Telemedicine: Aligning Technology

with High Quality Patient Care

James Coviello, MD
Regional Medical Director
UH Primary Care Institute

S. L. Scott Esposito, Esq.

Associate General Counsel

Andrew Moleski, MBA

Manager, Virtual and Telehealth Services
Objectives

1. To introduce telemedicine as an emerging technology in healthcare

delivery.
2. To identify current State and Federal legal considerations in the use
of telemedicine.
3. To understand how telemedicine aligns with current healthcare
reform tenets, including quality, patient experience, and emerging
insurance payment methodologies.
4. To review the UH telemedicine platform - current and future
programs.

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Definition of Telemedicine and Telehealth

• Telemedicine: The use of technologies to remotely diagnose,

monitor, and treat patients.

• Telehealth: The application of technologies to help patients

manage their own illnesses through improved self-care and access
to education and support systems.

Source: Connected Health: A Review of Technologies and Strategies to Improve Patient Care with Telemedicine and Telehealth. Health Affairs
2014

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 What is Telemedicine?
Telehealth Use Cases, Relevant Modalities, and Investment Required
Ongoing
Use Cases

Professional Diagnosis & Education & Monitoring

Consultation Treatment Engagement & Care
Coordination
Modalities

Videoconference Asynchronous Remote Telephone Patient Mobile App

Store-and- Device Portal
Forward
• Need software, • Need additional • More expensive • Little tech • High security • Minimal
secure internet bandwidth, hardware investment, needs require hardware
access for storage space investment requires proper significant investment for
patients staffing investment providers
• Can replace • Used for high-
• Home and non-urgent risk patients in • Used for pre-visit • Must integrate • Complex
hospital-based phone calls and non-hospital site triage EHR security and data
technology visits Source: Marketing and Planning Leadership Council storage issues
interviews and analysis. (Advisory Board)

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Medical Organization Telemedicine Guidelines

• AMA, ACP, and ATA have policy statements on telemedicine

• Overarching principles include:

o Establishment of valid patient-provider relationship
o Professional judgment in appropriateness for telemedicine in clinical
setting
o Continuity of care/shared medical record
o Use of evidence-based clinical guidelines for telemedicine
o Telemedicine held to same standard as in-person visit

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State of Ohio Telemedicine Overview

• Telemedicine law and regulations are governed at State level

– Definition: ORC 4731.296
– Regulations: OAC 5160-1-18
– State Medical Board of Ohio Position Statement on Telemedicine
• State Board proposed rule (4731-11-09) under review to update
prescribing guidelines for patients initially seen at remote location.
• Medicaid covers telemedicine (since January 2015), follows
Medicare site requirements, without geographic restrictions.
• No Ohio telemedicine coverage parity law, but exists in 29 other
states.

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State by State Medicaid and Private Payer Coverage

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Federal Telemedicine Overview
• Medicare provides limited telemedicine payment coverage.
• To qualify:
– Originating Site – location of eligible Medicare beneficiary. Must be a Health
Professional Shortage Area (HPSA) located either outside of a Metropolitan
Statistical Area (MSA) or in a rural census tract; or a county outside of an MSA.
Must also be one of 8 types of health care facilities (e.g., doctor’s office, hospital,
etc.)
– Distant Site – location of an eligible provider. Must be one of 10 types of
providers (e.g., physician, nurse practitioner, clinical psychologists, registered
dieticians, etc.)
– Covered Services – limited to certain HCPCS/CPT Codes
• Most UH locations do not qualify.
• Current (114th) Congress has introduced several telemedicine-
related bills, including Medicare coverage expansion.
Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

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THE TRAIN HAS LEFT THE STATION…..

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External Forces Driving Telemedicine Expansion

• Consumer demand
• Cost saving efforts: Commercial and employer-based insurance,
ACO shared savings program
• Value-based care and population management incentives
• Patient access/workforce limitations
• Expanding technology capabilities

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Consumerism in Healthcare

• Patients more discerning in health care spending and convenience.

• Non-traditional opportunities to access care address consumers’
preferences (i.e. retail clinics and virtual care platforms).
• Various studies have demonstrated high patient satisfaction.
• Journal of General Internal Medicine patient satisfaction study
(March 2016):

98% • “Very satisfied” patients with telehealth visit

95% • Patients who would use telehealth again

95% • Patients who would recommend telehealth visit to friend

Source: Patients’ Satisfaction with and Preference for Telehealth Visits. Polinski JM et al, J Gen Intern Med March 2016

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Smart Phone Medical Devices

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Challenges and Concerns
• Quality
– Provider credentials
– Continuity of care
– Efficacy
• Appropriate use/clinical triage
– Adequacy of virtual exam
– Patient selection
• Limited payer reimbursement
– Medicare
– Medicaid
– Commercial
• Effective implementation
– IT infrastructure
– Clinical workflow
– Licensing and credentialing
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HOW DID WE GET HERE?

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Health Care Reform Evolution

• CMS/Medicare Pay-for-Performance: PQRIPQRS incentive to

penalty. (July 2007)
• IHI Triple Aim: Experience of Care (Quality and Satisfaction),
Population Health, and Per Capita Care (May 2008)
• Affordable Care Act: Innovative reimbursement models, Medicare
Shared Savings Program—ACOs (March 2010)
• MACRA—APM and MIPS (April 2015)

IHI
CMS
TRIPLE ACA MACRA
PQRI
AIM

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MACRA Overview

• 2 Quality Payments Programs: MIPS and APM (replace PQRS,

VBP, Medicare EHR Incentive Programs)
• MIPS links FFS to quality and value
• Initial reporting period: January 2017 with payment adjustment
starting January 2019.
• Four performance categories: Quality (50%), Advancing Care
Information (25%), Clinical Improvement Activities (15%), Cost
(10%)

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Commercial Insurance Payment Models

• Commercial ACO programs

• Clinical Integration Network (CIN)
• Focus on quality care and cost containment aligns well with
Medicare current and future payment models (i.e. bundled
payments)

Expansion of value-based models will require health system innovation

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Delivery System and Payment Transformation

Current State: Future State:

Private Sector
• Provider-centered • Patient-centered

• Volume Driven • Value Driven

Public Sector
• Fragmented • Coordinated

As healthcare shifts from volume to value, the benefit of

providing care via telemedicine improves.

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Potential Telemedicine Uses

• Chronic disease management

• Post-discharge monitoring
• Expanded patient care access
• Ambulatory specialty care/resource efficiency
• Team-based care
• Population Health
• Remote critical care monitoring/consultation
• Direct to Consumer and e-Consultations

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Telehealth at UH
Direct to Consumer Video Consult Patient Access
Tele-Urgent Care Online Scheduling
Telepsychiatry
(UH Virtual Visit) (Zocdoc)
Rainbow Care Connection
Remote Second Opinion Telestroke
(Nurse Triage)
UH Patient Portal
Pediatric Specialty Consults Video Concierge
(Follow My Health)
Martii Virtual Translation
Tumor Board

Neurology

Genetic Counseling

Patient Education Population Health Management Store and Forward

UH Home Care –
Transplant Institute Tele-Radiology
Remote Patient Monitoring
Emmi Solutions Cardiac Remote Monitoring
Kidney Transplant -
Remote Monitoring

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Current UH Virtual and Telehealth Technologies

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UH Virtual/Telehealth Strategies and Initiatives

1. Virtual urgent care and primary care implementation

(UH Virtual Visit)

2. Expand telehealth clinical consults

(ex. Neurology, Psychiatry, Dermatology, Pediatric Specialty, ED, Post-
surgery follow up)

3. Grow remote monitoring of patients (home and facility)

4. Analyze feasibility of eICU
(Larger health system; national models)

5. Expand teleradiology to non-UH hospitals

6. Online scheduling optimization (Zocdoc and Referral Ease)

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Telehealth Programs In Development

• UH Virtual Visit • Referral Ease

• Expanding tele-psychiatry
• Genetic counseling
• Integrative oncology
• Proton therapy
• Palliative care and hospice
• Post-acute care
• Virtual specialty clinics
• Remote patient monitoring
• Pediatric specialty consults
• Sports medicine
• Travel medicine

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Virtual/Telehealth at University Hospitals
Future State
Direct to Consumer UH Facility to UH to
or Employer UH Facility External Partner

1. Online Scheduling 1. Video-consults 1. Video-consults

2. Tele-Urgent Care a) Inpatient a) Inpatient
b) Outpatient b) Outpatient
3. Virtual Medical
2. Store and 2. Store and
Office
Forward Forward
4. Home Remote
3. Transitions of 3. Transitions of
Telemonitoring
Care Care
5. Patient Portal
4. Secure 4. Secure
6. Remote 2nd
Messaging Messaging
Opinion
5. e-ICU 5. e-ICU
7. Patient Education

Patient Health Record

Clinical Information

Quality Measures
Contact Information
James Coviello, MD
Primary Care Institute
James.Coviello@UHHospitals.org
216-691-3510

S.L. Scott Esposito, Esq.

Associate General Counsel
216-767-8626
Salvatore.Esposito@UHHospitals.org

Andrew Moleski, MBA

Manager, Virtual and Telehealth Services
Andrew.Moleski@UHHospitals.org
216-286-6007

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Appendix

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State Medical Board of Ohio Position Statement

• Adopted May 2012

• Licensees are held to same standard of care as in-person medical
care
• Adequate staff training
• Verification of licensee-patient relationship
• Prescribing requires appropriate history/exam, therapeutic plan,
and medical record documentation of process (Note: Updated
Board rule on prescribing is forthcoming)
• Maintenance of complete medical record
• Proper licensure
Source: http://med.ohio.gov/DNN/PDF-FOLDERS/Prescriber-Resources-Page/Telemedicine/Telemedicine-Position-Statement.pdf

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Practice of Telemedicine Definition – Ohio (ORC
4731.296)
• The practice of medicine in this state through the use of any
communication, including oral, written or electronic communication,
by a physician located outside this state.

• In-state physicians who are licensed in Ohio do not need a

telemedicine certificate.

• Such Ohio licensed physicians may examine and diagnose patients

through the use of any communication, including oral, written, or
electronic.

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MIPS Payment Adjustment Summary

Source: CMS website: Quality Program training slide deck

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