This-week-in-collaboration

Welcome to our bi-weekly recap of the week’s best articles surrounding collaboration.

1. Distance Education 2.0

The MOOC movement allows professors to reach anyone in the world with an internet connection through these online open courses. Specifically, China has put a focus on MOOC’s in order to try and improve their domestic education.

2. Taking Video Conferencing out of the boardroom

With mobile devices being used for video conferencing increasing over the last couple years, companies have been able to expand their video environment outside of the boardroom. This is due in part to the interoperability and decreased costs that mobile devices bring to the video conferencing industry.

3. Doctor Visit in the Palm of your hand

New technology allows mobile users to pay a fee to find a practitioner for an immediate live video visit. This can help increase access to doctors regardless of time or location.

4. The tricky balancing act of mobile security

As the demand for mobility and BYOD increases, the need for more advanced mobile security policies increases as well. The main challenge when creating these policies tends to be allowing employees the information that they need without compromising the data or infrastructure.

5. The many advantages of Video Interviews 

Both employers and job seekers can benefit from using video conferencing for interviews. This outlines the benefits for both parties as well as certain things to take in to consideration as the interviewee.

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.

Congress
In the wake of the Government shutdown, Congress continues to debate several different legislative proposals and provisions. One aspect involves the repeal of the medical device tax which charges a 2.3% tax on all medical devices; including some telemedicine components. The provision to repeal this tax is on the table; however, Capistrant says while this is possible it is not probable.

Bill HR 3077 was introduced by Congressmen Devin Nunez and Frank Pallone to allow providers with one state license to provide care via telemedicine to Medicare beneficiaries wherever. A similar bill, HR 2001, by Charles Rangel would provide the same for VA beneficiaries. These bills will essentially make one license enough for healthcare providers working with federal agencies or federal programs. This will help expand access to telehealth services which can provide numerous cost benefits to both patients and providers.

Greg Harper’s bill, mentioned in the last webcast, to improve Medicare coverage for telehealth has not been introduced because of the shutdown. However, because this is the beginning of a two year congressional session, even if this bill does not get passed this fiscal year there is still next year.

FDA
The FDA has released final guidance on mobile medical applications in an attempt provide clear direction to device makers and application developers as to what constitutes as a medical device and needs to go through the FDA approval process. Their regulatory focus will be on medical apps that present a greater risk to patients if they do not work as intended. Additionally, the FDA will develop a web-based platform for developers to seek advice about devices and situations. This will provide better guidance and make it clear as to when the FDA needs to be engaged and what the provisions will be.

States
Fiscal year 2013 was a very busy year for state telehealth legislation and this year will be more of the same. Much of the legislation that was not enacted last year will be reintroduced in 2014. At the top are the 10 states that had proposals for parity with private insurance companies that were not enacted. These states include Connecticut, Florida, Illinois, Massachusetts, Ohio, New York, South Carolina, Tennessee, Washington, and Pennsylvania.

In other news, it was reported that an Oklahoma doctor was disciplined for using Skype to treat patients. However, the use of Skype was inconsequential to what physician Thomas Trow was doing wrong. The main disciplinary issues were Trow’s over prescription of narcotics and failure to maintain medical records. In fact, Trow had previously received disciplinary action from the Oklahoma Medical Board (OMB) for over prescribing, narcotics violations, and record violations. The OMB filed action September 12 and 16 and put out proposals that, according to Capistrant, may be over-reaching and affect telemedicine. The ATA is working with the OMB to ensure these new provisions do not negatively affect telehealth services.

Guidelines
ATA is currently working on a series of guidelines and telehealth best practices for remote ICU, burns and wounds, and primary and urgent care. They are currently awaiting review and approval from the Board and should be available in the next few months.

The next This Month in Telemedicine webcast is scheduled for October 29, 2:00-3:00PM EST.

Advancements in video technology have had a tremendous impact on the creation and proliferation of distance learning programs. By integrating video conferencing solutions, universities are able to extend the reach of their programs to students who otherwise wouldn’t be able to attend. Calvin Hughes, Instructional Technologist at the University of Nebraska Medical Center, talks about his experience with video conferencing and the impact it has had on the University.

IVCi: Can you give us a brief overview of your video environment?
CH: We currently have 5 classrooms that hook up locally at the College of Dentistry. There are also 6 or 7 locations across the state that have Cisco telemedicine carts for tele-dentistry purposes. We started the Dental Hygiene [distance learning] program in 2003 for the West division which currently graduates four students each year. There are currently about 50 hours of classes a week that are transmitted out to the West region. In 2010 we expanded into telemdecine carts.

IVCi: How do you connect local and remote students into one classroom?
CH: The main classroom has a 52” TV on the side of the wall that remote students show up on. They can hear and speak to them over speakers and portable microphones. For students in the west division, there are two screens, one with the professor and one with content, and individual monitors in front of each student.

IVCi: What were the drivers that led you to implement video?

We’re a State University with state funding and Nebraska Medical Center and University are located on the Eastern side of the state. There are some community colleges on the Western side that have nursing programs but nothing with dental programs. We have a duty to try and get dental students out in the field on the Western side which is less populated. If students are doing classes out there, they are more likely to stay and practice out there.

IVCi: What has been the end user (professor/student) reaction to video?

CH: Everyone is pretty open minded about it. We don’t have a problem getting students or filling up the distance classes. Remote students aren’t always as eager to answer questions sometimes but the instructors are good about making sure they participate by asking them questions directly.

IVCi: Can you point to any specific metrics that have been influenced by video?

CH: We graduate four students a year from the hygiene program and that’s four students who might not have gotten their degree.

IVCi: What was your favorite moment using video?

CH: The first tele-dentisry consult was very exciting. We put a lot of work in getting those telemedicine carts in and around the state. The Western part of the state is under populated and under-served by dentists and we wanted to reduce a patient’s drive time when needing to see a specialist. The carts are spread out across the state and allow for easier access to specialists. The initial consultation can be handled over video and a specialist can determine if patients need to come to their office or if their local dentist can fix the problem.

IVCi: Do you have any advice for universities implementing video for the first time?

First, have a good support group of people who want to push the technology. These people can be very valuable when implementing the solution. Also, most of our programs have been grant funded and it’s been hard moving away from the grant funding to be able to upgrade the technology ourselves. Have a plan in place for updates and replacement costs so that funding is in place when the time comes.

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.

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].”