9/8/2016

Implementing Telehealth in Pharmacy Practice

Disclosure  Appalachian College of Pharmacy ( ACP)  Rite Aid

SHAMLY ABDELFATTAH, PHARM.D ASSOCIATE PROFESSOR OF PHARMACY PRACTICE- APPALACHIAN COLLEGE OF PHARMACY

 Pharmacist Alliance

Learning Objectives  Describe telehealth and telemedicine components and   



platforms Setup a telehealth program in your pharmacy and how to use telehealth to sustain your new and existing pharmacy services Employ telehealth in Medication Therapy Management (MTM) and in chronic disease management Describe how to leverage telehealth to enhance collaboration with other providers and to advance pharmacy role in healthcare. Apply for grants to fund your telehealth services, recognize barriers to telehealth reimbursement and discuss direct and indirect reimbursement options for your pharmacy-based telehealth services

What is Telehealth?  Telehealth vs telemedicine  Telemedicine is the use of video in health care  Telehealth is the use of technology including

telemedicine in health care  For the purpose of this presentation we will use the

term telehealth and telemedicine interchangeably

Outline Definition of Telehealth Government telehealth’ s initiatives History of telehealth Barriers, benefits and drivers of telehealth Telehealth technology, equipment and technical issues Description of Virginia Medicaid telehealth program Chronic diseases is the only incentive for pharmacist to adopt telehealth  Description of pharmacy based programs for MTM, DSMT/E, MCC and TOC  Grant Sources for Telehealth  References       

Definition of Telehealth  According to Federal Health Resources and Services

Administration (HRSA) : Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.

 Official Definition depends on the payer: Federal (

HRSA/CMS/Medicare) and States ( Medicaid)

1

9/8/2016

State’s Definition of telehealth

Telemedicine

 “The mode of delivering health care services and

public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and selfmanagement of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.”

Real-Time Video  Live video (synchronous): Live, two-way interaction

between a person (patient, caregiver, or provider) and a provider using audiovisual telecommunications technology. This type of service is also referred to as “real-time” and may serve as a substitute for an in-person encounter when it is not available. Live video can be used for both consultative and diagnostic and treatment services.

Remote Patient Monitoring  Remote patient monitoring (RPM): Personal health and

medical data collection from an individual in one location via electronic communication technologies, which is transmitted to a provider (sometimes via a data processing service) in a different location for use in care and related support. This type of service allows a provider to continue to track healthcare data for a patient once released to home or a care facility, reducing readmission rates. Remote patient monitoring can help keep individuals stay healthy in their home and community, without having to physically go to the providers’ office

Store-and-forward  Store-and-forward (asynchronous): Transmission of

recorded health history (for example, pre-recorded videos and digital images such as x-rays and photos) through a secure electronic communications system to a practitioner, usually a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction. As compared to a real-time visit, this service provides access to data after it has been collected, and involve communication tools such as secure email. Store and forward technology can be utilized to help access specialty care, even when there are limited board-certified specialists in their community

Mobile Health (mHealth)  Mobile health (mHealth): Health care and public

health practice and education supported by mobile communication devices such as cell phones, tablet computers, and PDAs. Applications can range from targeted text messages that promote healthy behavior to wide-scale alerts about disease outbreaks, to name a few examples.

2

9/8/2016

Innovative solutions

Benefits of Telehealth

 Few innovative solutions under mHealth are  Patient monitoring devices/ Remote monitoring  Mobile telemedicine/telecare devices

 Better outcomes from more timely access to

specialists

 Higher quality of care  Reduced travel time

 Devices/modules for mLearning

 Reduced cost of care

 Microcomputers (wearables, patches)

 Increased collaboration of care

 Remote data collection software  Mobile applications (e.g. gamified/social wellness

solutions

 Reduced hospital admissions or readmissions  As much as $2 billion over 10 years, could be saved

by telemedicine according to an estimate by Avalere Health, a consulting firm

HISTORY OF TELEMEDICINE

EMERGENCY SERVICES AND DISASTER RESPONSE

Boston Logan Airport to Massachusetts General Hospital 1967

© American Telemedicine Association

OUTSOURCED AND SHARED SPECIALTY SERVICES

© American Telemedicine Association

ADVANCED TECHNOLOGIES

Remote Surgery Robotics © American Telemedicine Association

Live Monitoring via Cell Phones © American Telemedicine Association

3

9/8/2016

ONLINE SERVICES AND CONSUMER HEALTH APPS

Examples of telehealth uses

 Counseling  Physical and occupational therapy  Home health  Chronic disease monitoring and management  Disaster management  Consumer and professional education

© American Telemedicine Association

Specialist Telehealth

Other Specialist telehealth services

 Specialist care delivery -

Other avenues under telemedicine picking up pace are  Emergency telemedicine  Telenursing  Telepharmacy  Telerehabilitation  Teletrauma care

 Telecardiology  Telepsychiatry  Teleradiology  Telepathology  Teledermatology  Teledentistry

PATIENTS SERVED BY TELEMEDICINE 2012

PATIENTS SERVED (2012) Outsourced Specialists

Teleradiology

Internet Clinical Consults Internet-Pharmacy Services

North America data © American Telemedicine Association

Cardiac Monitoring Implanted Devices Remote Monitoring Federal Network Consults Civilian Network Consults

© American Telemedicine Association

4

9/8/2016

PATIENTS SERVED BY TELEMEDICINE2015  More than 15 million Americans received some kind

of medical care remotely last year, according to the American Telemedicine Association, a trade group, which expects those numbers to grow by 30% this year.  U.S. telemedicine spending will grow to $2.2 billion in 2018 from $240 million in 2013: annual growth rate of 56%.

What Fuels the Demand for telehealth? Drivers of Telehealth Demand (InMedica)  Federal-driven demand  Payer and State medicaid-driven demand  Provider-driven demand  Patient-driven demand

TRC

Who is providing telehealth?             

Physicians; Nurse practitioners; Nurse midwives; Psychiatrist Psychiatric clinical nurse specialist Psychiatric nurse practitioner Marriage and family therapist/counselor School psychologist Substance abuse practitioner Clinical nurse specialists; Clinical psychologists; Clinical social workers; Local Education Agency (billing speech therapy)

Federal telehealth’ s InitiativesFunding Telehealth Resource Centers  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 14 TRCs which include 12 Regional Centers, all with different strengths and regional expertise, and 2 National Centers which focus on areas of technology assessment and telehealth policy.

MATRC

5

9/8/2016

HR 3750: The Telehealth Modernization Act of 2013

HR 3077: TELE-MED Act of 2013

 Establish Federal standards for Telehealth

 Allows certain Medicare providers licensed in one

 Create a nationwide Telehealth definition to provide

state to provide Telehealth services to Medicare beneficiaries in another state  Builds on the STEP Act regulations to expand services to Medicare recipients  STEP Act: the Servicemembers’ Telemedicine & E  Health Portability Ac

clarity regarding the scope of healthcare services that can be safely delivered via Telehealth  To encourage health care providers to utilize innovative technologies to provide greater and more efficient patient care

States telehealth’ s Initiatives  37 states mandate that Private insurance pays

Virginia Medicaid Telehealth Program ( DMAS)  Equipment must be of sufficient audio quality and

providers for telehealth visit and include telehealth as a covered service for their members

visual clarity as to be functionally equivalent to a face-to-face encounter.  Staff must be proficient in the operation and use of the telemedicine equipment.  Costs for telemedicine equipment and communication lines are not reimbursed by Medicare/ Medicaid or private Insurance companies

Telehealth encounter

DMAS-Originating site

 Telemedicine encounters must be conducted in a

confidential manner, and any information sharing must be consistent with applicable federal and state laws and regulations and DMAS policy.  Health Information Portability and Accountability Act of 1996 (HIPAA) confidentiality requirements are applicable to telemedicine encounters.

 The telemedicine “originating site” is the office or

other location of a provider enrolled with DMAS or its contractors where the Medicaid member is located.  Provider offices, Local Education Agency, Rural Health Clinics, Federally Qualified Health Centers and Hospitals  The provider or a designee must be with the member at the originating site during the telemedicine encounter, with limited exceptions such as the member reporting injuries due to physical abuse.

6

9/8/2016

Originating Site-Cont.

Eligible provider

 The originating site has audio/video equipment and

 a.Psychiatrist, clinical psychologist, clinical social

an electronic connection with the office or other setting of a “remote provider”.  The originating site service is billed using procedure code Q3014 and procedure modifier GT  Originated site bill $20 as presenting fee  Remote site or the consultant site bills for a regular visit

worker, professional counselor, psychiatric, clinical nurse specialist, psychiatric nurse practitioner, licensed marriage and family therapist/counselor, licensed school psychologist, and substance abuse treatment practitioner;  b.Physicians;  c.Nurse practitioners and clinical nurse specialists

Approved telehealth services  Evaluation and Management  Behavioral health  Specialty medical procedures such as

echocardiography and obstetric ultrasound  Speech therapy (school-based)  Radiology procedures.  No reimbursement for email, telephone or FAX

Percentage have Telehealth in place

Hospitals are embracing Telehealth  72 percent of U.S. hospitals and 52 percent of

physician groups/clinics use telehealth

 Future plans focus on patients. Topping the

telehealth wish list are solutions for patient education and training (34 percent), remote patient home monitoring (30 percent) and primary care (27 percent).  About half of all organizations cite necessary investments for telehealth technology/infrastructure and (50 percent) and issues related to reimbursement (48 percent) as barriers.

Doctors are embracing the telehealth  In a poll of 1,500 family physicians, only 15% had

used telehealth in their practices—but 90% said they would use it if were appropriately reimbursed  On-demand, 24/7 Telehealth services: Typically, these are for nonemergency issues such as colds, flu, earaches and skin rashes, and they cost around $45, compared with approximately $100 at a doctor’s office, $160 at an urgent-care clinic or $750 and up at an emergency room.

7

9/8/2016

Large Employers Embracing Telehealth  in 2014, only 22% of large employers offered

telehealth. By as early as next year, 9 in 10 large employers plan to make telehealth services available to employees and 97% will offer telehealth services by 2019.

Barriers to telehealth  Cost to establish program  Reimbursement issues  Licensure  Infrastructure  Regulatory and institutional barriers  Technophobia

Currently Used Devices And Technology

Technical Issues  Key features: videoconferencing application, device

characteristics, privacy and security measures.

 Hardware, software, cloud application-based options.  Must meet all confidentiality and security requirements

issued in HIPAA and HITECH regulations.

 Connectivity: bandwidth of 384 Kbps or higher in each of the

downlink and uplink directions providing a minimum of 640 x 360 resolution at 30 frames per second.  Wired connection preferred method over wireless for greater reliability.  Point-to-point encryption that meets recognized standards: FIPS 140-2 Federal Information Processing Standard is the US Government security standard.

Other Technology Issues           

Technology

DIRECT CONNECTION HIPAA COMPLIANT AES ENCRYPTED HIGH-DEFINITION WEB-BASED APPLICATION-BASED LIVE CONTENT SHARING UNIVERSAL ACCESS H.323/SIP ROOM CONNECTOR DIAL BY NAME DIRECTORY FAR END CAMERA CONTROL UNLIMITED CONFERENCING

8

9/8/2016

24 inches Android computer

Polycom HDX 6000 on Ergotronic cart

Polycom HDX-7000 on Rubbermaid cart

Avizia Multipurpose Scope

Room system

9

9/8/2016

Laptops and iPads

Cloud Based System and Smartphones

Are You Ready for telehealth Services?

Chronic Care via Telehealth

 The services that you provide will depend on many   



factors: 1- Who pays for the services ( Medicare/Medicaid/ Private insurances, Employers or patients)? 2- Is the provider status is required? ( If yes you may want to partner or collaborate with a provider) 3- The type of services : Chronic Care (Chronic Disease Management, MTM, Coordination of care, Remote device monitoring, Transition of Care, Preventative medicine, wellness visits, patient education) and Acute Care (Retail clinics) 4- Equipment cost and maintenance

TSUNAMI OF CHRONIC ILLNESS

 Pharmacists should own Chronic Care with or

without provider status  “ Pharmacist should be allowed to open their own

Chronic Care Clinics and see patients and get paid for their services” My personal opinion

COST OF CHRONIC CONDITIONS

“Frequent Flyers” •5-10 percent of admissions, 1 percent of users •22 percent of costs •Primary chronic conditions: cardiac/COPD/mental health/diabetes © American Telemedicine Association

60

© American Telemedicine Association

10

9/8/2016

Pharmacist- Based- Telehealth services

Barriers to Pharmacist Providing Telehealth

 Real-Time Video : MTM, Chronic Disease

 1- Lack of time

Management, Diabetes classes and coaching  Remote Device monitoring : Transition of Care, coordination of care and chronic care management  Mobile Health: Applications for providing screening, preventative medicine, coaching , educational materials, messaging and disease outcome tracking  Retail Clinic : Virtual or Physical Retail clinic

 2- lack of training or know How  3- Lack of provider status  4- Lack of payment  5- Lack of referral

Provide MTM by Telehealth  No provider status is needed  You get paid for the services provided by telehealth  Will enhance your CMR completion rate which is one of

the start rating measures

 Low cost of entry : equipment and setup cost around

$1,000-$2,000

 It can cost less if you use existing computers and devices  You may need training and contract with insurance or

MTM companies and need a platform to use for documentation from OutcomesMTM, Mirixa and Pharmacist Alliance  Low patient volume is an issue

Pharmacist Alliance

Table 1-Revenue

Service

# per day

Rate

TIP‐ Patient TIP‐ Provider CMR‐ Chronic  Disease  Visit Total‐ Revenue

20

$10

Revenue/d Revenue/ Revenue/ ay wk year $200 $1,200 $62,400

20

$10

$200

$1,200

$62,400

4

$30

$120

$720

$37,440

$520

$3,120

$162,240

11

9/8/2016

Table 2- Expenses

Cost

#

Rate

Cost/day Cost/wk Cost/year

Rx  4 hours/day $15 Technician Pharmacist 2 hours/day $75

$60

$360

$18720

$150

$900

$46,800

Telemed  cost Total cost

$20

$120

$6,240

$230

$1,380

$71,760

4 $5 patients/day

Provide Diabetes Classes (DSME/T)  Diabetes –Self – Management Education and Training(

DSME/T)

 Provider status is required so you have to partner with an

accredited Diabetes program

 You will need 15 CE hours per year ( diabetes related) or

CDE or BC-ADM

 You will need training on the standard curriculum  You will need referral from providers  You have to conduct classes in person but you can use

other telehealth elements such as remote device monitoring and telehealth app

Pharmacist Alliance- PIDO project

PIDO

PIDO: Pharmacist Improving Diabetes Outcomes 1- Provide online training and hands-on-training 2- provide a contract with an AADE accredited program 3- will allow your pharmacy to be a branch office of Diabetes program and will contract with your pharmacist as instructors for the program 4- Your pharmacy /pharmacist will get paid for providing diabetes class at a rate of $120 /patient

12

9/8/2016

Chronic Care Management (CCM)  Recently, the Department of Health and Human Services

created a Medicare CPT code, 99490, for “chronic care management - CCM.” The CCM code incents the care team to engage with patients proactively, paying them for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.  If a provider spends 20 minutes each month reviewing a patient’s care plan, remotely engaging with them to ensure success of the recommended treatment, answering their questions and tracking their care.  The provider will get paid between $40-$60 per month per patient.

Opportunity for Pharmacists

CCM Via Telehealth

 2/3 DIABETES PATIENTS ELIGIBLE

 Telehealth(Use of Remote devices, EMR and APPs)

 2 out of 3 diabetes patients have two or more chronic

 24/7 access to care management services

   

diseases and are eligible to receive CCM. ≥20 MINUTES OF CLINICAL STAFF TIME such as a Pharmacist Directed by a physician or other qualified care professional The provider does not have to be present Remote Monitoring is considered CCM

 Continuity of care with a designated care team

member such as a pharmacist  Systematic assessment of needs: medical, functional

and psychosocial  Timely receipt of all recommended preventative care

services

Remote Patient Devices

13

9/8/2016

Remote Patient Monitoring

Transition of Care ( TOC)  Nearly half of all adults in the U.S. (117 million

people) suffer from Chronic Conditions with nearly 58 million suffering from 2 or more.  86% of the total cost of total U.S. healthcare goes to pay for these chronic diseases.  CHF, Asthma, COPD and Diabetes are often responsible for patient’s early readmission to the hospital after discharge and results in costly penalty and loss of revenue

Use Telehealth for TOC

Retail Virtual Clinics

 Medication reconciliation and review: adherence,

potential interactions and oversight of patient selfmanagement  Patient-centered care plan  documentation congruent with the patient’s choices and values  Care transitions management: among providers and settings, follow-up after ER visits and post-health care facility discharge

TOC/CCM  The Federal Government is paying for this virtual, “non-

face-to-face” monitoring for Medicare patients for 19 Chronic Conditions under CMS’ Chronic Care Management Code 99490 and post hospital discharge under Transitional Care Management Codes 99495 and 99496.  With Digital Medicine and Remote Patient Monitoring, these patients can now be directly monitored in their homes to either prevent exacerbation of their chronic conditions or prevent medically unnecessary and costly 30day readmissions.

Where Can I Get Help?  Grant Money could help you with equipment from

HRSA and USDA-RUS DLT( see the next few slides )  Technical help: TRC’s ( MATRC), ATA and vendors

such as Polycom, Cisco, Life Size, Vydo, Zoom and others  Clinical help: Colleges of Pharmacy, VPhA , ADA, AADE and vendors

14

9/8/2016

Telehealth Network Grant Program-TNGP

Rural Veterans Health Access Program ( RVHAP)

 TNGP is a competitive grant program funding projects that

   



demonstrate the use of telehealth networks to improve healthcare services for medically underserved populations in urban, rural, and frontier communities. More specifically, the networks can be used to: Expand access to, coordinate, and improve the quality of health care services; Improve and expand the training of health care providers; and/or Expand and improve the quality of health information available to health care providers, patients, and their families. The primary objective of the TNGP is to help communities build the human, technical, and financial capacity to develop sustainable telehealth programs and networks. View most recent TNGP opportunit

 The RVHAP provides funding to enhance mental health

    



services for veterans of Operation Iraqi Freedom and Operation Enduring Freedom, including: Crisis intervention and diagnostic assessments; Detection of post-traumatic stress disorder; Traumatic brain injury; and Other mental health conditions associated with veterans. To deliver services to veterans in rural areas, RVHAP focuses on regional approaches, including networks, health information exchange, telehealth, and/or telemedicine. View most recent RVHAP opportunity

What Will make Telehealth Work for Pharmacists?

USDA-RUS-DLT  The Distance Learning and Telemedicine program

helps rural communities use the unique capabilities of telecommunications to connect to each other and to the world, overcoming the effects of remoteness and low population density. For example, this program can link teachers and medical service providers in one area to students and patients in another. For more information on other programs administered by RUS Telecommunications

References  https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/AWV_Chart_ICN9 05706.pdf https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/TelehealthSrvcsfctsht .pdf The American Telemedicine Association (ATA) released the Practice Guidelines for Video-Based Online Mental Health Services in May 2013.

 Provider Status  Removal of origination site requirement  Inclusion of the Pharmacist as a provider of telehealth  Allowing Pharmacists to provide DSME/T via telehealth  Making MTM a required and a covered benefit for each

patient with two or more chronic disease conditions  Increasing reimbursement for MTM, DSME, MCC and

TOC

References-continued  Ward BW, Schiller JS, Goodman RA. Multiple

chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11:130389. DOI: http://dx.doi.org/10.5888/pcd11.130389.  Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook.[PDF - 10.62 MB] AHRQ Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; 2014.

15