Session One: Telehealth Program Implementation: Strategies for Success June 21, 2017

Agenda Housekeeping Opening Remarks Presentation Q&A Closing Remarks

Introduction to atom Alliance Multi-state alliance for powerful change composed of three nonprofit, healthcare QI consulting companies.

Objectives Attendees will learn about: Implementation of telemedicine services in your current workflow Navigation of compliance & HIPAA Concerns Telemedicine billing with payers in Tennessee Using telemedicine to expand outside of the walls of the hospital Using telemedicine to ensure the patient is in the appropriate setting

Housekeeping Items: Chat To ensure maximum sound quality, participant lines have been muted; however we welcome ALL questions and comments via the chat board on the right hand side of your screen To submit questions or comments: Use WebEx chat – send messages to the panelists or all participants using the chat feature drop down menu

Housekeeping Items: Q & A To ask panelists questions directly, and privately The panelist can then decide to answer the question privately (only the person that asked the question will see the response), or the panelist can answer publicly, and all participants will see the question and the answer.

Housekeeping Items: Polling During today’s presentations you may be asked to participate in some polling questions. These questions will come up on the right side of your screen. When you do answer a polling question, be sure to hit the submit button so we can capture your answer.

Polling Question 1 What is the status of telehealth at your organization? Do not plan to participate in telehealth In the beginning stages of planning for telehealth services We have been providing telehealth services for less than 1 year We have been providing telehealth services for more than 1 year

THIMA represents approximately 2,600 health information management professionals in TN and is a component state association of the American Health Information Management Association (AHIMA). Our mission is to advance the health information management profession through development, education, member representation, and life long learning to ensure quality health information. Our focus: Quality healthcare through quality information

Telehealth Program Implementation: Strategies for Success Penni Kyte, Director, EPMO Mountain States Health Alliance

Telehealth Lessons Learned Penni Kyte, Director, EPMO Mountain States Health Alliance

“In a rural setting, telehealth isn’t just helpful – it’s a necessity “In a rural setting, telehealth isn’t just helpful – it’s a necessity. Our patients typically require multiple visits over multiple months, so telehealth saves them a lot of time, miles and money. With telehealth, we get to follow patients more closely and can see them quicker too. I only travel to outreach clinics a few times each month, but if there’s an urgent need I can see patients almost immediately via telehealth.” Arvin L. Santos, MD, FACP, FASN Avera Medical Group Nephrology Sioux Falls Avera eCare is a health care system that has over 500 hospitals and 2000 clinical practices that utilize telemedicine over 5 states. They are the pioneers in telehealth. We visited the eCare program when we began this system telehealth Journey in December 2015.

Service Area 13 Hospitals, including region’s only children’s hospital Urgent Care, SNF, JV Rehab Hospital, Home Health, Hospice 29-County Service Area – 4 States MSMG 107 Locations 315 Providers (200 Physicians, 115 mid-levels) 25 Specialties 12,000 team members, physicians and volunteers 1.1 Million Service Area Population The MSHA system spans across a vast terrain has a 1.1 million service area. Many of our locations are over 2 hours away one way. Therefore to provide a specialty provider in those areas would mean a provider would spend 4 hours in a car driving. Our most rural locations are some of the locations that need specialty care such as infectious disease, pediatrics, and neurology yet trying to recruit a provider to this location has not been successful or the volume in some of these locations does not constitute a full time provider. Also, because of the ever changing landscape of fee for service to value based payments, we now need to play a more proative role in providing healthcare to these areas. However, because of the terrain, trying to share a provider between some of the locations is not possible. Therefore, we had to come up with alternatives to meet these needs. $1.1 Billion in Revenue 61,559 Total Admissions 1,732,808 Total Outpatient Visits 255,536 Total ER Visits

Why Telemedicine? Solve a Problem such as lack of specialty service in an area, increase provider utilization Increase actual Doc to patient face time Provide for a healthcare need in a rural area that wouldn’t otherwise have this service Create convenience for the patient Create additional access to patients Iterate not enough infectious disease providers, neurologists, for this area. Topology make driving time increased and not good use of provider time.

Which Specialties to Focus on? Review the data In-House providers before community providers Provider buy-in Market need/environment change First, we try to go to the data. One of our biggest issues is transfers to our tertiary hospital from the rural hospitals with a discharge from the ED and/or a discharge in less than 48 hours. Clinically, a discharge in less than 48 hours could have been retained at the rural hospital. One of our biggest transfers with this criteria was Peds, behavioral, and neurology. Therefore we began our focus on each. We always tried to focus on MSHA providers with capacity compared to community (or outside providers). Reasons: many of our process would not have to change, we would not have to integrate third party systems, less security risk, IT buy-in. We learned early on that pushing an initiative on the providers and/or nursing stuff was not successful because they felt it was mandated and additional work. Therefore, we learned to spend additional time in creating buy-in both clinically and non-clinically. Again, we reviewed the data. We saw the areas where our market lacked pediatric services yet our ED volument for peds was very high. We reviewed this for specialties with the most need yet there weren’t services in these areas.

Polling Question 2 What type of services is your organization providing None Pediatric Specialty Neurology Behavioral Health

Contracts/Legal Legal Contracting Provider contracts for additional pay for services Third party contracts Legal - State and Federal requirements for telehealth (different for certain service lines such as behavioral) - Consent for telehealth (explaining no captured video, audio, images of the visit)

Privileging/Credentialing Possible addition to by-laws for telemedicine Mid-levels and the overseeing physicians duties in a telemedicine situation Provider to be credentialed/Privileged at hospitals Providers need privileging for telemedicine Third party contracts Providers have to be credentialed payer contracts

Compliance Consent forms Reimbursement New process for telemedicine HIPAA concerns Emailing/faxing of documents to remote facility Use of a facilitator and definition of facilitator Use of telehealth without facilitator Clinical checklists of review of services with patient

Information Technology Equipment Design according to Service Line Investment in the appropriate equipment/instruments Provider buy-in on equipment HIPAA Approved Ensure no capture of images, video, data Wireless Security (IT Security Assessment) Ensure data security to and from Third Party Qos on network with a distinct Service level agreement of minimum video/voice packet loss Minimize systems to 3 manageable systems or less Explain difference in reliability of emergency room and school based telemedicine.

Billing/Reimbursement Review and understand state and federal guidelines on reimbursement Understand Medicare is significantly different than Medicaid/commercial payer in payment Change billing systems to modify for GT Modifiers, place of service, etc. Review commercial payers rules on telehealth Create a 90 day process to review reimbursement and denials Build telemedicine reimbursement into payer contracts

Polling Question 3 What are the major concerns that your organizations has regarding telehealth? Getting paid for telehealth services Technology functioning correctly Patient Privacy/Security compliance concerns Documentation in medical record

Marketing/Outreach Educating community on telehealth Marketing to rural areas of provision for specialty services Survey patients of telemedicine to see how to improve the process Face to face communication with local community providers on what the service will bring to area to obtain buy-in Communication Plan: how communication will flow to community, third party, etc.

Training Training of clinical & non-clinical team at rural facilities Hands-on training with instruments Understand your facilitator and their concerns Understand environment for telemedicine to be performed Re-train every 12 months Create yearly nursing/provider competency for telehealth service Create touch base for users that struggle on an actual telehealth call Provider/Nurse Relationship

Operationalization Standing orders – how they will work? Utilization of physician orders to begin the telehealth process (change in IT system) Consent form changes/verbal consent use Emailing/faxing clinical information Mimic the face to face workflow as much as possible Survey providers of telemedicine to see how to improve the process

Operationalization Intake criteria/evaluation for new telemedicine initiatives Need for photo ID – risk assessment Consent form expiration need (school-based telemedicine) 60, 90, 120 day check after operationalization Need for system focus on telehealth Clinical and non-clinical SME (nursing, provider, and business owner for service line)

Lessons Learned Clinical and non-clinical SME (nursing, provider, and business owner for service line) Outside of the box thinking for providing healthcare outside of hospital walls Clinical buy-in on IT systems Different states with different rules for telemedicine compared to face to face service Billing/Reimbursement changes

Lessons Learned Provide ramp up time for service to be used (1 to 3 years) Senior Leadership buy-in/Executive Sponsor Frontline Buy-in (Providers/nurses) Do not change the process from the face to face process unless absolutely necessary Hire a dedicated operational person for telemedicine

Questions?

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Thank you for joining us! Please complete the survey that will come up as you exit the webinar – we value your feedback in developing future events! Please visit us at www.atomAlliance.org This material was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 16.ASD1.05.014

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Upcoming Sessions: (All Sessions begin at 1 p. m Upcoming Sessions: (All Sessions begin at 1 p.m. CT) July 12 - Making the Right Call on Telemedicine (Speaker: Yarnell Beaty) Aug. 16 - Overview of Telehealth: Outcomes and Lessons Learned Sept. 20 - Telehealth Provider Training: Education and Simulation Oct. 18 - Tele-Psychology This presentation was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the CENTERS for MEDICARE & MEDICAID SERVICES (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 17.ASB1.05.009