1. Telemedicine: Transforming the Delivery of Healthcare Debbie Voyles, MBA HOM Director of Telemedicine F. Marie Hall Institute for Rural and Community Health June 2013

2. Five Core Programs Telemedicine –community-based telemedicine in Texas; one of 2 correctional programs; one of longest running programs in nation; 45,000+ consultations TexLa Telehealth Resource Center Rural Research – Project FRONTIER, TARC, Alzheimer’s Disease Health Education – West Texas Area Health Education Center (WTAHEC), Hot Jobs, Double-T Health Service Corps, region-wide community health needs assessment Electronic Health Records – West Texas Health Information Technology Regional Extension Center (WTxHITREC) Texas Tech University Health Sciences Center F. Marie Hall Institute for Rural and Community Health

3. Unique challenges for Rural Health Care What is Telemedicine Benefits to using Telemedicine Challenges/Barriers to Telemedicine Critical Steps to Implement Telemedicine Reimbursement TexLa Telehealth Resource Center Today’s Discussions :

4. US 2010 Census Population = 308,745,538 9.7% increase from 2000 83.7% live in the nations 366 metro areas (population over 50K) 10.0% live in the nations 576 micro areas (population between 10K and 50K) 6.3% live in rural areas (population less than 10K) US Department of Commerce Population Distribution and Change: 2000 to 2010

5. Current Challenges in Rural Health Care Workforce shortages Geographic isolation – limited transportation Diminishing community economics Low healthcare margins Difficulty recruiting physicians Increasing dependence on specialty and expensive technologies Demand for quality

6. Is this the Future of Healthcare?

7. Health Professional Shortage Areas

8. HPSA – Mental Health Designated Populations

9. HPSA – Dental Health Designated Populations

10. Ratio of Providers per 100,000 Population Primary Care Doctors Physician Assistants Nurse Practitioners RNsLVNs U.S., 201067.434.422.8882.5244.0 Texas, 2011 (2005) 69.5 (68.5) 20.8 (14.7) 25.8 (17.7) 712.7 (628.6) 281.7 (269) West Texas, 2011 60.81828.5746.4415.4 West Texas/Border, 2011 48.013.424.82577.54193.18

11. Family Practice Physicians in Rural Counties

12. Texas Counties Without a Pharmacists Source: Texas Department of Rural Affairs, August 2010

13. Dentists in Rural Counties

14. ACCESS Hospital: Clinics: Physicians: Nurses: P.A.s: 0 1 2.5 (nearest 85mi.) Presidio, TX Presidio to Lubbock: 398 mi. / 7.5 hrs. Presidio to Lubbock: 398 mi. / 7.5 hrs. El Paso to Lubbock: 343 mi. / 7 hrs. El Paso to Lubbock: 343 mi. / 7 hrs. Population: Medicaid Enrolled: 4167 705

16. We know a need exists

17. If we can dream it – we can do it!

18. Could healthcare be better? If it were available anywhere at anytime to anyone Costs were reduced and outcomes improved Practitioners could consult with experts and each other anytime and anywhere Chronically ill and homebound patients could be monitored remotely 24/7/365 Preventive care could be integrated into work, home, school, or any environment With Telemedicine it is possible!

19. What is Telemedicine? American Telemedicine Association It the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. It has evolved to telehealth to incorporate health education, prevention and anticipatory guidance that does not always involve clinical services It may include videoconferencing, transmission of images, e-health, m-health, patient portals, remote monitoring of clinical information, etc. It is not a separate medical specialty!

20. Three Links to Effective Telemedicine

21. How can Telehealth/Telemedicine be used? “ Shrinking the distance” Increasing access Bridging the gaps Serving the needs “Care closest to home ” Medically underserved rural areas Health professions shortage areas Saves travel time / increases convenience Lowers costs Aging & chronic conditions Special populations (Prisons) Disaster response & relief efforts Refocus on prevention, team- based community-centric care

22. How it Works Video conference system (SF & RT) Various medical peripherals (heart rate, blood pressure, ekg, dematomes, otoscopes, etc.) Connectivity (High-speed T-1 phone lines, DSL, Wireless, Satellite, Cloud, etc.) Consultant – physician or specialists Presenter – in Texas any certified healthcare provider working within the scope of their license

23. Telemedicine Components Equipment standardization Peripherals Otoscope General Exam Camera Dermatology Burn Care Wound Care  Stethoscope Color Printer

24. Telemedicine Components

25. Digital - Electronic Stethoscope

26. General Exam Camera

27. Fiber Optic Otoscope

28. Electrocardiogram (ECG)

29. Emerging Technology Applications

31. Service Lines Burn/Wound Care Dermatology Genetics Infectious Disease Mental Health Neurology Nutritional Orthopedics Primary Care Pulmonology Cardiology Endocrinology Geriatrics Internal Medicine Nephrology Oncology/Hematology Pharmacy Pulmonology Urology

32. Telemedicine Philosophy Telemedicine does not alter the practice of medicine. It is only a tool.

33. Telemedicine Access Response to: Fewer physicians in rural/frontier communities Fewer specialists throughout region Technology advancements Changes to state rules Services w/out taking too much time off from work/school Reduces escalating (spiking) personal travel costs Another way to see a health care professional; comparable to face-to-face care… Meeting increasing need for specialties due to increasing chronic illnesses (diabetes, obesity, psychiatric, geriatric, cognitive…) Expand benefits that health services bring to rural and frontier communities …and patients like telemedicine

34. Benefits to Using Telemedicine Improved access to specialty services and care – “care closest to home” High patient satisfaction – improved access, reduced travel costs (mileage and travel time) reduced time away from home/school/work Improved patient outcomes – earlier interventions, reduced complications, consistent use of evidenced based medicine Healthy People/Healthy Communities - better relationships with rural communities – create, improve and maintain local access to appropriate high quality care

35. Challenges/Barriers to Telemedicine Keeping up with changes in technology Investment in equipment and training Credentialing/licensing (especially across state lines) Limits on reimbursement from insurance companies, Medicare, Medicaid Connectivity issues Regulatory Restrictions Systems implementation and interoperability End user adoption and training

36. Critical Steps to Implementation Community Assessment – in person Be clear on goals – what are you trying to achieve? Identify a telemedicine team – find champions Determine how telemedicine will fit into the organizational structure Develop a plan for educating and training Continually educate senior leadership, medical staff, community and state leaders, on performance and advances

37. Treat Telemedicine The Same As Any Other Practice of Medicine Apply same protocols, techniques, standards and style Treat patient in the same manner as if they were presented in the same room

38. Licensure State licensing – does not require a different license Physician must be licensed in the same state the patient is located Federal licensing proposal

39. Telemedicine Credentialing and Privileging Requirements If seeing patients in a hospital setting must be credentialed with facility as if seeing the patient in person New CMS rule, which applies to all hospitals that participate in Medicare, and inpatients at critical access hospitals, upholds The Joint Commission's current practice of allowing the hospital or CAH to utilize information from the distant-site hospital or other accredited telemedicine entity when making credentialing or privileging decisions for the distant-site physicians and practitioners. Effective July 5, 2011

40. Confidentiality and Consent Forms Employee confidentiality forms Patient consent to treatment form – same as if being seen face to face Release of medical records forms

41. Telemedicine Reimbursement Medicare Medicaid Third-Party Private Pay

42. Medicare Eligible areas include : Health Professional Shortage Area (HPSA) County that is not included in metropolitan statistical area (MSA) Eligible sites include: Office of physician or practitioner Critical access hospital (CAH) Rural health clinic (RHC) Federally qualified health clinic (FQHC) Hospital Skilled nursing facility (SNF) Hospital-based or CAH-based Renal Dialysis Centers (including satellites) Community mental health center (CMHC)

43. Medicare Practitioner who may bill: Physician Nurse practitioner (NP) Physician assistant (PA) Nurse midwife Clinical nurse specialist (CNS) Clinical psychologist (CP) and clinical social workers (CSW) (CPs and CSWs cannot bill for psychotherapy services that include medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90805, 90807, and 90809) Registered dietitians or nutrition professionals

44. Medicare – Eligible Medical Services Office or other outpatient visits (99201-99215) Individual psychotherapy (90804-90809) Pharmacologic management (90862) Psychiatric diagnostic interview examination (90801) End stage renal disease related services included in the monthly capitation payment (90951, 90952, 90954, 90955, 90957, 90958, 90960 and 90961) Individual Medical Nutritional Therapy (G0270, and 97802- 97804) Individual and group diabetes self-management training services (G0108-G0109) Neurobehavioral status examination (96116)

45. Medicare – Eligible Medical Services Individual and group health and behavior assessment and intervention (96150-96154) Follow-up inpatient Telehealth consultations (G0406, G0407 and G0408) Emergency department or initial inpatient telehealth consultations in hospitals and SNFs (G0425-G0427) Subsequent hospital care services (but not more frequently than once every 3 days) (99231-99233) Subsequent nursing facility care services (but not more frequently than once every 30 days) (99307-99310) Individual and group kidney disease education services (G0420-G0421) Smoking cessation services (99406-99407, G0436-G0437)

46. Medicare – New for 2013 7/30/12 Proposed Rule to add two codes for “alcohol and/or substance abuse (other than tobacco) structured screening (e.g. AUDIT, DAST) and intervention services” (G-0396 – 15-30, G0397 – more than 30 minutes) (NOTE: not screening services but as part of diagnosis or treatment of an illness or injury) Preventive Services added in 2012 now available. G0442-G0443. Annual alcohol misuse screening and counseling, G0444 Annual depression screening, G0445 Screening for sexually transmitted infections and counseling, G0446 Intensive behavioral therapy for cardiovascular disease G0447 Intensive behavioral therapy for obesity

47. Medicare Distant site physicians and practitioners submit claims for Telehealth services using the appropriate CPT or HCPCS code for the professional service along with the Telehealth modifier GT, “via interactive audio and video telecommunications system.

48. Medicare Originating sites are paid an originating site facility fee HCPCS Code Q3014. The originating site facility fee is a separately billable Part B payment. Current fee is $24.24

49. Telemedicine Reimbursement Medicaid 35 States Reimburse for Telemedicine Alabama, Alaska, Arizona, Arkansas, California, Colorado, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, Wyoming

50. Texas Medicaid Reimbursement Current Texas Medicaid Started reimbursing in 1998 One of the first states in the country Must be “face to face” interactive video, no store and forward, except for Tele-radiology Patient site bills for a facility fee – Code Q3014 Must use GT modifier, indicating it was a telemedicine visit

51. Texas Medicaid Reimbursement Eligible areas include: Rural county – less than 50K Medically Underserved Area (MUA) or Medically Underserved Population (MUP) Patient Site Location State hospital State school Physician office Hospital Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Intermediate care facility for persons with mental retardation (ICF/MR) that is not a state school Community Center as defined in Health and Safety Code  534.001 or outreach site associated with a community center Local health department

52. Texas Medicaid Reimbursement Patient site presenter: Licensed or certified in this state to perform health care services Qualified mental health professional (QMHP ) Eligible Medical Services Consultations Office or other outpatient visits Psychiatric diagnostic interview Pharmacologic management Psychotherapy

53. Private Payers States with government mandated legislation California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas, Virginia All prohibit payers from excluding services solely because they are delivered via telemedicine

54. Private Payers Providers Texas Insurance Code (Chapter 1455) generally requires health care coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment. JUST BILL THEM

55. Self Pay Patients are billed at a discounted rate similar to what they would be billed if seen in person

56. TexLa Telehealth Resource Center Telehealth Resource Centers (TRCs) are funded by the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) Office for the Advancement of Telehealth, which is part of the Office of Rural Health Policy. Nationally, there are a total of 15 TRCs which include 12 Regional Centers, all with different strengths and regional expertise, and 3 National Centers which focus on areas of technology assessment, telehealth policy and technical assistance regarding State policies affecting the use and deployment of telehealth services.

57. What does a TRC do? TRC’s provide technical assistance to health care organizations, health care networks, and health care providers in the implementation of cost- effective telehealth programs to serve rural and medically underserved areas and populations

58. TexLa TRC

59. Primary Objectives To provide telehealth technical assistance and resources to new and existing telehealth programs throughout Texas and Louisiana To evaluate telehealth programs in Texas and Louisiana for effective delivery of telehealth services, efficiency, sustainability, and patient satisfaction To develop an interactive hands-on training center to provide guidance in telehealth planning, implementation, management and sustainability To educate policy makers about legislative and regulatory barriers to the use of telehealth in Texas and Louisiana and work to improve reimbursement for telehealth services with CMS and third party payors To collaborate with other regional TRCs to share resources as well as lessons learned to help promote best practices in telehealth across the United States

60. Project Oversight PI – Billy U. Philips, PhD, M.P.H  Executive Vice President and Director  The F. Marie Hall Institute for Rural and Community Health  Texas Tech University Health Sciences Center Co-PI – John Griswold, M.D, F.A.C.S  Professor and Chairman,  Department of Surgery  Texas Tech University Health Sciences Center Project Director – Debbie Voyles, M.B.A, H.O.M  Director of Telemedicine  The F. Marie Hall Institute for Rural and Community Health Site Coordinator, LSU – Ted Lambert  Telemedicine Program Coordinator  Medical Informatics and Telemedicine  Louisiana State University, Health Care Services Division

61. Funding for Project This project was made possible by grant number G22RH24748 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS.

63. Texas Tech Telemedicine Q&A Contact information: Debbie Voyles, MBA, HOM TTUHSC Telemedicine debbie.voyles@ttuhsc.edu 806-743-4440