Click to edit Master title style

Click to edit Master subtitle style

5/21/2020 0

Telemedicine

1

Speaker Bio

As a senior patient safety and risk consultant for MedPro Group, Laura Nordberg identifies issues and solutions pertinent to risk management and patient safety for insureds.

In her most recent position before MedPro Group, Laura was the assistant counsel for continuing care at Trinity Health. During her 22-year tenure at that health system, Laura served as a claims manager and loss prevention/control director, where she focused on risk assessment and risk modification programs for physicians, hospitals, and post-acute care providers.

Laura obtained a bachelor of science degree in nursing at Oakland University and a master of business administration from Michigan State University. She earned her Juris Doctor degree from Wayne State University. She is a member of the Michigan Society for Healthcare Risk Management (MSHRM), the American Society for Healthcare Risk Management (ASHRM), and the American Bar Association.

Laura is an attorney and a registered nurse. As a registered nurse, she has cared for patients in acute renal, medical/surgical, high-risk obstetrics, labor and delivery, surgery, critical care, and ambulatory care. As an attorney, Laura was a malpractice defense attorney in private law practice, and she represented hospitals and healthcare providers. Additionally, she has served as in-house legal counsel, claims manager, and loss prevention strategist for a health system.

Laura Nordberg, RN, MBA, JD, Senior Patient Safety & Risk Consultant, MedPro Group (Laura.Nordberg@medpro.com)

2

At the conclusion of this program, you should be able to:Define telemedicineIdentify the benefits of telemedicineList types of technologies used in telemedicineList the risk issues and risk reduction strategies related to telemedicineDefine readiness to provide telemedicine servicesConduct a telemedicine visit and complete associated documentation

Objectives

3

Telemedicine versus Telehealth

Telemedicine refers to the use of medical information exchanged from one site to another via electronic communications.

Telehealth includes consultative, diagnostic, treatment, and educational services.

The exchange of information can take place in real time, or information can be forwarded and analyzed at a later time.

Source: MedPro Group Resource: Telehealth/Telemedicine (Risk Q&A) https://www.medpro.com/documents/10502/3019648/Q_A_Telehealth-Telemedicine.pdf

4

Audio-only communicationA telephone call or voice mail messageElectronic mailInstant messaging conversationMessages sent by facsimileInternet questionnaireTelephone consultationInternet consultation

Check with your applicable state laws.

Telemedicine is NOT:

5

Improved access to careCost efficiencyImproved qualityPatient satisfactionConvenienceCare continuity

Benefits of telemedicine

Source: American Telemedicine Association. Retrieved at: http://www.americantelemed.org/main/about/about-telemedicine/telemedicine-benefits

6

Severe symptomsCertain protocol-driven proceduresAggressive interventionsEmergenciesAny condition requiring an in-person examinationUpon the provider’s judgment

When telemedicine is not appropriate

7

Delivered through secure networks, email, landline, and wireless communication . . . telephone, satellite, Internet, and VPN:

VideoconferencingStore-and-forward imagingPatient monitoring centersMobile technologies (delivered by smartphone, tablets, etc.)Internet e-health patient services or professional educationRobotic services (monitoring, tele-stroke, surgery, etc.)

Types of telemedicine technologies

Source: American Telemedicine Association. (2013, July). State Medicaid best practice: Store-and-forward telemedicine. Retrieved from http://www.americantelemed.org/docs/default-source/policy/state-medicaid-best-practice---store-and-forward-telemedicine.pdf?sfvrsn=6

8

Physical EnvironmentPrivate spaceAdequate lightingAbility to see and hearMinimal interruptionsAccess to information, tools and records

Patient ExperienceProfessional appearanceOrganized and informedEmpathy and active listeningHow is your “webside manner”?

Physical environment supporting the telemedicine visit

9

Are we documenting any technical problems? How?Are we documenting the mode of service delivery, or have a policy establishing the modes of technology used by our practice?Does our technology include time-stamps to account for different time zones?

Risk management considerations: technology

10

When someone asks for an appointment?When a provider agrees to examine, diagnose or provides care?Providers can usually refuse

But need to say soException: emergency careNot based upon discrimination

May be first, subsequent or sole visitDuty to treat according to standard of careCan be sued for malpracticeCan be sued for abandonment

Provider-patient relationships in telemedicine

11

National telemedicine claims data

Source: Murphy, D. (2015, July). Telemedicine and MPL: The story so far. Inside Medical Liability Online. Retrieved from https://piaa.us/docs/IML/IML_Online_Telemedicine_July2015.pdf

Of the 94,228 total claims in the PIAA data sharing project (DSP) during the period from 2004–2013, a total of only 196 claims were linked with telephone treatment. Of those 196 reported claims, 56 resulted in some form of claim payment.

The total indemnity loss related to telephone treatment was $17M compared with $8B for the total of all MPL losses in the DSP.

Telephone treatment claims thus represented only about 0.21% of all MPL losses.

The average indemnity loss was also lower for telephone treatment — $303,691 compared with $328,815 for all MPL claims within the DSP.

12

Malpractice claims experience

Little information available

Increased use, more questions

May involve acts of commission or omissionMay involve numerous

defendantsPotential for vicarious

liabilityPotential for

miscommunicationProvider−patient

relationship

13

Risk Management Considerations: Claims

When does the doctor-patient relationship begin?

Is the technology reliable? How about image quality?

Do you understand federal and individual state regulations?

Have you considered these issues: licensing, on-line prescribing, credentialing, informed consent, privacy?

Does your carrier cover delivery of telemedicine services?

Whose jurisdiction? Usually the court relies on where the patient is…

14

Licensing Credentialing & privileging

Online prescribing

Informed consent

Privacy & security

Standards of care

Reimbursement Coordination of Care

Major areas of concern

Source: MedPro Group, Risk Tips: Addressing Risks Associated with Telehealthhttps://www.medpro.com/documents/10502/3667697/Risk+Tips_Addressing+Risks+Associated+With+Telehealth.pdf

15

State regulations vary; some states address telemedicine directly, others indirectly, and some not at all.In the absence of direct or indirect guidance, doctors can assume that they likely need a license in the state where the patient is located.

State licensing board regulations

Source: HealthIT.gov https://www.healthit.gov/faq/are-there-state-licensing-issues-related-telehealth

16

CMS regulations, The Joint Commission

Credentialing by proxy

Requirements

Ensure that providers at distant sites are legally allowed to provide services to the originating site’s patients

Credentialing

17

Offered by CMS and The Joint CommissionPermits the hospital receiving the telemedicine services (known as the “originating site”) to rely upon the privileging and credentialing processes of the other entityThe hospital or entity providing the telemedicine services is known as the “distant site”Medicare Conditions of Participation require written agreementsCare must adhere to scope of practice standards

Credentialing by proxy

18

Provider–patient relationshipAdequate physical examAccuracy of patient historyState licensing board requirementsFederal regulations

Online prescribing

19

Telemedicine-specific:Types of visits permitted (state law)Names of all involved healthcare providers, as well as credentials and locationPlan for ongoing care (and who is responsible)Security/privacy measuresRisks associated with use of telehealth services (e.g., technical problems, equipment failure, power outage)Contingency plan in case of emergency/malfunction

Should be documented in the patient’s medical record

Informed consent

20

Transmission of data for telehealth services must comply with HIPAA and HITECH standards, as well as any relevant state laws (same duty as in-person care)

Safeguards must be in place at every point in the process (originating site, transmission medium, distant site).

Providers must be aware of approved vs. nonapproved technologies for telehealth

Policies/protocols for confidentiality, including: encryption, passwords, anti-virus protection, plan for when devices are lost or stolen

Privacy/security of PHI

21

Recommendation: Review by legal counsel

Third-party agreements supporting telemedicine

Proof of HIPAA and HITECH compliance?

BAA included?

Where is the data housed or stored?

Who owns the data?

Is notice required prior to data destruction?

Does the agreement allow the vendor to subcontract?

Have the parties negotiated who carries liability for breaches?

How long does the contract last?

How can I exit the agreement?

Some elements within vendor contracts

22

Medicare

Restrictions on types of services and geographic location

Medicaid

The service must be medically necessary

Commercial Payer

Review applicable payer contracts

Reimbursement

23

Know federal and state laws and regulations

Stay informed regarding changes in regulations and standards of care

Ensure practitioners are properly credentialed

Implement patient selection criteria and standardized clinical protocols

Ensure technology and equipment used are functional, properly maintained and servicedAssess privacy and security risks

Educate telehealth providers and staff

Include telehealth events in your incident reporting and evaluate telehealth activities as a part of your quality improvement program

Risk strategies

Source: MedPro Group, Risk Tips: Addressing Risks Associated with Telehealth. https://www.medpro.com/documents/10502/3667697/Risk+Tips_Addressing+Risks+Associated+With+Telehealth.pdf

24

Practice Readiness

How to provide telemedicine services

Is my practice specialty amenable to telemedicine?

Am I credentialed to provide telemedicine services?

Will the care I provide be reimbursed?

Do I have an appropriate distant site provider selected (if applicable)?

Does my liability insurer cover my telemedicine practice?

Do I have a secure technology to use for telemedicine?

Source: HealthIT.gov. Assess your Organization’s Readiness for Telemedicine. August 2017

25

Patient readiness

How to provide telemedicine services

Will the availability of telemedicine help my patients?Are my patients good candidates for telemedicine?Has my patient consented to receive telemedicine services in accordance with state law requirements?Do I already have a pre-established provider-patient relationship with my patient?Is my patient eligible to receive telemedicine services?

ConditionTechnical skillsThird-party payor

Source: Centers for Medicare and Medicaid Services, Outreach and Education, Medicare Learning Network, Telehealth Services. March 2020.

26

1. Confirm your patient’s identity in accordance with your practice’s policy—photo ID is best

2. Confirm patient’s readiness and consent for a telemedicine visit

3. Establish the purpose/topic of the visit

4. Establish connection through approved technology

5. In general, conduct telemedicine visit as you would an in-person visit

6. Complete verbal exchange of data7. Complete data exchange (e.g., vital

signs, blood sugar readings, weight, height)

8. Complete general visual assessment9. Discuss diagnosis, recommendations,

treatment plan and progress toward goals, answer questions

10. Provide a telemedicine visit summary to the patient

11. Document telemedicine visit in the medical record

12. Send notification to the PCP13. Process for billing, as permitted by

payers

How to conduct a telemedicine visit

Source: American Medical Association, Steps Forward, Telemedicine: Connect to Specialists & Facilitate Better Access to Care for Your Patients,October 7, 2015.

27

CMS allows for reimbursement at the same rates as face-to-face encounters, so long as the same documentation standards are met.CMS: reimbursement is based on time, rather than physical examination“This visit was a telemedicine visit”Confirmation of patient identity and patient consentProvider name and license-based role (physician, NP, podiatrist, etc.)Physical locations of provider(s) and patientNames and roles of all other participants presentLength of time of visit, and note that more than 50 percent of the encounter was spent on counseling/coordinating careInclude: differential diagnosis, active diagnosis, prognosis, risks, benefits of treatment, instruction, compliance, risk reduction and coordination of care with other providers.Include: a statement of risk (most patients will meet a “moderate risk”)

Record content for a telemedicine visit, Part I

Source: American Health Information Management Association (AHIMA), Telemedicine Toolkit, 2017.

28

Telemedicine Provider Assessment should:Include 4-level history of present illness (HPI)Include 10+ factor complete review of systems (ROS)Include all three: past, family and social history (PFSH)

Telemedicine Orders: Documentation should include: Review/Order of clinical lab testsReview/Order of radiographsReview/Order of medical tests (PFTs, ECG, Echo, Cath)Review/Summary of old records

Any unusual events (medical emergency, power outage, unable to complete the visit)

Record content for a telemedicine visit, Part II

Source: American Health Information Management Association (AHIMA), Telemedicine Toolkit, 2017.

29

Risk Perspectives in Telehealth: Credentialing & Privileging https://www.medpro.com/telehealth-credentialing-privileging-risksRisk Perspectives in Telehealth: Online Prescribing https://www.medpro.com/telehealth-onlineprescribing-risksRisk Perspectives in Telehealth: Privacy & Securityhttps://www.medpro.com/telehealth-privacy-security-risksRisk Perspectives in Telehealth: Informed Consenthttps://www.medpro.com/telemedicine-informedconsentRisk Q & A: Telehealth/Telemedicinehttps://www.medpro.com/documents/10502/3019648/Q_A_Telehealth-Telemedicine.pdfRisk Tips: Addressing Risks Associated with Telehealthhttps://www.medpro.com/documents/10502/3667697/Risk+Tips_Addressing+Risks+Associated+With+Telehealth.pdfTelehealth/Telemedicine Risk Resourceshttps://www.medpro.com/documents/10502/2824311/Resource+List_Telehealth-Telemedicine.pdfTop 10 Risk Management Strategies for Telehealth/Telemedicinehttps://www.medpro.com/telemedicine-risk-strategies

Resources: MedPro Group

30

American Health Information Management Association (AHIMA), Telemedicine Toolkit, 2017.American Hospital Association, The Promise of Telehealth for Hospitals, Health Systems, and Their Communities. January 2015.American Medical Association, Steps Forward, Telemedicine: Connect to Specialists and Facilitate Better Access to Care for Your Patients. October 2015.American Society for Healthcare Risk Management (ASHRM), Telemedicine: Risk Management Considerations, 2018.Centers for Medicare and Medicaid Services, Outreach and Education, Medicare Learning Network, Telehealth Services. March 2020.HealthIT.gov. Assess your Organization’s Readiness for Telemedicine. August 2017.The Physicians Foundation: The Telehealth Initiativehttps://physiciansfoundation.org/the-telehealth-initiative/

Other Valuable Resources

31

Disclaimer

The information contained herein and presented by the speaker is based on sources believed to be accurate at the time they were referenced. The speaker has made a reasonable effort to ensure the accuracy of the information presented; however, no warranty or representation is made as to such accuracy. The speaker is not engaged in rendering legal or other professional services. The information contained herein does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, if legal advice or other expert legal assistance is required, the services of an attorney or other competent legal professional should be sought.