TELEMEDICINE UPDATE:WHAT S NEW IN 2014? Vanessa A. Reynolds, P.A.

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1 TELEMEDICINE UPDATE:WHAT S NEW IN 2014? Vanessa A. Reynolds, P.A.

2 What is telemedicine? Telemedicine has been defined as broadly as the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment, and services (American Telemedicine Association),... Copyright Broad and Cassel

3 What is telemedicine?... and as narrowly as the practice of medicine using electronic communication, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening healthcare provider (Federation of State Medical Boards). Copyright Broad and Cassel

4 What is telemedicine? Telemedicine is not audio only, telephone conversation, /instant messaging or fax. Typically uses secure videoconferencing to replicate the interaction of a traditional in-person encounter between a provider and a patient, or may use store and forward technology, such as digital imaging for consultations. Copyright Broad and Cassel

5 How and by whom is telemedicine used? Teleradiology used by hospitals, imaging centers and other outpatient settings to read and interpret diagnostic tests Specialist consultations to assist other practitioners in diagnostic or treatment decisions Stroke diagnosis and treatment Intensivists in critical care treatment areas Rural or medically underserved areas Telepsychiatry to assess Baker Act and other mental health patients Copyright Broad and Cassel

6 How and by whom is telemedicine used? Home health; remote monitoring of patients recently discharged from a hospital Specialized populations, such as the military or prison inmates Military personnel in war zones (including robotic surgery in emergencies) Integration into physician practices Copyright Broad and Cassel

7 How and by whom is telemedicine used? University of Virginia (UVA) Center for Telehealth 118 sites offering telemedicine services in more than 40 specialties and sub-specialties. Services include single consultations and follow-up visits, emergency consultations, and screenings such as mobile digital mammography and retinopathy. Depending on specialty, patient may have an initial in-person visit with specialist at UVA and then continue with followup appointments via telemedicine. Copyright Broad and Cassel

8 University of Arkansas for Medical Services (UAMS) provides subspecialty care services to high-risk pregnant women, mothers and their infants at approximately 30 telemedicine sites. It uses a variety of telemedicine technologies to deliver care, including specialized ultrasound equipment that digitally transfers sonogram images to UAMS, and devices to perform colposcopies via telemedicine for remote cervical examination and biopsy. Copyright Broad and Cassel

9 AccessDerm a teledermatology program providing primary care practitioners working in participating clinics caring for underserved patients with free access to dermatologic consultations. The primary care practitioner and participating dermatologist use either personal mobile devices or the Internet to transmit the information required for the consultation. Copyright Broad and Cassel

10 What are the current drivers of telemedicine?

11 Telemedicine drivers The Affordable Care Act More people with coverage means increased access to healthcare, which requires increased availability of healthcare providers and services. Projected Physician Shortages Cost-effectiveness: Efficient distribution of resources Chronic disease management Hospital readmission penalties Copyright Broad and Cassel

12 Telemedicine drivers Medicaid/Commercial Insurers/Employers Medicare Reduce costs Wellness initiatives Disease management Limited, with only incremental expansion of coverage Copyright Broad and Cassel

13 Telemedicine drivers Market factors Major telecommunication and health care firms wanting to create nationwide telemedicine businesses Revenue expansion of telehealth is estimated to increase to nearly $2 billion in 2018 from $240 million in Patient volume is estimated to be 3.2 million patients in 2018, compared to 250,000 in Copyright Broad and Cassel

14 What are the risks associated with telemedicine?

15 Privacy, Security and Patient Confidentiality Telemedicine providers have same privacy and security obligations as any other healthcare provider. Must comply with HIPAA and HITECH Act, and more stringent state law. Institutional providers should verify security of telemedicine vendors' systems and operations to protect patient information. Avoid unencrypted communications platforms such as Skype or Google Talk. Copyright Broad and Cassel

16 Credentialing Practitioners who provide services to hospital patients must be credentialed and privileged by that hospital (originating site). The Joint Commission and CMS now permit "credentialing by proxy," allowing hospitals to rely on credentialing by the distant site hospital if criteria are met. Hospital's medical staff bylaws should provide for credentialing by proxy. Copyright Broad and Cassel

17 Credentialing by Proxy The distant site hospital offering telemedicine services to patients in another location must be a Medicare participating hospital or meet all applicable CoPs, including Medicare credentialing standards. Practitioners providing telemedicine services at the originating site hospital must be credentialed at the distant site hospital or entity where he or she routinely works. Copyright Broad and Cassel

18 Credentialing by Proxy Telemedicine physician must have a medical license issued or recognized by the state where the hospital whose patients are receiving care is located. The hospital receiving telemedicine services must review the services provided to its patients by telemedicine practitioner pursuant to the agreement. The hospital must provide written feedback to the distant site hospital or entity regarding, at a minimum, adverse events and patient complaints related to the telemedicine services. Copyright Broad and Cassel

19 Consent Patients should be aware of and consent to the potential risks and benefits of telemedicine. Informed vs. general consent? Depending on clinical context, informed consent may not be practicable. If informed consent obtained, should be in accordance with facility policy and procedures; e.g., physicians must obtain informed consent and documentation of informed consent should be included in patient's record. Copyright Broad and Cassel

20 Continuity of Care Documentation of telemedicine encounters must be included in the patient s ongoing medical record to ensure accurate and complete patient history that can be referenced by subsequent providers. Copyright Broad and Cassel

21 Reliability of the Technology If technology fails during patient encounter, patient or practitioner may receive incorrect information. Vendor contracts usually disclaim liability and/or limit damages to in that event. Vendor arrangements should include protocols for accuracy of transfer information, regular maintenance and testing of equipment, etc. Copyright Broad and Cassel

22 Appropriateness in the Clinical Context Appropriate in acute primary care and care of patients with chronic conditions. Should not replace in-person evaluation and management for escalating medical conditions (e.g., patients with chest pain or high fever), but can be appropriately used for consultation with the inperson practitioner. Copyright Broad and Cassel

23 Emerging Issues in Telemedicine

24 Physician licensure Federation of State Medical Boards American Medical Association Physicians must be licensed in state where patient is located American Telemedicine Association States should allow flexibility in licensure Florida 2014 Legislation failed to pass, but some provisions included in new Department of Health regulations allowing non-florida licensed physicians to review and interpret diagnostic tests. Copyright Broad and Cassel

25 Florida laws governing telemedicine Only a physician licensed in Florida or otherwise authorized to practice medicine in Florida may order, from a person located outside this state, electroniccommunications diagnostic-imaging or treatment services for a person located in Florida , Fla. Stat. Copyright Broad and Cassel

26 Florida laws governing telemedicine Physicians and PAs shall not provide treatment recommendations, including issuing a prescription, via electronic or other means, unless the following elements have been met: A documented patient evaluation, including history and physical examination, adequate to establish the diagnosis for which any drug is prescribed. Sufficient dialogue between the physician or PA and the patient regarding treatment options and the risks and benefits of treatment. Maintenance of contemporaneous medical records. Copyright Broad and Cassel

27 Florida laws governing telemedicine Effective July 22, 2014: Established standards for telemedicine practice; Acknowledged existence of physician-patient relationship through telemedicine; Standard of care same for in-person and telemedicine encounters; Controlled substances cannot be prescribed via telemedicine except in in-patient hospital setting; Copyright Broad and Cassel

28 Florida laws governing telemedicine Physicians and PAs providing telemedicine services are responsible for the quality of the equipment and technology employed and are responsible for their safe use; Reaffirms patient confidentiality and recordkeeping requirements; Does not prohibit consultations between physicians or the transmission and review of digital images, pathology specimens, test results, or other medical data by physicians or other qualified providers related to the care of Florida patients. Copyright Broad and Cassel

29 Florida Legislation Proposed Senate Bill 7028 (2014) Would permit practitioners licensed in other states to provide services by registering with Fla. licensing Board; Would make registered telemedicine practitioners subject to Fla. Board jurisdiction; Registration not required for out-of-state practitioners with 10 or fewer telemedicine encounters per year; Licensure or registration not required for consultations between providers or for imaging review; Copyright Broad and Cassel

30 Florida Legislation (proposed) Would establish standards for telemedicine, including encryption of transmission; Telemedicine practitioner not required to conduct history and physical before engaging in encounter; Prohibits prescription of legend drugs without a visual examination; Prohibits prescription via telemedicine of controlled substances for chronic, non-malignant pain; Provides for reimbursement parity by Medicaid and insurers. Copyright Broad and Cassel

31 Reimbursement Medicare Medicare eligible services include initial and follow up inpatient consultations; office or other outpatient visits; psychiatric diagnostic interview examinations; ESRD related services; neurobehavioral status exams; screenings for, and behavioral counseling to prevent, STDs; intensive behavioral therapy for cardiovascular disease; transitional care management services (added in 2014). Copyright Broad and Cassel

32 Reimbursement Medicare Limited to medically underserved and rural areas; Must have both interactive audio and video with real-time communication; Recently expanded definition of rural areas, slightly increased reimbursement; Bill pending in Congress to further expand reimbursement for telemedicine Urban areas, retail clinics, patient homes Remote patient monitoring for chronic conditions Copyright Broad and Cassel

33 Operational/Contracting concerns Assumptions about ease, reliability of technology Focus on technology bells and whistles at expense of Clinical program development and oversight Physician engagement Strategy Device and site assessment Lack of accountability by vendor Copyright Broad and Cassel

34 Risk Mitigation Verify vendor qualifications and licensure to do business Ensure credentialing standards of facility providing telemedicine practitioners Incorporate CMS/TJC standards into medical staff bylaws Adopt protocols for services by not-physician providers Develop informed consent forms and incorporate telemedicine into general consent forms Copyright Broad and Cassel

35 Risk Mitigation Educate medical staff about telemedicine requirements and potential liabilities Establish process for sharing PHI and monitor for compliance Review telemedicine agreements Compliance with Medicare CoPs Indemnification Insurance coverage Copyright Broad and Cassel

36 Risk Mitigation Review telemedicine insurance for facility and telemedicine vendors/providers Geographic limitations (state and foreign) Educate staff about documentation requirements Mode of service delivery Sites that were linked Participants' names Technical difficulties, if any, affecting the consultation Copyright Broad and Cassel

37 References Sec , Fla. Stat. Rules 64B and 64B , Fla. Admin. Code Rules 64B and 64B , Fla. Admin. Code Fla. Senate Bill 7028 (2014) 42 C.F.R (a) Medicare State Operations Manual, App. A, A-0052 Federation of State Medical Boards, Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine, MB_Telemedicine_Policy.pdf Copyright Broad and Cassel

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