American Telemedicine Association’s policy duo, Jonathan Linkous, CEO, and Gary Capistrant, Senior Director of Public Policy, return with updates and new information regarding telemedicine.

Medicare
Several weeks ago Medicare created its proposed rulemaking for the physician fee schedule, set to begin on January 1st, 2014. There have also been two major improvements proposed for telehealth. One is the expansion of the definition of a rural health shortage area. The purpose of this is to increase coverage of telehealth by allowing more areas to be considered metropolitan counties. This proposal will help the 104 counties that lost their telehealth coverage due to their lost status as a metropolitan county.

The second proposal would provide telehealth coverage for CPT codes for transitional care management services. With this process however, there are some difficulties. While there will be a website people can visit to find out if they are covered, it does not have direct yes or no answers, making it hard to determine coverage. Another issue is that eligibility for coverage is renewed yearly, meaning one year a person may be eligible and the next they are not.

Congress
In last month’s installment of This Month in Telemedicine, Linkous and Capistrant mentioned legislation that Congressman Greg Harper was working on. His bill is moving forward, and some changes were made in the process of finalizing it. “The effort is to really deal with the Congressional Budget Office and what they will end up saying about telehealth provisions” explained Capistrant. There have also been several proposals to get a savings estimate from the CBO.

  • To have a Medicaid option for high risk pregnancies. Two years ago ATA got an estimate that it would save Medicaid 168 million over 10 years.
  • Giving hospitals an incentive for doing a better job in reducing their number of readmissions. It would allow the hospitals to share in the savings and will pay for home monitoring and video.
  • Have Accountable Care Organizations currently under Medicare (which serve about 4 million beneficiaries) use telehealth the same way Medicare’s managed care plan does. Medicare has started an effort to experiment with bundling with hospital payments with post-acute payments. There has participation in almost 400 hospitals all over the country. The goal is to have those hospitals be able to use telehealth to deal with that post-acute care and not have the restrictions that are in Medicare’s statute continue to apply.
  • Allow home video to people who are doing dialysis at home. This will empower more home dialysis and yield savings.

Other Harper package provisions that have been added include: restoring coverage for 104 counties, provision to go for coverage for telestroke diagnosis country wide, as well as some provisions dealing with critical access hospitals that are in metropolitan areas. These hospitals will not be included in the health shortage area because it is a hospital.

States
There has been a lot of progress among the states with telemedicine. The Governor of Missouri has signed a bill that will allow a parody law for private insurance covering telehealth. Missouri is now the 19th state that has this law. The ATA is finalizing three of the state best practices for Medicaid uses of telehealth, as well as a final report of major gaps in each state about telehealth

The ATA Board just recently approved online, web-based mental health services. It is also interested in developing practice guidelines for teleICU, web based or online primary and urgent care services that are starting to be developed, and remote health date management on wounds and burns, according to Linkous. Telepathology guidelines are also being rewritten.

Fall Forum in Toronto
The focus of the Fall Forum in Toronto is to examine some of the problems that have recently been discussed involving telemedicine. A major focus will be reducing readmission rates in hospitals. “A big topic in every hospital, in not only this country but around the world, is how do you reduce the readmission rate within the hospital and there’s a lot of work that’s been done on this using telemedicine as part of the answer. Not as the answer, but part of it,” explained Linkous. They will also be covering issues such as Telehealth networks, and how you can make those networks sustainable, as well as how to engage customers. They will also be covering topics such as mainstreaming in health applications, or “apps” to be integrated into the healthcare system. Other topics include virtual care and provider services.

The thought of implementing a new Electronic Medical Records (EMR) system is enough to make anyone in a healthcare organization wake up in a cold sweat. Switching from paper charts to an entirely new way of providing patient care is a daunting task for most physicians as it requires a brand new set of processes and procedures.

However, the benefits of EMR can no longer be ignored. Not only does storing medical records digitally help prevent filing errors, patient records can be backed up in multiple locations significantly reducing the threat of losing patient health information in an emergency. Plus, the data is accessible almost anywhere allowing physicians to view medical history and treat a patient regardless of where they are.

As a result, five leading health systems have created the Care Connectivity Consortium to pioneer the use of electronic medical records. Together, Intermountain Healthcare (based in Utah), Geisinger Health System (Pennsylvania), Group Health Cooperative (Washington), Kaiser Permanente (California), and Mayo Clinic (Minnesota) are working to develop a secure way of sharing patient information regardless of the vendor used to originally create the record.

The five healthcare systems involved have an enormous geographic reach and access to large volumes of patients. They must work together to develop, test and implement processes and procedures to quickly access and share patient information across multiple different EMR systems. Additionally, the Consortium must address how to obtain a patient’s advance consent and then store it properly to ensure it is readily accessible in the event of an emergency visit, states Todd Allen in a blog article.

Visual collaboration technologies can help connect geographically dispersed members of the Care Connectivity Consortium and enhance the collaboration experience. Audio visual integrated rooms designed to support complex data allow participants to share multiple forms of content from multiple sources. Therefore, members participating in collaboration sessions can view different EMR interfaces side by side along with other data to help advance the EMR process.

These collaboration rooms can also be used within different areas in the health systems. For example, operations staff can meet to discuss best practices around EMR and other hospital operations. Roundtable sessions can also be conducted by connecting medical specialists and allowing them to discuss recent findings, best practices and treatment options.

Once the Care Connectivity Consortium has created an effective process, the organization can utilize collaboration solutions to train physicians, administrators and other staff members through recorded Video on Demand sessions. Embedded video clients can then allow anyone with questions to connect via video to an EMR specialist and receive clarification. Furthermore, embedding video solutions in the EMR system itself would allow doctors or nurses to connect with a patient’s primary physician.

As a mother of three very accident prone children, I have been to the Emergency Room in Intermountain Healthcare’s network. There is a small peace of mind in knowing that when we arrive, my child’s entire medical history will be available with just a click of a mouse. I applaud the Care Connectivity Consortium for their effort in advancing Electronic Medical Records and hope that one day mothers across the country are able to experience these same benefits.

American Telemedicine Association’s policy guys, Jonathan Linkous, CEO, and Gary Capistrant, senior director of public policy, are back with another monthly installment of This Month in Telemedicine.

They’re predicting an additional 30 to 40 million Americans will be added to Medicaid roles by next year, and there are now 20 states looking to expand Medicaid coverage to accommodate this surge. Better start preparing now, says Linkous. “I think next year we’re going to see a whole different world, in a few short months it’s happening so the time to gear up is now,” he says.

Funding Opportunity
The Center for Medicare and Medicaid Innovation has just launched another billion dollar funding opportunity. It’s looking for “big, bold projects,” particularly any that will be actionable on a multi-state level. Letters of intent are due by June 28, and the full applications are due August 15.

Austin Meeting Recap
Linkous and Capistrant also discussed the ATA’s recent meeting that was held at the beginning of May in Austin, Texas. During the meeting, the first of four best practices was released. They’re for state Medicaid programs, and the ATA has been working with special interest groups and refining the guidelines, and they should be available soon. They cover specialties such as telemental health, home telehealth and remote monitoring, school-based telehealth, and specialties like diabetic retinopathy.

The ATA also distributed a draft version of their state best practices guidelines, which is now being reviewed by special interest groups. Additionally, a new and expanded version of their toolkit is now available on the ATA website.

“We try and provide more information for you all to use,” says Capistrant. “But also to try and act as a clearing house and identify what the various states are doing so that all the other states can benefit from that without duplicating efforts or trying to draft something from scratch.”

Federal News
On the federal level, the ATA is very focused on dealing with getting Medicare coverage approved, and some opportunities for Medicaid as well. The bill sponsored by Senator Scott Thompson is working its way through the system, but because that bill is more of a big-picture attempt to solve and clarify telemedicine issues, the ATA felt the need for a bill that would deal with smaller-scale issues that could move quickly and be approved relatively easily. To that end, they’ve been working with Congressman Greg Harp, R-Mississippi, to assemble a package of incremental changes. “Hopefully, [it will be] easier to get support and budget estimates,” said Capistrant. They’re also hoping to be involved in physician payment reform.

As discussed during previous ATA webcasts, 104 counties lost Medicare coverage in February because of redesignation as metropolitan areas. The ATA is working on restoring coverage to the affected counties. The ATA is also working to remove some major barriers, like metropolitan area access, stroke diagnosis, and services for homebound patients that aren’t currently covered by Medicare. Homebound patients present a particularly strong argument, says Capistrant. “They’re not in the position to travel to a doctor’s office, so there’s a compelling clinical case for care in the home.”

Bipartisan Effort
There’s bipartisan interest in telemedicine, says Linkous, which is something the ATA has cultivated. “We’ve always made sure this is a bipartisan effort,” he says. “We’ve worked very hard to avoid any type of partisan positioning.” The ATA has had congress people of both stripes approach, and voice support for telemedicine.

In state action, Georgia and Alabama both have proposals from their respective medical boards under review. They’re improved versions of past proposals although still there are still issues: they don’t deal with the full range and diversity of telehealth uses and situations e.g. emergencies, and also interpretative services such as cardiology, radiology, etc. For example, in Georgia, telehealth ICU would require patients to I.D. every health practitioner who had previously served them, which is a burdensome task for all involved.

In the Alabama proposal, telehome care is exempt from rules if delivered by a licensed homecare health agency but community health centers and physician practices are excluded.

The pair also took issue with certain language in both proposals, identifying it as “anti-telehealth”; particularly requirements for prior physician-patient relationships, meaning the physician has to see patient in his or her office first. “That’s a code word for people who want to kill telemedicine,” says Linkous. ”It’s about protecting your market and protecting yourself from competition that telemedicine provides. And when you do that, there are 5.5 million Americans received teleradiology services and they’re gone, they don’t get it anymore because of the prior physician-patient relationship [requirement].”

This month’s telemedicine videocast from the American Telemedicine Association focused on a major change in the population tabulation that directly affects telemedicine reimbursement, as discussed by ATA’s CEO Jonathan Linkous and Gary Capistrant, senior director of public policy.

Federal Policy Changes & Activity
The hot topic was the re-designation of many counties from rural to metropolitan, which resulted in the loss of Medicare telehealth reimbursement. Due to a change to the Standard Metropolitan Statistical Areas, 97 counties newly designated as “urban” will lose reimbursement privileges because Medicare reimbursement for telehealth services is not available to populations in metropolitan areas. On the other hand, 28 counties will gain coverage because they are now designated rural.

While this is a setback for telemedicine and Linkous proposed two ways to deal with the situation: the first, to grandfather in counties that have been redefined as metropolitan; the second is to expand Medicare reimbursement for urban populations. “This really shows the need to do that,” said Linkous.

Also mentioned was the F.I.T.T bill (Fostering Independence Through Technology), which is sponsored by South Dakota Democratic Senator John Thune and Minnesota Democratic Senator Amy Klobuchar. The bill aims to establish a pilot program for home health agencies serving rural communities to use remote patient monitoring.

Capistrant and Linkous also discussed FDA regulations about medical devices, licensure and interstate health commerce, and the need to coordinate the various roles that the federal government plays in healthcare. Linkous points out the very real potential for backlogs—the FDA, Linkous says, has received 100 or so applications but can only process 20 a year.

“The good thing is there’s a lot of innovation in mobile health. The bad is it’s taking a long time to get through regulation, and, number two, you can’t get paid for it.” - Jonathan Linkous, CEO American Telemedicine Association

State Activity
They also discussed the ongoing issue of licensure, and the burden acquiring multiple state licenses places on telehealth providers. The Federation of State Medical Boards is proposing a form of state reciprocity but, Linkous points out, getting all the states on board could take a long time—a decade or more. He offered the example of the nursing compact, which was started 15 years ago and less than half the states have signed on to date. (The ATA has not endorsed any one approach).

Big Med Developments
Larger healthcare systems are seeing the potential business benefits of telehealth, and are looking to expand their footprint and brand by providing more services to a larger population. Linkous gave the example of the Mayo Clinic Care Network, an affiliation program. They have a goal of reaching 200 million patients by 2020, through both their own hospitals and the affiliation network by using “e-consults”, i.e. telemedicine. Cleveland Clinic also has an affiliate program. “It’s an interesting contest,” says Linkous, noting this is a business decision and cost-reduction tool. Mercy Healthcare is using telehealth for a broad range of services, including stroke, autism, and cardiac care, and they’ll soon be breaking ground for a virtual healthcare center which will house subspecialists and a teaching facility at their headquarters outside of St. Louis.

New Online Education
ATA will be launching an education service on their website with webinars, videocasts, and online courses, with many continuing medical education accredited. The organization is looking to develop a major educational center—online, of course—for telemedicine providers.

Annual Meeting
ATA’s annual meeting will be held in Austin, Texas, from May 5 to 7. For a free exhibit hall pass, click here to register and enter  the code VIPcomp13.

The next This Month in Telemedicine videocast is on April 23.

Significant advancements in video conferencing technology have allowed for greater accessibility and interoperability. As a result, video is becoming more integrated into consumers’ professional and personal lives. This opens significant opportunity in business-to-consumer video which can have a dramatic impact on the way we view and receive healthcare.

Picture yourself sitting in a waiting room with several other patients who all seem to be spreading their contagious ailments through coughing and sneezing. It’s not very appealing, so perhaps you decide to “wait out” your symptoms or Google them for a self-diagnosis. Unfortunately, the internet can easily turn a simple upset stomach into appendicitis and send you rushing to the emergency room in a panic.

Now picture yourself sitting on the couch or even at your desk between meetings and connecting to a doctor, nurse or other medical professional via video. You can list your symptoms, ask questions and receive medical advice without driving to the doctor’s office. The medical professional can then let you know if you most likely have an upset stomach (take some Pepto and if you don’t feel better in a couple of days make an appointment) or appendicitis (go to the emergency room right away).

Advancements in video technology are making this possible; which is not only great for patients but for medical facilities as well. Waiting rooms will be less crowded because patients will only go to the office when a physical visit is required. Post-operational follow ups or other routine visits can also be conducted over video at a central location while rural hospitals can have access to medical specialists creating numerous efficiencies and revolutionizing the healthcare industry!

Check out this quick video from American Telemedicine Association (ATA) that demonstrates the future of telehealth.