Colorado Medical Society

http://dev.cms.org/articles/telehealth-primer/

Telehealth primer

Tuesday, September 01, 2015 12:18 PM

Colorado legislators voted to remove some of the restrictions to telehealth during the 70th General Assembly, paving the way for expanded access to remote primary and specialty care for patients across the state. Now that House Bill 15-1029 has been signed into law, there are a few things for physician practices to consider when moving forward with telehealth visits.

First, the specifics. As defined in the law, telehealth is a mode of remote health care delivery through telecommunications systems to facilitate the assessment, diagnosis, consultation, treatment, education, care management or self-management of a patient while he or she is located at an originating site and a provider is located at a distant site. Health care services can include medical, mental, dental or optometric care, hospitalization or nursing home care. This law does not include care delivered via telephone, fax or email.

The law takes effect on Jan. 1, 2017. It removes the current population restriction of 150,000 or fewer residents, opening up payment for telehealth for any patient in any area of the state. It bars health plans from requiring an initial physical encounter before telehealth can be used and it requires health plans to reimburse providers the same amount for a telehealth encounter as a physical encounter. Providers do not have to demonstrate that a barrier to in-person care exists before engaging in telehealth.

Getting paid
Once the law takes effect, Colorado third-party payers will reimburse the treating or consulting provider the same amount for a telehealth visit as an in-person visit. Until then they are only required to reimburse for telehealth in those smaller-population counties, though some carriers have telehealth operations in place or in development. Practice staff would need to contact the insurer of a potential telehealth patient and inquire about their policy or contact Colorado’s Telehealth Resource Center, Southwest TRC (www.southwesttrc.org) for information.

Colorado Medicaid currently reimburses for telehealth for any service already covered by Medicaid regardless of location. And Medicare reimburses telehealth at 100 percent equal to a face-to-face service with the telehealth modifier “GT” if the originating site of an eligible Medicare beneficiary is in a rural Health Professional Shortage Area located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract, or in a county outside of an MSA. See Table 1, next page, for a list of reimbursable codes.

The Centers for Medicare and Medicaid Services lists “acceptable practitioners” for telehealth as the following.

• Physicians.
• Nurse practitioners.
• Physician assistants.
• Nurse midwives.
• Clinical nurse specialists.
• Certified registered nurse anesthetists.
• Clinical psychologists and clinical social workers.
• Registered dietitians or nutrition professionals.

The agency designates most health care settings as acceptable originating sites for service, including physician or practitioner offices, hospitals, federally qualified health centers, skilled nursing facilities and community mental health centers. A patient’s home or an independent renal dialysis facility are not currently acceptable to Medicare as an eligible originating site.

Choosing the technology
When choosing telehealth equipment, the type of services to be provided will determine what type of equipment is needed. For example, a physician conducting a mental health visit could use a simple cloud-based application with a computer and webcam but a dermatology visit would require a general exam camera or a digital camera where a close-up of a skin condition would be captured and sent to the provider prior to the visit. A cardiologist might need an electronic stethoscope and an otolaryngologist might need an ENT scope.

Physicians must also consider their budget, system portability, HIE or EMR integration requirements, scalability, and hosting and data archiving.

“There really is not a one-size-fits-all approach to telehealth equipment,” said Ryan Westberry, MS, MBA, project manager and business analyst for the Colorado Telehealth Network. “It is also important to consider the telehealth platforms or solutions being used by affiliate hospitals and practices. Interoperability is critical.”

“You can spend 15 minutes online and find all kinds of gizmos and gadgets that you can plug into your computer or smartphone that can give EKG readings, temperature, pulmonary function tests or let you listen to the heart,” said Clay Watson, MD, an infectious disease specialist and director of infection prevention at Saint Joseph Hospital in Denver. “All of those things are already out there and for sale and they’re getting cheaper by the day. Where telehealth robots or the big systems that cost $20,000 or $30,000 used to be the standard, now you can get into the market with a tablet or smartphone and a front-facing camera. It’s evolving to the point where now it’s affordable for everyone.”

“Remember the Internet connection has to be HIPAA secure,” Watson said. “That’s your first step. Then I would just start with simpler visits and see what you’re really missing. What pieces of information do you really need to obtain and then find the gadget that helps with that.”

Telehealth and HIPAA
The Consortium of Telehealth Resource Centers (more information available at:
www.telehealthresourcecenter.org) outlines considerations for physicians regarding compliance with HIPAA. As the Consortium says in a fact sheet, it is more complex than simply using products that claim to be HIPAA-compliant. True compliance entails an organized set of monitored, documented security practices within and between covered entities. Because HIPAA does not contain any special section devoted to telehealth, all personal health information (PHI) handled during a telehealth visit must meet the same HIPAA requirements as an in-person visit.

Some products may contain elements or features that allow them to be operated in a HIPAA-compliant way like a telehealth software program with an encryption feature or password protection. According to the fact sheet, “the entity will need to conduct an accurate and thorough assessment of the potential risks and vulnerabilities to PHI confidentiality, integrity and availability. While some specifications exist, each entity must assess what are reasonable and appropriate security measures for their situation.”

Additionally, regulations state that for transmission security, practices must “implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network.” Practices would need to assess their network, including their wireless connection, to ensure it meets requirements.

This caution extends to web-conferencing systems like Skype and FaceTime, which have been used as platforms to provide clinical telehealth services, but fall under the classification of a “conduit” – an entity that transports information but does not access it except on a random or infrequent basis as necessary to perform the transformation services. Ultimately it is up to the practice to determine whether they can use certain technology or outlets and still “implement procedures to regularly review records of information system activity, such as audit logs, access reports and security incident tracking systems.”

Other considerations
There are many other issues to be considered before embarking on remote patient visits, including the following.

• Whether the bandwidth between locations is adequate to ensure a good connection.
• Whether the payer requires the presence of a patient presenter during the telehealth visit and who can act as a presenter. There is no requirement for Medicare; however, it would be difficult to have a patient use a general exam camera or stethoscope on him or herself.
• How the encounter will be documented and who is responsible for ensuring the information is recorded in the patient’s medical record.
• How the patient exam room is set up – lighting, camera view, etc. – to ensure that the provider gets the best view of the patient as possible. Quality is important to ensure that it is equal to an in-person visit.
• How to provide training on the use of the equipment and best practices during a telehealth visit regarding eye contact and clear communication.

The promise of telehealth is great but this new frontier should be explored thoughtfully and carefully.