Who are the Telehealth Resource Centers?

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The Telehealth Resource CenterGrant Program

www.telehealthresourcecenter.org

Technical assistance forstarting or expanding telehealth services.

Phone: 1.877.643.HTRC (4872)Email: [email protected]: www.HeartlandTRC.org

Gordon AllowayProject Director, HTRC

What areTelehealth Resource Centers (TRCs)?

Federally funded through HRSA/ORHPTRC Grant Program established 2006Extensive telehealth program implementation experience12 Regional TRCs, plus1 Telehealth Technical Assistance Center1 Telehealth Policy Assistance Center

Regional Telehealth Resource Centers

California Telemedicine & eHealth Center (CTEC)CALIFORNIA HEALTH FOUNDATION AND TRUST, SACRAMENTO, CA

Great Plains Telehealth Resource & Assistance Center (GPTRAC)UNIVERSITY OF MINNESOTA, MINNEAPOLIS, MN

Heartland Telehealth Resource Center (HTRC) UNIVERSITY OF KANSAS , KANSAS CITY, KSMid-Atlantic Telehealth Resource CenterUniversity of Virginia, Charlottesville, VA

Northeast Telehealth Resource Center Medical Care Development, Augusta, Maine

Northwest Regional Telehealth Resource Center SAINT VINCENT HEALTHCARE FOUNDATION, BILLINGS, MT

Pacific Basin Telehealth Resource CenterUNIVERSITY OF HAWAII, HONOLULU, HI

South Central Telehealth Resource CenterUNIVERSITY OF ARKANSAS, LITTLE ROCK, AR

Southeast Telehealth Resource CenterGEORGIA PARTNERSHIP FOR TELEHEALTH, WAYCROSS, GA

Southwest Telehealth Resource Center UNIVERSITY OF ARIZONA, TUCSON, AZ

TexLaTelehealth Resource Center Texas Tech University, Lubbock, TX

Upper Midwest Telehealth Resource CenterINDIANA RURAL HEALTH ASSOCIATION, TERRE HAUTE, IN

Regional Telehealth Resource Centers

HTRC Service Area

Kansas - Missouri - Oklahoma

HTRC PARTNERS

University of Kansas Medical CenterProgram started in 1991 with one hospital now over 2,000 clinical consults/yr

University of Missouri Health SystemMTN began in 1994 with 10 sitesnow over 200 endpoints in the network

University of Oklahoma Health Sciences CenterProgram since 1993 with 60 rural/regional hospitalsParticular expertise in store-and-forward consults

TelehealthorTelemedicine?

Technology Terms

Telehealth - the use of electronic information and telecommunications technology to support long-distance [delivery]:clinical health carepatient and professional health-related educationpublic healthhealth administration

Health Resources and Services AdministrationU.S. Department of Health and Human Services

ARRA American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT Computed Tomography scan

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Technology Terms

Telemedicine - the use of electronic communication and information technologies to provide or support clinical care at a distance.

HRSA Rural Health Glossary & Acronymshttp://www.hrsa.gov/ruralhealth/about/telehealth/glossary.htmlGoogle: HRSA telemedicine

ARRA American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT Computed Tomography scan

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Benefits of Telemedicine

Improve health care accessAddresses physician shortageReduce unnecessary patient transportReduce provider travel time/cost to outreach sitesReduce patient travel time and cost (Outpatient)Retain patients locally in their home communities

1. The newly formed Council on Physician and Nurse Supply says the United States may lack as many as 200,000 needed physicians (and 800,000 nurses) by 2020.

2. The Bureau of Labor Statistics predicts there will be 212,000 physician openings by 2014 due to growth and net replacement of retiring physicians. That number represents more than 25 percent of the current physician work force.

3. The American Medical Association (AMA) says that as the U.S. population rose 31 percent between 1980 and 2003, its number of medical school graduates remained static.

4. The National Ambulatory Healthcare Administration says people aged 66 and older average six physician office visits per year; individuals aged 46 to 65 average 5.4 visits annually; and people 25 to 35 years old average 2.2 visits a year. Increasing numbers of older patients mean heightened healthcare demand. Baby boomers aging bodies require more therapy, treatment, and surgery.

5. Of course, as boomer patients are aging, so are boomer physicians. Many of todays practicing physicians are retiring, or soon will. The AMAs data state that matures (people over age 61) and baby boomers (people between age 42 and age 60) now make up 67 percent of the existing physician population. Generation Xers (age 27 to age 41) make up only 33 percent of todays practicing physicians.

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History

Telehealth Feasible for many years.

Telemedicine appeared in the 1950sFirst documented consult 1959Brief projects in 1970sIn the American Journal of Psychiatry, Dr. Thomas F. Dwyer, a Massachusetts psychiatrist, said that he has practiced telepsychiatry via video teleconferencing, for five years. Its adoption by psychiatrists and patients, he predicted, will proceed quickly . . ..

(August, 1973)

During the 1970s, it appeared primarily in short-term projects or programs. One such program lasting for two years connected Boston Hospital to a remote site.

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Telemedicine in U.S.

Late 1980s - Current telemedicine movement beganInitial growth came from at least one telemedicine program per stateMany based in university medical centersCombination of grant and state funding; few are self-sustainingResearch and development focused

ARRA - American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)

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Late 1990s - Federal support for telehealth beganThe Balanced Budget Act of 1997 (BBA) Effective January 1999Mandated Medicare reimburse telehealth care Limited in scopeLimited to Health Professional Shortage Areas (HPSA)Practitioner had to be with the patient during consultConsulting and referring physicians had to split feeLimited to specific CPT CodesNo originating site reimbursement

Source: CTeL http://www.ctel.org/expertise/reimbursement/medicare-reimbursement/ New statutory language did not match the practical realities of telehealth practice.Live consultations constitute only about 10% of telehealth servicesA major concern in revising the telehealth reimbursement provisions was the exceedingly high cost (scoring) affixed to telehealth reimbursement legislation by the Congressional Budget Office (CBO). In 2000, the Center for Telemedicine Law, with funding from the Office for the Advancement of Telehealth, coordinated a project to use available telehealth reimbursement claims data to develop a more accurate funding projection.

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Dec 2000 Historic Legislation amends SSA- Consolidated Appropriations Act of 2001 (CCA)Telemedicine reimbursement policies (H.R. 5661, Section 223) - H.R. 5661 - Benefits Improvement and Protection Act of 2000 (BIPA)Objective: to expand rural accessEstablished many of todays guidelines- Medicare Improvement to Patients and Providers Act of 2008 (MIPPA)Introduced incentives for e-prescribing useAdded more originating sites

High cost (scoring) affixed to telehealth reimbursement legislation by the Congressional Budget Office.

ARRA - American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)Limited locations to : Offices of a physician or practitioner, CAHs, RHCs, FQHCs and hospitalsSNF Skilled Nursing Facilityhttp://www.federalregister.gov/articles/2010/07/13/2010-15900/medicare-program-payment-policies-under-the-physician-fee-schedule-and-other-revisions-to-part-b-for

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American Recovery and Reinvestment Act of 2009 (ARRA) Significant investments in health technologyBroadband services to rural and underserved areasHealth IT support for hospitals/physicians in reaching EMR meaningful useTelehealth and e-health technologies grant funding

ARRA - American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)SNF Skilled Nursing Facility

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Historical Challenges for Telemedicine

ReimbursementFederal legislation not until 1999Many initial restrictions Medicare only; rural sites; split fees; specific codesSlow expansion of federal restrictionsLack of private insurance coverage standardizationMedicaid reimbursement optional; varies by stateTechnologyHigh initial investment in equipmentLimited ongoing support availableLittle initial standardizationInconsistent broadband internet serviceSecurityUncertainty about HIPAA requirements

Good News! There Is Reimbursement

Medicare (2001)Medicaid varies by state, but generally followed Medicare guidelines. In HTRC Service Area:Kansas (2004)Missouri (2008)Oklahoma (1998)

2014Medicare Benefit Policy Telehealth Services

[email protected]

Telehealth Service

CPT / HCPCS Codes

Emergency department or initial inpatient consultations

HCPCS codes G0425 G0427

Follow-up inpatient consultations (hospitals or SNFs)

HCPCS codes G0406 G0408

Subsequent hospital care services,limitation 1 telehealth visit every 3 days

CPT codes 99231 - 99233

Subsequent nursing facility care services, limitation 1 telehealth visit every 30 days

CPT codes 99307 - 99310

Office or other outpatient visits

CPT codes 99201 -- 99215

Individual and group diabetes outpatient self-management training (DSMT) services, with a minimum of 1-hr. of in-person instruction to be furnished in the initial year training period to ensure effective injection training

HCPCS codes G0108 and G0109

Individual and group Kidney Disease Education (KDE) services


End Stage Renal Disease (ESRD) related services

CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961

Individual and group Medical Nutrition Therapy

HCPCS code G0270 and CPT codes 97802 -- 97804

Individual and group health and behavior assessment and intervention (HBAI) services

CPT codes 96150 - 96154

Psychiatric diagnostic interview examination

CPT code 90791 and 90792

Individual psychotherapy

CPT codes 90832 -- 90834 and 90836 -- 90838

Pharmacologic management

CPT code 90862

Neurobehavioral Status Exam

CPT codes 96116

Smoking cessation services

HCPCS codes G0436 and G0437, andCPT codes 99406 and 99407

Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services


Annual alcohol misuse screening, 15 minutes

HCPCS code G0442

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

HCPCS code G0443

Annual depression screening, 15 minutes

HCPCS code G0444

High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes

HCPCS code G0445

Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

HCPCS code G0446

Face-to-face behavioral counseling for obesity, 15 minutes

HCPCS code G0447

Transitional care management services

CPT code 994951and 994962

Telehealth originating site facility fee (short description: telehealth facility fee)

Q03014

RHC Rural Health ClinicHPSA Health Professional Shortage AreaKDE _ Kidney disease educationDSMT Diabetes Self-Management Training

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Medicare Benefit Policy Telehealth ServicesNEW for 2014(Effective 01/01/14)

Transitional care management services

CPT code 994951and 994962

1. Communication with patient and/or caregiver within 2 business days of discharge; face-to-face visit within 14 calendar days of discharge and moderate complexity of medical decision-making during service period

2. Communication with patient and/or caregiver within 2 business days of discharge, face-to-face visit within 7 calendar days of discharge and high complexity of medical decision-making during service period

Email: [email protected]

RHC Rural Health ClinicHPSA Health Professional Shortage AreaKDE _ Kidney disease educationDSMT Diabetes Self-Management Training

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Telemedicine in U.S.Multiple Federal Funding Resources

HRSA Network Planning and Network DevelopmentGrant assistance for upfront planning and initial developmenthttp://www.grants.gov/web/grants/search-grants.html USAC Rural Health Care SupportWill pay for % of Internet access costhttp://wireless.fcc.gov/outreach/index.htm?job=fundingDept. of Commerce National Telecomm. and Information Admin.Expanding broadband Internet accessState Broadband Initiative & Tech Opp. Pgm.http://www.ntia.doc.gov/grants-combined

Universal Service Administrative Company open to public or non-profit rural health care providers.

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USDA Rural Development (RD) Grants & LoansCommunity Facilities (CF) Program - $70 million Direct Loans / $10 million GrantsAreas/towns up to 20,000 pop.Construction or renovation of hosp., NF, Clinic (inc. necessary equipment)Purchase of specific equipment (new CT scanner), technology, softwareApplication is once a year (end of May/early June)Announced 60 days in advance of due dateRD staff assistance available for application processhttp://www.rurdev.usda.gov


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USDA Rural Development (RD) Grants & LoansDistance Learning and Telemedicine (DLT) Program - $15 millionAreas/towns up to 20,000 pop.15% matching requirementMinimum grant award: $50,000; maximum: $500,000Purchase of computer hardware/software, computer network components, terminal equip., inside wiring, and inside equip. warrantiesApplication is once a year (end of May/early June)Announced 60 days in advance of due dateRD staff assistance available for application processhttp://www.rurdev.usda.gov


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Insurance & Licensure

Standard malpractice insurance covers telehealthVery low risk service to date3-4 known cases (2 were online prescribing)2 New Mexico cases bring up telehealth use If available and not used, there may be liabilityNo national physician licenseA few states require telemedicine licenseSupplemental licensing

Credentialing & Privileging

Where patient is located is place of serviceProviders need to be credentialed / privileged/ licensed at each place of service

Effective July 2011 hospitals governing body still responsible for all privileging decisions, but can accept credentials from distant-site Medicare hospital for telemedicine providers. CMS

Effective July 5, 2011, CMS has new Medicare hospital Conditions of Participation (CoPs) for credentialing and privileging of physicians and practitioners providing telemedicine services at hospitals and Critical Access Hospitals. As stated by CMS: The removal of unnecessary barriers to the use of telemedicine may enable patients to receive medically necessary interventions in a more timely manner. It may enhance patient follow-up in the management of chronic disease conditions. These revisions will provide more flexibility to small hospitals and CAHs in rural areas and regions with a limited supply of primary care and specialized providers. In certain instances, telemedicine may be a cost-effective alternative to traditional service delivery approaches and, most importantly, may improve patientoutcomes and satisfaction.

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Privacy/Security Issues

Generally, all current videoconferencing systems include encryption technology.Security Rule does not require encryption (Live events are not ePHI), but technology easily encriptsPrivacy rule DOES applyTelemedicine room should be private just like any other clinic roomUse private connections when possible

HIPAA Security Rule

The standards and specifications of the Security Rule are specific to electronic protected health information (e-PHI). . . E-PHI does not include paper-to-paper faxes or video teleconferencing or messages left on voice mail, because the information being exchanged did not exist in electronic form before the transmission. In contrast, the requirements of the Privacy Rule apply to all forms of PHI, including written and oral.US Dept. of Health & Human Serviceshttp://www.hhs.gov/ocr/privacy/hipaa/faq/securityrule/2010.html

All quotes: HHS, CFR Parts 160, 162, 164 Health Insurance Reform: Security Standards; Final RuleFederal Register, Feb 20, 2003 pg 8342

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Applications

Group Sessions and Educational Events

Telehealth technology has proven particularly useful for distance education purposes, particularly with reductions in time and budget for travel.

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Specialty Consultation via ITV

Telestroke / Physician-to-Physician

School-Based Programs

Pediatrics, Public health, Nutrition/Weight management, Behavioral health, Counseling

2010 Photo, nurse has now gone to desktop ITV

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Electronic Otoscope for Pediatrics

Intra-Oral Scope (Tele-Sleep Study)

What Tele-Sleep Presenter Sees

Oncology Care (Hospital Exam Room)

Home Monitoring

Newest, most active segmentPreventive careRemote management of chronic illnessReduce hospital readmission ratesPopular with aging population in U.S.Delay Nursing Facility placementAllows remaining at home longerNo evidence of technology fears

LatestDevelopments

Technical Advances

Next generation:

Tablets PlaybookWirelessSmart PhonesFlexible, wearable screensNurse walking with RP Xpress

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Robotics

Igo in OK working with kids

InTouch Health Robot

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Interactive Tele-Video (ITV)Putting technology concerns into the past.

PROVIDERS OFFICEw/ Desk Top Computer

TABLET

SMARTPHONE

Telehealth Resource Centers

How can they help me?

Telehealth Resource Centers How can they help me?

Example #1 - Make grant implementation easier

June 2011 - AIDS Education and Training Center Telehealth Training Centers Program (TTCP) - a HRSA-funded program designed to expand access to and improve healthcare and health outcomes for hard-to-reach, HIV-positive persons in medical care residing in historically underserved communities. The skills of each TTC are required to be clinical, managerial and educational, not technical.TRCs can fill a technical need:TRCs are available for organizational partnershipsTRCs have telehealth program implementation experience8 out of 9 funded grantees were in TRC Service Areas

http://www.telehealthresourcecenter.org


Example #2 Provide ongoing education, training and certification on all aspects of telehealth/telemedicine TRCs offer online and onsite training, plus regional conferences:Telehealth toolkits are accessible on a variety of sites, includingCertifications include: Telemedicine Clinical Presenter, Telemedicine CoordinatorOther resources: Program Assessment Tools, Program Developer Kit, Program Administration Consultation, etc.Assistance available online, all the time


Telehealth Resource Centers http://accesstelehealth.org/

Example #2 (Continued)

Interactive Websites

Telehealth Resource Centers http://learntelehealth.org/



Telehealth Resource Centers http://HeartlandTRC.org/



Example #2 (Contd.)

E-Newsletters

http://learntelehealth.org/

http://HeartlandTRC.org/

The National Telehealth Resource Center Webinar Series

www.telehealthresourcecenter.org

Key telehealth topics from experts!3rd Thursday of Every Month1:00 PM Central Time


Example #3 Help make healthcare accessibleSummer 2012 Benton County Health Unit, Rogers, ArkansasWere able to give top-of-the-line care, says Sharon Loftis, womens health nurse practitioner. We have a physician at our fingertips, literally, for any complications that we have with our maternity patients.Telemedicine has cut down big time on transportation, Loftis says. We used to make an appointment in Little Rock and hustle around to find transportation if they didnt have it. Its tremendous for so many clients that have trouble getting gas money ,to see us as opposed to going to Little Rock. Its beyond awesome for our clients.

Lutz, Angela; Top-notch telemedicine: Resource center grantees improve patient care; Rural Roads; Summer 2012; p.34,35



We want to bring rural communities together and show them how they can improve their patients outcomes within their own communities. Adam Rule, south Central TRC project director.We offer expert advice from people in the field who have been doing it a long time. We are able to put them in contact with other telehealth experts and allow collaboration and sharing of best practices.To help health care providers recognize the benefits of post-grant sustainability, Rule recommends the telehealth impact calculator available on learntelehealth.org. It approximates how much time and money a hospital or clinic might save by utilizing telemedicine.

Lutz, Angela; Top-notch telemedicine: Resource center grantees improve patient care; Rural Roads; Summer 2012; p.34,35


Who do the TRCs serve?

Rural ClinicsFederally-Qualified Health Centers (FQHC)Critical Access Hospitals (CAH)Community & Urban HospitalsPrimary Care ClinicsProvidersHealth Care OrganizationsAmbulatory Care CentersNursing Homesand others

Kimble HospitalJunction, TX


How TRCs can help. . .

Proven resources Legislation/RegulationsForms & ProtocolsToolkitsEvent AnnouncementsStaff trainingOnsite Basic Protocols TelepresentersPeer-to-peer connectionsLearn from others mistakesTele-All (Stroke, ICU, etc.)No regional limitations



Technical AssistanceAssessmentsMarket ConditionsNeeds & PrioritizationOrganizational ReadinessTechnologyPeer Comparison

Basic strategic planningSources for revenue generationExpense reductionsCost Center/Residual benefitsStart Up / Replacement funding



Technical Assistance (contd.)Business Model DevelopmentEquipment SelectionProgram developmentOperational supportEducation on InsuranceReimbursementQuality Assessment



For Technical Assistance:

Call or Email -

Photo courtesy of RP-X Press

FREE


Its

Phone: 1.877.643.HTRC (4872)Email: [email protected] IP: 169.147.3.125 ext. 7010109

Gordon AllowayProject Director, HTRC

http://www.telehealthresourcecenter.org/

Who are the Telehealth Resource Centers?

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