use of computers and tablets, robotics

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“Telehealth” vs. “Telemedicine”

• Often used interchangeably (ATA)

• Two types of distinctions are made -

• “Telemedicine” = billable interactive clinical services performed at a distance

• “Telehealth” =• All remote health activities (CME, etc.)

• Clinical remote monitoring (usually at home)

Types of Telehealth• Specialty/Subspecialty

• Allergy/ImmunologyAnesthesiaCardiologyCritical CareDentistryDermatologyOtolaryngology (ENT)EndocrinologyFamily/General PracticeGastroenterologyInfectious DiseasesInternal MedicineMaternal/Fetal MedicineMental/Behavioral HealthNeurologyOncology/HematologyOphthalmology/OptometryOrthopedicsPathologyPediatricsPsychiatryPulmonologyRehabilitative MedicineRheumatologySurgeryUrology

• Services

• Case ManagementCorrectional telehealthDeaf/hearing servicesDiabetic retinopathy screeningDietician servicesDisease managementDoctor-to-doctor consultationEnterostomal therapyForensic/court servicesGenetic counselingLong-term CareNeonatal/Pediatric intensive care unitPain managementPalliative carePre/post-natal careSpeech therapySpine therapyTelestrokeWound careAdult, Individual and Group TherapyBehavioral psychology and healthChemical dependency aftercareChemical dependency therapy (Addiction therapy)Consultation to SchoolsCouples’ counselingDevelopmental (lifespan) counselingPsychiatric medication therapy managementPsychological Assessment

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1906 - Einthoven’s Telecardiogram

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1950s - John Mackenzie at Smith Kline

televises over 300 medical and surgical procedures

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1960s – Dr. Kenneth Bird (Harvard)

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Murphy RL, Bird KT. Telediagnosis: a new community health resource. Observations on the feasibility of telediagnosis based on 1000 patient transactions. Am J Public Health. 1974;64(2):113-119.

1965 - Transatlantic Telemedicine

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1971 – Child Psychiatry (Nebraska)

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The Bare Necessities

• Clinical Business Model

• Team of Champions

• Solid Partners

• Appropriate Technology

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Clinical Business Model

• Identifiable need(s)

– Assessment tools

– Consensus value

• Value-bearing service to meet the need(s)

– Reimbursement, cost savings, or other value

• Services that fit within best practices and legal limitations

– Licensing boards (regulations)

– Payers (conditions of payment)18

Legal Limitations

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• Professionals (doctors, nurses, counselors, etc.) are regulated by state licensing boards

• Medicare: Pays for certain outpatient professional services (CPT codes) for patients accessing care in rural counties and HPSAs in rural census tracts.

*Codified as “conditions of payment”

• Medicaid: Most states (46) cover at least some telehealth services.

Three Domains of Telehealth

• Hospital & Specialty Care• Specialists see and manage patients remotely

• Integrated Primary Care• Mental health and other specialists work in

primary care settings (e.g., PCMH’s, ACO’s)

• Transitions & Monitoring• Patients access care (or care accesses patients)

where and when needed to avoid complications and higher levels of care

**Value proposition differs among these types**

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Hospital and Specialty Care

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primary care settings (e.g., PCMHs, ACOs)




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Integrated Primary Care

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Transitions and Monitoring

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Three Axes of Telehealth

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Three “Hard Lines” in Telehealth

Encounter Patient Location Service Type

Live videoHealthcare facility

(hospital, clinic, office, etc.)

Individually codedand billed services

Store & Forward (images)

Non-facility(home, etc.)

Monitoring & Management

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NOT: telephone, email, fax

Multiple Business Models Apply

Strategies Dependent Upon:

• Revenue Stream

• Cost Avoidance

• Added Value

• Shared Savings

**Each may apply to different stakeholders

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Business Models for Telehealth

• Tele[specialty] Services

• Travel Reduction/Resource Distribution

• Remote Hiring/Recruiting/Retention

• Remote Monitoring & Access

• Kiosks and mHealth

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Business Models for Telehealth - 1

SPECIALISTS TO REMOTE SITES

• Traditional “Hub & Spoke” arrangement

• Standard Pro-fee Payment (CPT-based) goes to Specialist or Hub (“remote site”)

• Facility fee goes to Patient or Spoke Site

– Called “originating site”

– Commonly $22-$25 per encounter

– NOT the same as “facility fee” in Part A

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Telemedicine - The Standard Model

Professional Fee(Part B)

Facility Fee(Part B)

Rural “originating

site”

Specialist at “distant

site”


TRAVEL REDUCTION/SERVICE DISTRIBUTION

• Site-to-site within an organization

• No real “hub” or “spoke”

• Facility fees excluded (?)

• Goals:

– Reduced travel

– Increased capacity

– Increased efficiency

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REMOTE HIRING, RECRUITMENT & RETENTION

• Recruit from anywhere to anywhere

• Recruit from lower cost locales

• Retain staff when they move

• Key consideration: Licensure

– Services occur at the site of the patient

– Providers must be licensed and credentialed at the patient's location

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REMOTE MONITORING & ACCESS

• Moving the care site to the home (or street)

• Multiple privacy/confidentiality issues

– Informed consent is critical

• Tremendous potential for cost savings

• Overall quality of life improvements

– Staying out of the hospital = better

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HEALTH KIOSKS AND mHEALTH

• Standalone diagnostic centers and smart phone/tablet apps

• Developed and distributed by providers, payers, or third parties

• Targeted directly to consumers

– Enhanced access, self-care, motivation

• Used doctor to doctor or hospital

– Image distribution, diagnosis, consultation36


HEALTH KIOSKS AND mHEALTH

• FDA has moved to regulate health apps

– Regulated if it measures or calculates data

• Direct patient payments are a small part of all health care dollars

• Goals are varied (and sometimes unclear)

– Access (to doctors, labs, charts, etc.)

– Outreach (to patients)

– Health behavior change (diet, exercise)37

The Triple Aim - A Realistic Approach

• Services done right will improve Patient Experience (Better Care)

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• Providing the right services will improve Population Health

• Better Health will lead to Lower Cost

Telehealth in a Triple Aim ContextThe right tool changes everything…

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A Team of Champions

• Leadership must understand and communicate the vision

• Key players must be flexible and open to new ideas, processes, and technologies

• Knowledgeable support – The TRCs

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Key Players

• Key players must be flexible and open to new ideas, processes, and technologies

– Start with those most interested and easiest to work with

– Let excited team members recruit peers

– Leave the last 20%

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A Note About Physicians

• Trained to lead

• Compliance is their livelihood

• Deathly allergic to “not knowing”

SO…

• Build trust

• Test in “non-critical” environments

• Emphasize relationships not technology

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The Right Partners

• Multiple types of partnerships are available

• Build on existing relationships

• Ask for what you want –

Be the Hub!

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Telemedicine - The “Legacy” Model

Professional Fee(Part B)

Facility Fee(Part B)

Rural “originating

site”

Specialist at “distant

site”

Direct Contracting – P2P

• Newer model

• Driven by:

– Accessibility of technology

– More sophisticated primary care

– Demand for services closer to patient

– Breakdown of traditional “Hub & Spoke” spheres of influence

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Hub and Spoke Telemedicine

HUB

Spoke

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Spoke

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Spoke

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Spoke

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MD

MD

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MD

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PhD

DO

NP

Spoke

ptpt

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Spoke

ptpt

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Peer-to-Peer Telemedicine

CLINICpt

pt

pt pt

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MD

MD

CSW

NP

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MD

Peer-to-Peer Telemedicine

– Peer-to-Peer Model

• Clinicians anywhere

• Patients anywhere

• Patient site bills, receives payment

• Clinician gets paid by patient site (as an employee or contractor)

• Clinicians anywhere

• Patients anywhere

• Patient site bills, receives payment

• Clinician gets paid by patient site (as an employee/contractor)

• “Telecommuting” (IN)

Wholesale vs. Retail

• Buying specialist time is easier using a Retail provider, but Wholesale is likely to be cheaper

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Appropriate Technology

• Connectivity

– Site of Service

• Hardware & Software

• Skills & Service Design

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Connectivity

The Foundation of Telehealth• T-1 (minimum necessary, 1.5 Mbps)

• Business cable internet (3-10 Mbps upload)

• Top-shelf options (fiber, business ethernet)

• Latency and Quality of Service are as important as bandwidth

• Keep the line free of competing demands

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Site of Service

Hard line: Office vs Home• Privacy & Security

• Connectivity

– Rely on what’s available, or…

– Take connection to the site (4G hotspot)

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Hardware & Software

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Equipment

• H.323 Standard Video End Point ($5k-$50k)• LifeSize, Polycom, Cisco/Tandberg

• 32” HDTV (monitor + speakers)

• Desktop stand or rolling cart

• Web-based System ($1k+)• Software (Zoom, Vidyo, etc.)

• Mini computer + HD webcam

• 26-32” HDTV monitor + speakers

• Desktop stand or rolling cart

Equipment

• Web-based System ($500)• All-in-one desktop computer

• HD webcam

• Software package

Equipment

• Key considerations for DIY telemedicine• Good USB webcams beat built-in (laptop) webcams

• USB speakerphones beat built-in mics and speakers

• Wired beats wireless internet

• Monitors need only 720p (“low HD”)

• Keyboard/mouse inputs needed

Peripherals

Exam Camera – Dermatology, wound evaluation

• Tremendous detail, resolution, lighting options

• Unnecessary for many applications

Stethoscope –

• Several very good models available

• Bluetooth (wireless) connections, excellent audio

Otoscope –

• Multiple models available

• Modular, easy to use

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Stethoscope

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Otoscope

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Skillsets

• Technology + Skillsets = Capabilities

• Capabilities + Practice = Execution

Training without practice is (mostly) wasted

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Skillsets

• Rollout schedule that includes practice

• Low-pressure exposure (meetings, training)

• Mock codes/encounters with debriefing

• Process helpers/kits (laminated cards, etc.)

The biggest hurdle in implementation is

fear of the unknown

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Technology Considerations

● High speed internet at both sites– 1-3 Mbps or more (nominal) for HD

– Test at www.internetfrog.com/mypc/speedtest/

● Endpoints – Two Major Classes– H.323 – Standalone system

● Hardware based, often older and/or larger

● Tandberg, Polycom, LifeSize, Sony, etc.

– SIP/Web-based – Client/server system● Software based (using a host computer)

● Skype, Oovoo, Vsee, ClearSea, Zoom, etc.

● Mobile apps

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http://www.internetfrog.com/mypc/speedtest/

InternetH.323 H.323

Encrypted session

InternetSIP/WEB SIP/WEB

computer

webcam

Server

Encrypted sessions

???

webcam

computer

HIPAA Considerations

• Communications involving PHI (including live video) must be encrypted

• Any entity that stores PHI must sign a Business Associate Agreement (BAA)

• As long as live video is encrypted and not stored, BAA is not technically required

Some type of signed agreement to enforce this is likely to be helpful and is recommended

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Peripherals

Exam Camera – Dermatology, wound evaluation

• Tremendous detail, resolution, lighting options

• Unnecessary for many applications

Stethoscope –

• Several very good models available

• Bluetooth (wireless) connections, excellent audio

ENT Scope –

• Multiple models available

• Modular, easy to use

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Staff Training & Integration

Manipulation of peripherals

• Document training in equipment use

Professional Skills (within scope of licensure)

• Telemedicine (in general)

• Palpation, other specific techniques “under direct supervision” (up to licensed providers pending rule)

Key Strategies

1. Trust – Develop strong working relationships

2. Documentation– Policies & Procedures for TM (“same standard of care”)

– Case/Progress Notes (start & stop times, locations, consent)

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Technology Resource - TTAC

Telehealth Technology Assessment Center

– HRSA-funded technology-focused TRC

http://www.telehealthtechnology.org/toolkits

● Objective introductions to technologies

**Information ages quickly, newest and most expensive equipment isn’t covered

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http://www.telehealthtechnology.org/toolkits

Special Considerations

• Almost any client will adapt quickly to technology, given sensitive guidance (providers take longer)

• Clinical skills are the same – rapport is key

• Recognize and foster client understanding

• Refer to technology experiences outside TM

• Involve family/caregivers throughout

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Conclusions

• Telemedicine is a complex and rapidly changing field

• Telemedicine offers a range of potential benefits to a variety of stakeholders

• Careful examination of business models, clinical strategies, and technologies is necessary to maximize benefit

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Questions

• Introduction to UMTRC

• Introduction to Telehealth

• Business Models for Telehealth

• Telehealth Regulation and Reimbursement

• Telehealth Technology Considerations

• Conclusions

• Questions

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Contact Information

Jonathan Neufeld, PhD

Upper Midwest Telehealth Resource Center

(574) 606-5038

[email protected]

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