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Telemedicine: Aligning Technology with High Quality Patient Care
James Coviello, MD Regional Medical Director UH Primary Care Institute S. L. Scott Esposito, Esq. Associate General Counsel Andrew Moleski, MBA Manager, Virtual and Telehealth Services
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Objectives To introduce telemedicine as an emerging technology in healthcare delivery. To identify current State and Federal legal considerations in the use of telemedicine. To understand how telemedicine aligns with current healthcare reform tenets, including quality, patient experience, and emerging insurance payment methodologies. To review the UH telemedicine platform - current and future programs.
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Definition of Telemedicine and Telehealth
Telemedicine: The use of technologies to remotely diagnose, monitor, and treat patients. Telehealth: The application of technologies to help patients manage their own illnesses through improved self-care and access to education and support systems. Source: Connected Health: A Review of Technologies and Strategies to Improve Patient Care with Telemedicine and Telehealth. Health Affairs 2014
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What is Telemedicine? Telehealth Use Cases, Relevant Modalities, and Investment Required Ongoing Monitoring & Care Coordination Professional Consultation Diagnosis & Treatment Education & Engagement Use Cases Modalities Videoconference Asynchronous Store-and- Forward Remote Device Telephone Patient Portal Mobile App Need software, secure internet access for patients Home and hospital-based technology Need additional bandwidth, storage space Can replace non-urgent phone calls and visits More expensive hardware investment Used for high- risk patients in non-hospital site Little tech investment, requires proper staffing Used for pre-visit triage High security needs require significant investment Must integrate EHR Minimal hardware investment for providers Complex security and data storage issues Source: Marketing and Planning Leadership Council interviews and analysis. (Advisory Board) 4
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Medical Organization Telemedicine Guidelines
AMA, ACP, and ATA have policy statements on telemedicine Overarching principles include: Establishment of valid patient-provider relationship Professional judgment in appropriateness for telemedicine in clinical setting Continuity of care/shared medical record Use of evidence-based clinical guidelines for telemedicine Telemedicine held to same standard as in-person visit
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State of Ohio Telemedicine Overview
Telemedicine law and regulations are governed at State level Definition: ORC Regulations: OAC State Medical Board of Ohio Position Statement on Telemedicine State Board proposed rule ( ) under review to update prescribing guidelines for patients initially seen at remote location. Medicaid covers telemedicine (since January 2015), follows Medicare site requirements, without geographic restrictions. No Ohio telemedicine coverage parity law, but exists in 29 other states.
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State by State Medicaid and Private Payer Coverage
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Federal Telemedicine Overview
Medicare provides limited telemedicine payment coverage. To qualify: Originating Site – location of eligible Medicare beneficiary. Must be a Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or a county outside of an MSA. Must also be one of 8 types of health care facilities (e.g., doctor’s office, hospital, etc.) Distant Site – location of an eligible provider. Must be one of 10 types of providers (e.g., physician, nurse practitioner, clinical psychologists, registered dieticians, etc.) Covered Services – limited to certain HCPCS/CPT Codes Most UH locations do not qualify. Current (114th) Congress has introduced several telemedicine-related bills, including Medicare coverage expansion. Source:
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THE TRAIN HAS LEFT THE STATION…..
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External Forces Driving Telemedicine Expansion
Consumer demand Cost saving efforts: Commercial and employer-based insurance, ACO shared savings program Value-based care and population management incentives Patient access/workforce limitations Expanding technology capabilities
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Consumerism in Healthcare
Patients more discerning in health care spending and convenience. Non-traditional opportunities to access care address consumers’ preferences (i.e. retail clinics and virtual care platforms). Various studies have demonstrated high patient satisfaction. Journal of General Internal Medicine patient satisfaction study (March 2016): 98% “Very satisfied” patients with telehealth visit 95% Patients who would use telehealth again Patients who would recommend telehealth visit to friend Source: Patients’ Satisfaction with and Preference for Telehealth Visits. Polinski JM et al, J Gen Intern Med March 2016
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Smart Phone Medical Devices
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Challenges and Concerns
Quality Provider credentials Continuity of care Efficacy Appropriate use/clinical triage Adequacy of virtual exam Patient selection Limited payer reimbursement Medicare Medicaid Commercial Effective implementation IT infrastructure Clinical workflow Licensing and credentialing
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HOW DID WE GET HERE?
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Health Care Reform Evolution
CMS/Medicare Pay-for-Performance: PQRIPQRS incentive to penalty. (July 2007) IHI Triple Aim: Experience of Care (Quality and Satisfaction), Population Health, and Per Capita Care (May 2008) Affordable Care Act: Innovative reimbursement models, Medicare Shared Savings Program—ACOs (March 2010) MACRA—APM and MIPS (April 2015) CMS PQRI IHI TRIPLE AIM ACA MACRA
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MACRA Overview 2 Quality Payments Programs: MIPS and APM (replace PQRS, VBP, Medicare EHR Incentive Programs) MIPS links FFS to quality and value Initial reporting period: January 2017 with payment adjustment starting January 2019. Four performance categories: Quality (50%), Advancing Care Information (25%), Clinical Improvement Activities (15%), Cost (10%) MIPS: Merit-based Incentive Payment System APM: Alternative payment model
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Commercial Insurance Payment Models
Commercial ACO programs Clinical Integration Network (CIN) Focus on quality care and cost containment aligns well with Medicare current and future payment models (i.e. bundled payments) Expansion of value-based models will require health system innovation
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Delivery System and Payment Transformation
Current State: Provider-centered Volume Driven Fragmented Future State: Patient-centered Value Driven Coordinated Private Sector Public Sector As healthcare shifts from volume to value, the benefit of providing care via telemedicine improves.
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Potential Telemedicine Uses
Chronic disease management Post-discharge monitoring Expanded patient care access Ambulatory specialty care/resource efficiency Team-based care Population Health Remote critical care monitoring/consultation Direct to Consumer and e-Consultations
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Population Health Management
Telehealth at UH Direct to Consumer Video Consult Patient Access Tele-Urgent Care (UH Virtual Visit) Telepsychiatry Online Scheduling (Zocdoc) Remote Second Opinion Telestroke Rainbow Care Connection (Nurse Triage) UH Patient Portal (Follow My Health) Pediatric Specialty Consults Video Concierge Tumor Board Martii Virtual Translation Neurology Genetic Counseling Patient Education Population Health Management Store and Forward Transplant Institute UH Home Care – Remote Patient Monitoring Tele-Radiology Emmi Solutions Cardiac Remote Monitoring Kidney Transplant - Remote Monitoring
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Current UH Virtual and Telehealth Technologies
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UH Virtual/Telehealth Strategies and Initiatives
Virtual urgent care and primary care implementation (UH Virtual Visit) Expand telehealth clinical consults (ex. Neurology, Psychiatry, Dermatology, Pediatric Specialty, ED, Post- surgery follow up) Grow remote monitoring of patients (home and facility) Analyze feasibility of eICU (Larger health system; national models) Expand teleradiology to non-UH hospitals Online scheduling optimization (Zocdoc and Referral Ease) Urgent Care – MDLive Online Scheduling – ZocDoc Clinical Video Telemed – Pediatric IP, MFM, Neonatology, Telestroke
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Telehealth Programs In Development
UH Virtual Visit Expanding tele-psychiatry Genetic counseling Integrative oncology Proton therapy Palliative care and hospice Post-acute care Referral Ease Virtual specialty clinics Remote patient monitoring Pediatric specialty consults Sports medicine Travel medicine
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Virtual/Telehealth at University Hospitals Future State
Direct to Consumer or Employer Online Scheduling Tele-Urgent Care Virtual Medical Office Home Remote Telemonitoring Patient Portal Remote 2nd Opinion Patient Education UH Facility to UH Facility Video-consults Inpatient Outpatient Store and Forward Transitions of Care Secure Messaging e-ICU UH to External Partner Video-consults Inpatient Outpatient Store and Forward Transitions of Care Secure Messaging e-ICU Patient Health Record Clinical Information Quality Measures
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Contact Information James Coviello, MD Primary Care Institute S.L. Scott Esposito, Esq. Associate General Counsel Andrew Moleski, MBA Manager, Virtual and Telehealth Services
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Appendix
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State Medical Board of Ohio Position Statement
Adopted May 2012 Licensees are held to same standard of care as in-person medical care Adequate staff training Verification of licensee-patient relationship Prescribing requires appropriate history/exam, therapeutic plan, and medical record documentation of process (Note: Updated Board rule on prescribing is forthcoming) Maintenance of complete medical record Proper licensure Source:
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Practice of Telemedicine Definition – Ohio (ORC 4731.296)
The practice of medicine in this state through the use of any communication, including oral, written or electronic communication, by a physician located outside this state. In-state physicians who are licensed in Ohio do not need a telemedicine certificate. Such Ohio licensed physicians may examine and diagnose patients through the use of any communication, including oral, written, or electronic.
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MIPS Payment Adjustment Summary
Source: CMS website: Quality Program training slide deck
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