DIAGNOSING FROM A DISTANCE aka Telehealth Illinois Association, MSS April 11, 2019 Presented by Christine S. “Cris” Mobley, CPMSM, CPCS President, C Mobley & Associates, LLC Co-Founder/Owner, Edge-U-Cate, LLC Colorado Springs CO Proprietary – for educational purpose only

Learning Objectives Define the telehealth regulations Identify the options for meeting these regulations Respond to concerns and issues that the profession is having with telehealth Describe scenarios where telehealth can be effective in treating patients C Mobley & Associates and Edge-U-Cate

Definition of Telehealth Telehealth is the use of technology to deliver health care, health information or health education at a distance. Telehealth can be divided into two general types of applications: real-time communication, and store-and-forward.* Real-time communication may be a patient and a nurse practitioner consulting with a specialist via a live audio/video link. Store-and-forward refers to the transmission of digital images, as in radiology or dermatology, for a diagnosis. source: HRSA www.hhs.gov *Also remote monitoring; e.g. e-ICU C Mobley & Associates and Edge-U-Cate

What it is today A multi-billion-dollar industry and with nearly every major healthcare system leveraging it to transform and to re-invent healthcare. Currently about 200 telemedicine networks, with 3,500 service sites in the US. Nearly 1 million Americans are currently using remote cardiac monitors and in 2011, the Veterans Health Administration delivered over 300,000 remote consultations using telemedicine. Over half of all U.S. hospitals now use some form of telemedicine. C Mobley & Associates and Edge-U-Cate

Today No real distinction between telemedicine and telehealth “Telehealth” now commonly used to encompass all Note: CMS does not differentiate between “telemedicine” and “teleradiology,” so credentialing rules for telemed/telerad are same C Mobley & Associates and Edge-U-Cate

Benefits Improved access – increases service to millions of patients Cost efficiencies – reducing or containing healthcare cost Reduced travel times Fewer or shorter hospital stays Shared professional staffing Better management of chronic disease Improved quality – studies show services provided through telehealth are as good as those given in person Patient demand – consumers want it! source: American Telemedicine Association C Mobley & Associates and Edge-U-Cate

A little history Started with Teleradiology Expanded to: Tele-Radiologists were in Australia, other countries Later, had to relocate to the U.S. Expanded to: E-ICU Sub specialties that are not available in many communities Many services offered by academic settings CMS did not originally condone Contracts/Agreements for “proxy” credentialing and there were issues Created dilemma for hospitals who were using (accreditors allowed it) Legislation in 2011 gave hospitals the ability to choose Organizations updated their telemedicine policies to comply with CMS as did the accreditors . C Mobley & Associates and Edge-U-Cate

What did we do before telehealth?? On-call physician called and waited for them to come into the hospital E.g., radiologists for an accident Transfer to another facility By air By ambulance Outcomes could be tragic – delayed treatment/surgery Other? (audience) C Mobley & Associates and Edge-U-Cate

Telehealth – The Accreditors: DNV, HFAP, TJC standards address telemedicine privileges which follow CMS guidelines. C Mobley & Associates and Edge-U-Cate

Diagnosing from a Distance Telehealth Diagnosing from a Distance Telemedicine (via electronic link) LIP has either total or shared responsibility for pt care, treatment, services (i.e.; authority to write orders and/or direct responsibility for care), LIP provides official interpretative services (readings of images, tracings or specimens), all thru telemed link Originating site (where pt is located) fully credentials internally (may use a CVO); or Originating site uses distant site info (hospital or telemedicine entity) to privilege practitioners if distant site has CMS “deemed status” when making its privileging decision; or C Mobley & Associates and Edge-U-Cate C Mobley & Edge-U-Cate

Telehealth 3. Originating site may choose to accept credentialing and privileging decision from distant site when making final privileging decision IF governing body, through written agreement, ensures distant-site’s credentialing/ privileging process and standards meet or exceed CoPs (& have “deemed status”); and Practitioner privileged for same privileges at distance site; and Evidence of internal review of performance of practitioner Distance site provides originating site with a current list of LIPs’ privileges. (No copies of credentialing information is necessary nor recommended.) source – paraphrased from TJC HAS 2017 C Mobley & Associates and Edge-U-Cate

Diagnosing from a Distance Telehealth Cont’d Diagnosing from a Distance APPROVAL Regardless of method used to credential, practitioner credentials must still go through MS for privilege recommendation and Board for approval. Again, in the case of “proxy” credentialing, a list is given to originating site by distance site of those providing services for approval by distance site. No “membership” category necessary – privileges only - TBD Can be utilized in a temporary privilege situation if it meets the definition of “pressing need.” Remember – Provider must be licensed in distant and originating state/s Must do NPDB query unless assigning distance site as authorized agent; separate NPDB query must still be obtained (and de-enroll when no longer providing service) Originating site still has duty to monitor performance (and report any issues to distant site if utilizing #3) C Mobley & Associates and Edge-U-Cate C Mobley & Edge-U-Cate

What do you use it for? Audience C Mobley & Associates and Edge-U-Cate

Industry Video conferencing Remote monitoring of vital signs Cardiac, pulmonary, fetal monitoring Mental health Hospitalists/nocturnists Intensive care services e.g., vent mgmt/fluid/pain mgmt., other Many more specialties CME credits for those in remote locations C Mobley & Associates and Edge-U-Cate

REAL CASE SCENARIO: the Facts Northern CA – rural, critical access hospital Access to nocurnist medicine – chronic issue 2009 brought in robot for p.m. hospitalist Hospital admissions increased by 2% within 60 days Nursing staff, patient satisfaction increased Resulted in better patient care outcomes and fewer transfers C Mobley & Associates and Edge-U-Cate

Medicine Department Meeting C Mobley & Associates and Edge-U-Cate

Good news – didn’t have to credential the robot Conclusion – expense was more than offset by increases in revenues & patient & staff satisfaction AND………………….. Good news – didn’t have to credential the robot C Mobley & Associates and Edge-U-Cate

Credentialing and privileging Telehealth is NOT a separate medical specialty Same training Same Boards Telehealth is NOT a medical staff category Where is it defined in your bylaws? Where should it be defined in your bylaws? Telehealth IS a “methodology” for providing patient care services C Mobley & Associates and Edge-U-Cate

Decision points In-House credentialing v. credentialing by proxy May use either depending upon factors below Factors to consider: Staffing Volume Competency (OPPD) at distance site Timing Recruiting individual from an accredited organization Accredited organization must have “deemed status” to be able to credential by proxy; otherwise, originating site must credential C Mobley & Associates and Edge-U-Cate

Telehealth credentialing – Proxy efficiencies TRADITIONAL TELEHEALTH NEW WORLD Signed application for MS membership Contract – select providers Signed release/authorization n/a Grant MS membership 2 year cycle Primary source verification Rely on contract Query NPDB Signed privilege delineation form One common privilege delineation Grant privileges 1 year annual contract review Individual credentials file One list for all contract providers C Mobley & Associates and Edge-U-Cate

Telehealth credentialing – Proxy efficiencies TRADITIONAL TELEHEALTH NEW WORLD OPPE Report adverse events/complaints FPPE Signed reappointment request n/a Signed privilege delineation request Contract C Mobley & Associates and Edge-U-Cate

Telehealth credentialing - efficiencies MEDICAL STAFF OBLIGATIONS/PREROGATIGES Parking n/a ED call coverage Dues/fees Annual meeting attendance Department meeting attendance Committee Service Vote on medical staff actions C Mobley & Associates and Edge-U-Cate

Your role Get involved in telehealth discussions Help to determine which telehealth path to follow given the facts (see previous slides) Know what your organization’s letter of agreement/contracts state (if using Proxy route) Know and monitor your State’s laws Facilitate the approval process through Medical Staff and Board approval process regardless of which path chosen C Mobley & Associates and Edge-U-Cate

Resources American Telemedicine Association www.americantelemed.org/about-telemedicine Illinois State Medical Society The Joint Commission Medical Staff Standards, MS. 13.01.01 HRSA www.hhs.gov UC Davis Medical Center, Sacramento Stanford University Hospital (see on line forms, etc) Google it!! C Mobley & Associates and Edge-U-Cate

Questions???? Comments!!!! C Mobley & Associates and Edge-U-Cate