1. Telepsychiatry: What Infrastructure Will You Need? Mick Pattinson, Ph.D., CEO Susan Morley, LCSW, Deputy Director Nancy Rowe, BA, Telemedicine Manager Northern Arizona Regional Behavioral Health Authority

2. NARBHAnet Background

3. 3 NARBHA Overview Private, non-profit corporation Contracts with AZ Dept. of Health Services to serve Medicaid-eligible & SMI populations Monitors behavioral health services provided by community-based agencies Serves the five northern counties of AZ, including Tribal areas; all are Mental Health Professional Shortage Areas 3

4. 4 NARBHA Overview (cont.) Northern Arizona: Approx. the size of New York plus New Jersey 62,000 square miles (54.4% of AZ area) Population 708,500+ (11.5% of AZ pop.) 4

5. 5 NARBHAnet History Drivers for starting telemedicine network: Large geographic area, sparse population Provider and/or patient travel times/cost Recruitment/retention of psychiatrists State Hospital monthly staffings for patients NARBHA staff travel to provider sites/clinics Provider staff travel to outlying sites Provider staff travel to trainings/meetings 5

6. 6 1996 NARBHAnet established with $250,000 Tobacco Tax and $250,000 state funding. Six video sites. 1997 NARBHAnet has 12 sites; named to Top Ten in U.S. 1998 Connects to U of A network, southern RBHA network, and AZ Division of Behavioral Health Services. Named to Top Ten 2nd year. 1999 Named to Top Ten 3rd year. 2001 Central website, www.rbha.net, goes online.www.rbha.net 2006 Celebrates 10th anniversary. NARBHAnet History (cont.) 6

7. 7 2007: 32 video endpoints in 21 locations. Newest sites are on AZ Strip (north of Grand Canyon), Apache and Navajo Reservations. Connections to U of A (171 sites) & RBHA (24 sites) telemed networks blanket the state. 7

8. 8 NARBHAnet Activity 8 Network use (in hours) by conference type July 1, 2006 - June 30, 2007 Total hours of video connection for the year: 12,210.5 (3,376 hookups)

9. 9 NARBHAnet Activity (cont.) August 2007: 10 psychiatric providers August 2007: 616 patient sessions via telemedicine Est. total patient services over NARBHAnet, November 1996 – August 2007: 36,637 9

10. NARBHAnet Infrastructure

11. 11 NARBHAnet Endpoint Equipment 11 Basic videoconferencing setups: Room has one codec (transmission device/camera) Pan and zoom Remote control Sits on top of TV Plugs into ethernet jack Can dial 1 to 3 other codecs Microphone (basic sites have 1 or 2 table mics) Two TV monitors or single monitor with picture-in- picture (gen. 32-inch CRT TVs; larger for large rooms)

12. 12 Basic videoconferencing setups, cont.: Some sites have peripheral devices: – DVD player/recorder – document camera – laptop/PC connected Network gear required: – router – switch – Cat5 (ethernet) cabling with dedicated jack for video Endpoint Equipment (cont.) 12

13. 13 Videoconferencing Rooms For psychiatrists, office-size rooms with one TV using picture in picture Viewing angle: appearance of eye contact by having camera just above TV 13

14. 14 Videoconferencing Rooms Fluorescent is fine, full-spectrum bulbs are best Sufficient lighting is crucial, especially for darker skin tones—facial features must be lit up In this room, faces are too dark, back- ground is too bright and busy Codec is not above TV so participants are not making “eye contact” 14

15. 15 Camera should not face windows, whiteboards, doors, or busy backgrounds: Robin’s-egg blue is best background for camera and life-like skin tones For large conference rooms: ceiling mics, projectors and screens recommended instead of TVs and tabletop mics Videoconferencing Rooms

16. 16 NARBHA Network Design NARBHA has a hub and spoke network: Hub: NARBHA HQ in Flagstaff Spokes: clinics, agencies, state hospital, DBHS Each spoke has telemedicine coordinator & at least one video- conference room 16

17. 17 NARBHA: private network with dedicated T1 lines carrying video & data between spoke sites and hub T1 line = bandwidth of approx. 24 phone calls Hub not necessary for smaller networks NARBHA video uses H.323: Internet Protocol (shares resources with data network) Other network protocols and connection types are options (fractional T1s, Public Internet, etc.) Videoconferences are transmitted at 384K, 30 frames per second (some clinicals @ 512K) Network Design (cont.) 17

18. 18 Network connections: One T1 line to the phone co. allows video and audio calls off-network to anywhere Off-network providers use this line to dial in to NARBHA network Dependable, consistent 384K signal As secure as a land-line phone call Dial-in users incur long-distance charges x 6 Access to NARBHA through Public Internet is extremely limited & tightly controlled Connections to other networks generally through point-to-point T1 lines 18 Network Design (cont.)

19. 19 Videoconferencing bridge (optional) Only needed for multi-site or multi-protocol conferences; smaller networks can use no bridge or small bridge. Allows up to 48 sites to connect simultaneously (bridges are scalable). Meetings are preprogrammed in bridge with any combination of sites (can accommodate ISDN, IP, and different bandwidths). Users can request different meeting setups: – voice-activated: participants see whoever is talking – continuous presence: all participants see each other All calls have a 30-minute pretest to correct issues. NARBHA Hub Equipment 19

20. 20 Hub Equipment (cont.) Videoconferencing bridge, cont. Sites can be added to, moved among, or removed from multi-site calls upon request. Requires trained staff to run it. Other hub equipment: Dedicated server to run: – gatekeeper (IP video traffic controller) – endpoint management software (optional) Core router At least one computer with bridge controller software Ideally, a video endpoint for testing/troubleshooting 20

21. 21 Telemedicine staff of three at NARBHA HQ: Customer service: Make sure spoke sites remain happy about signing up and paying for telemedicine Schedule and monitor all videoconferences Carry dept. cell phone at all times during work hours Stay in or near building All conf. rooms have “Telemed” speed dial Work with all site telemedicine coordinators and telemedicine managers of all connected networks Technical expertise, troubleshooting User support, training 21 NARBHAnet Central Staff

22. 22 Telemedicine staff of three (cont.): Manage T1 circuits: RFPs and contracts, installation, testing, trouble calls to telcos Equipment advice, quotes, purchasing, installation Universal Service applications, grant applications Interface with vendors on behalf of spoke sites Work with WAN Manager on tech. issues Responsible for staffing “Telemed” email account Use troubleshooting / recording video endpoints in telemedicine offices for instant response to issues Maintain and update website Central Staff (cont.)

23. 23 NARBHA Scheduling System www.rbha.net www.rbha.net telemedicine website: Information, news, policies, tips, links, instructions Circuit RFPs Contact info Scheduling tool 23

24. 24 Scheduling System (cont.) www.rbha.net www.rbha.net scheduling tool: NARBHA staff can request meetings, view room calendar Site telemedicine coordinators can request, cancel, reschedule & edit meetings and can accept & decline invitations 24

25. 25 Scheduling System (cont.) Requesting a videoconference: Can choose one or multiple dates Check the video endpoints to be invited Emails go to each invited endpoint telemed coordinator Coordinators can accept or decline 25

26. 26 Scheduling System (cont.) NARBHA telemedicine staff: Program video bridge daily based on meeting requests on website (Clicking on meeting title provides names of all sites to be connected based on sites’ responses to invitations) Assign conference rooms at NARBHA HQ with online room calendar 26

27. 27 Central Staff (cont.) Wide-Area Network Manager Needed for IP-based videoconferencing Spec and purchase routers, switches Configure network equipment Troubleshoot network gear issues Has designated backup Available by cell phone for emergencies WAN and telemedicine share same equipment and lines, so collaboration & communication are KEY! Networks of only a few sites would not require centralized staff, bridge, or scheduling software. 27

28. 28 Business Continuity Backup plans: If T1 goes down or equipment fails, doctor uses land- line telephone. If power outage, doctors use non-electric analog phones (separate lines from telemedicine network) in rooms with natural light. If analog lines down or NARBHA headquarters unavailable, doctors can use digital (not analog) cell phones—as secure as a land-line phone call. Non-clinical videoconferences (admin. or training) use phones to conference-call, cancel or reschedule meetings, or travel to meet in person.

29. HIPAA Security

30. 30 Private, point-to-point leased lines Firewalls at NARBHA (hub) and endpoints NARBHA firewall allows Public Internet access only through approved VPNs or firewall traversal device Codecs (cameras) are password-protected, set to auto-answer mute, and set to disallow dial-ins during calls Codecs are turned off or camera lenses covered when not in use HIPAA Security 30

31. 31 Clinical / privacy: Door signs (e.g., “in session, do not disturb”) Window coverings White-noise generators No tech. staff in rooms unless invited Duplicate client records kept in locked cabinet, in locked office w/ private fax machine Staff training on lens covers, muting Best if TV does not face door HIPAA Security (cont.) 31

32. Telemedicine Obstacles

33. 33 Startup Costs Cost to start a telemedicine network can be high if network is large and video bridge is needed BUT… Grant funding is available for new networks: http://www.hrsa.gov/telehealth/ http://www.usda.gov/rus/telecom/index.htm http://www.fedgrants.gov/ Cost of equipment can be more than offset by savings in provider travel costs/time 33

34. 34 Physician Attitudes Psychiatric providers’ concerns: quality of patient care will suffer ability to relate using a technological interface sitting in a room with a TV all day BUT… Interviews with NARBHAnet providers have shown that most providers like telemedicine more than they expected to. 34

35. 35 Patient Attitudes Concern about how patients will react to receiving psychiatric services from a TV BUT… Recent patient satisfaction survey showed: 86% said quality of care through telemedicine is same as or better than in person. 60% had no preference between seeing psych. practitioner in person or via telemedicine; 20% prefer telemedicine. 79% are now more at ease with telemedicine compared to their first sessions. 35

36. 36 Staff Attitudes Dislike videoconferences where presenting site shows the whole room (tiny heads, no facial features, can’t tell who is talking) BUT… Staff training to use codec remote control: Camera presets let participants easily pan/zoom to whoever in the room is talking. Far-end sites see one to three people at a time on screen, focus on the speaker. Much easier for remote sites to engage in meeting. 36

37. 37 Staff Attitudes (cont.) Don’t Do

38. NARBHAnet Costs and Reimbursements

39. 39 Equipment: $11,053 per site (router, codec, 32-inch CRT TV, cart), plus shipping and installation $166,732 for MGC100 video bridge, plus installation $6,576 for dedicated server w/ warranty Annual maintenance agreements: Highly recommended Costs vary by equipment type and price NARBHA’s maintenance agreements have paid for themselves over and over Equipment Costs 39

40. 40 T1 line charges NARBHAnet lines range from $381 to $2,200 per line per month (unlimited use) Installation fees generally 1 month or waived more costly for microwave--$4,000 T1 move fees varies by telco monthly cost can change) Contract termination fees (usually remainder of contract) Circuit Costs 40

41. 41 Administrative Costs Staff NARBHA has three full-time telemedicine staff: Salaries / benefits Training Recruitment Office space, computers, supplies Liability insurance Subscriptions, memberships Travel 41

42. 42 Universal Service Federal program funded by fees on every phone bill Reimburses nonprofit, rural health care providers for difference in cost between rural and urban telecommunications services Must meet Universal Service’s definition of “rural” Arizona urban rate is currently $224.60/month http://www.rhc.universalservice.org/overview/ Cost Reimbursements 42

43. 43 Universal Service, cont. In FY 2006/2007, clinical NARBHAnet sites paid $252,134 for 17 T1 lines Not including taxes and fees In same year, these sites were reimbursed $211,327 by Universal Service Net cost for 17 clinical T1s: $40,807 Recommend that central staff file for rebates due to steep learning curve Cost Reimbursements (cont.) 43

44. 44 AHCCCS Arizona Health Care Cost Containment System (Arizona Medicaid) Medicaid reimbursement for services over telemedicine is available at state’s option At least 34 states now reimburse AHCCCS has reimbursed for NARBHA telepsychiatry services since day one (1996) NARBHA provides “Telemed allowable codes” spreadsheet for users on www.rbha.netwww.rbha.net Cost Reimbursements (cont.) 44

45. 45 AHCCCS, cont. AHCCCS funds for behavioral health services are paid on a capitated basis through RBHAs and are not restricted to rural areas For capitated providers the 15% facility fee is 1.15 times the service value of face-to-face Appropriate authorizations required but no specific telemed authorizations necessary Use “GT” modifier on service code www.cms.hhs.gov/home/medicaid.asp Cost Reimbursements (cont.) 45

46. 46 Medicare Started paying in 1999 and has expanded coverage Covered services: Provided to eligible Medicare beneficiary Patient is in eligible facility—rural only (originating site located in non-metropolititan statistical area) Real-time, interactive video Non face-to-face services (e.g., EKG, radiology, pathology) Home telehealth services (with restrictions) Cost Reimbursements (cont.) 46

47. 47 Medicare, cont. No limitation on location of health professional delivering medical service (referring site) Eligible providers include: Physician Nurse practitioner Physician Assistant Clinical psychologist, clinical social worker Cost Reimbursements (cont.) 47

48. 48 Medicare, cont. Payment same as current fee schedule for service, plus rural site facility fee: $22 Use “GT” modifier NARBHA provides brief “Telemed allowable codes” spreadsheet for users on www.rbha.net For more info: www.cms.hhs.gov/home/medicare.aspwww.cms.hhs.gov/home/medicare.asp Private payers: many are willing to reimburse for telemedicine services Cost Reimbursements (cont.) 48

49. NARBHAnet Savings and Benefits

50. 50 August 2007, assuming same psych. services to same clinics without telemedicine network: 10 providers 33 trips / 8,009 miles 140.6 hours drive time, sacrificing 180 patient sessions $3,885 car cost (48.5 cents per mile based on gov. mileage reimbursement rate for private vehicles) $1,724 for meals (based on NARBHA policy) $1,797 for lodging (based on federal rate for Navajo Cty.) $12,384 in provider salaries (based on ea. hourly rate) TOTAL cost: $19,790 for August ($207,943 for full year) 50 Provider Travel w/o Telemed

51. 51 Provider Telemed Cost Annual cost of endpoints used for doctor-patient meetings: 10 endpoints with video codecs, routers, TVs, carts Assuming 5-year life for all equipment Including annual maintenance for 10 endpoints Including net cost of nine T1 lines after Universal Service rebates Not including costs of central staff or video bridge, because clinical meetings could run with neither Total clinical telemedicine cost for the year: $65,400 51

52. 52 Provider CO 2 Savings August 2007: Gas use: At 27 mpg, 296.6 gallons total would be used Total of 2.9 tons of CO 2 added to earth’s atmosphere in one month. As much CO 2 as driving a Toyota Prius for over a year (14,000 miles) Extrapolated for a full year: Without telemedicine network, CO 2 added to earth’s atmosphere in one year: 30.5 tons As much CO 2 as driving a Hummer H3 for 3 years (12,000 miles per year—29.4 tons) 52

53. 53 For NARBHAnet clinical services alone: Annual cost of telemedicine network: $65,400 Est. annual doctor travel savings: $207,943 Net annual savings: $142,543 Plus 30.5 tons of CO 2 not emitted Plus 1,903 patient services not forfeited Plus happier psychiatric providers—no travel Plus happier patients—no long wait times Overall Provider Savings 53

54. 54 Overall Travel Savings 54 For NARBHAnet clinical services alone: 10 providers traveling Net annual savings: $142,543 Plus 30.5 tons of CO 2 not emitted Extrapolated to cover all the staff travel required for admin. and training meetings now held via video: Over 100 staff traveling 2,797 site connections in FY 2006-07 Financial and CO 2 savings: ??

55. 55 Psychiatric services available to areas of physician shortage Improved access to care (patients seen sooner and more frequently) Psychiatric providers see more patients with the time they would otherwise spend driving Patients treated in their own communities Emergency assessments available immediately Specialty consults available Telemedicine Benefits Recap 55

56. 56 Family involvement in treatment of inpatients Improved recruitment and retention of psychiatric providers More training and CMEs for clinicians, staff, psychiatric providers Improved staff efficiency, productivity, morale due to less travel time Better communication/camaraderie among clinicians, staff, psychiatric providers Impromptu meetings can be hooked up at will Telemedicine Benefits (cont.) 56

57. Q & A

58. 58 Susan Morley, MSW, LCSW NARBHA Director of Administrative Services/ Deputy Director 928-774-7128, susan.morley@narbha.org Nancy Rowe, BA NARBHA Telemedicine Program Manager 928-214-2163, nancy.rowe@narbha.org www.rbha.net www.narbha.org For More Information 58