Telehealth Task Force draft1 11/12/08Preliminary Report Draft

blue font means draft section has been included in this draft report

Cover PageTable of ContentsExecutive Summary

Background and Statement of Need (Linda from Deb’s proposals)

Needs AssessmentsProject Summaries – trends and analysis from project summaries (Deb, Linda)HMSA past and current presidents re their perspectives (Joe)NRTRC needs survey (Joe)MedQuest – follow up with Lydia Hemmings re needs assessments that mention or imply telehealth (Christine)HPCA - any relevant excerpts from needs assessment from 2 years ago (Christine)

Telehealth Projects in Hawaii - Current use of telemedicine and equipment [so far only inserted sections from first and second proposals, also appendixes D and E]

Potential Barriers - Potential difficulties or problems during or after implementation [still need to distill info from project summaries on success factors, barriers, and lessons] (Deb/Linda)

Business Models - plan to plan, including need for business model prior to launch and ATA template (Karen)

Reimbursement and Funding - (Linda)

Malpractice Issues – ATA concerns, in-state vs cross-state, descriptions not recommends (Joe)

Coordination and Collaboration (Christina, Christine, Jana)

Added Value and Incentives – plan to plan, including plans for lit search, surveys, focus groups [this section needs further development, i.e., as noted above]

Political Will and Institutional Leadership – including recent/current bills/statutes (Dale, Jana) [App E has only current bills so far, need past bills and laws]

AppendixesA. Hawaii Telehealth Collaborative Symposium Aggregate ResultsB. Telehealth Task Force Members and Work Group MembersC. Malpractice reference material (edit, do not include all)D. Telehealth Project SummariesE. Hawaii Telehealth Projects – August 2008F. Hawaii Telehealth Bills and Laws

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Background and Statement of Need

[sections taken from first and second grant proposals]

There is a critical and growing shortage of available, affordable healthcare resources throughout the State of Hawai’i. Telehealth has the potential to leverage scare healthcare resources across geographic and other barriers that limit access to healthcare services. Telehealth solutions play a critical role for the mandated imperative to improve access to care in Hawai’i.

Telehealth promises to improve access to care and clinical outcomes at lower costs. The initial concept was that of “telemedicine” where services such as consultations or continuing education would be provided via video-conferencing for rural and underserved communities. From these earlier efforts to reproduce a patient encounter, the scope of telemedicine has blossomed into a broad range of services and technologies. We now have telehealth applications in many medical areas, including radiology, pathology, ophthalmology, dermatology, nursing, hospice, emergency care, surgery, psychology, psychiatry, rehabilitation, and distant monitoring both from home and from remote ICUs.

Hawai’i’s experience with telehealth has been similar to that in many other communities, in that, although there have been a number of successful application implementations, success has not been universal. In the late 1990s Hawai’i had a number of funded initiatives to promote telehealth. The largest was the Akamai Project at Tripler Army Medical Center that provided connectivity and consultations to Micronesia and the Pacific Rim. The experience and technology from the Akamai Project has been used in developing the military’s telemedicine capabilities that are currently operational in the conflicts in the Middle East. During the same time period, the Weinberg Foundation funded 29 hospitals with grants of $200,000 each to purchase telehealth equipment and provide start-up funding. The Department of Defense through the John A. Burns School of Medicine, University of Hawai’i at Manoa, funded infrastructure development for community health centers and other institutions providing video-teleconferencing equipment and broadband bandwidth. These early efforts were based on the naive assumption that, if we build the network, the system would be used. Even though the feasibility of distant consultations was established, none of these earlier efforts produced viable, long-term consultative services due to high upfront costs and reduced frequency of usage over time.

In 1999, the Hawai’i State Telehealth Access Network (STAN) was initiated by the Hawai’i Health Systems Corporation (HHSC), the University of Hawai’i Telecommunications and Information Policy Group (TIPG), and the High Technology Development Corporation. Since its inception, STAN has matured and provides the technical infrastructure to support telehealth in the State of Hawai’i. STAN just recently received a five-million dollar grant from the Federal Communications Commission (FCC) to further improve the system, including high definition video-conferencing and increased connectivity among the partners. Today the STAN network interconnects approximately 40 healthcare facilities and provider networks throughout the State for telehealth applications. Yet, despite the sophisticated and extensive infrastructure provided

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by STAN, Hawai’i has fallen behind a number of states in the use of telehealth to deliver clinical services.

Consistent with the experiences on a national level, most of the earlier projects were scaled back or discontinued once external funding was withdrawn. There was limited acceptance on the part of providers and patients, partly due to the significant cost to provide simultaneous encounters at two facilities and the telecommunication line fees for broadband transmissions. HMSA and Medicare developed payment systems to cover telemedicine; however, the eligible fee does not cover the significant cost involved. As with all new technologies, there was concern for over use and little evidence that the technology improved care or reduced cost.

There has been little argument, however, that telehealth improves access for services not otherwise available in a community. Further, the body of evidence is growing that telehealth programs are clinically efficacious and cost efficient. Used appropriately, telehealth applications increase access to care, reduce cost, and improve quality. Many of the cost savings are only realized by sharing cost across a large or significant population. Small projects and programs have demonstrated proof of concept for aspects of telehealth, but the viability of the telehealth lies in the appropriate use of the newer technology and the scalability to serve a significant population.

Hawaii has the network capacity for telehealth through the STAN system and other networks, including the anticipated launch of HMSA’s Online Care program in early 2009. In addition, the Internet and new technology opens inexpensive options making many previously costly systems more financially feasible. There is a rapid merging of technologies and systems. Electronic health records (EHRs) and disease management software are integrated into home monitoring systems and consultative services. Interoperability of health information systems will allow continued information sharing across platforms. Wireless technology including cell phones further frees patients and providers from the telehealth facility. Video conferencing, digital photography, and automated data upload via the internet add another level of accessibility to health care.

Telehealth Symposium

In recognition of the need to take full advantage of the potential of telehealth, the Hawai’i Telehealth Symposium, held on November 15, 2007 and funded by the HMSA Foundation, provided a forum for major stakeholders in healthcare and healthcare information technology to identify critical needs, explore common interests and mutual benefits, and lay the foundation for a working community collaborative. There was a clear mandate from the participants of the symposium that Hawai’i needs better structured coordination of telehealth activities to provide the required scalability and sustainability of telehealth services. The participants of the symposium reached a consensus that the five priorities that need to be addressed with respect to telehealth in Hawai’i are: the business model, reimbursement and funding, coordination and collaboration, added values and incentives, and political will and institutional leadership. See Appendix A for a short overview and see the symposium website for the complete summary.

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The symposium steering committee also developed a website (www.hawaiitelehealth.net) to introduce the participants to the symposium and share information regarding telehealth in Hawai’i. The list of participants and the symposium summary are posted on the website. The website allows participants to stay connected with the organizing committee. The website is maintained by the University of Hawai’i Telecommunications and Information Policy Group (TIPG).

The symposium steering committee has held regular meetings since the Symposium to plan follow-up activities. Further funding from the HMSA Foundation allows the priorities identified and concepts developed during the symposium to be further developed into a strategic plan for Hawai’i to guide the adoption and implementation of telehealth activities to address the healthcare needs of the State. The current steering committee continues to provide oversight and input into the activities related to the strategic plan. The planning process will involve the extended network of symposium participants and other major stakeholders, both to solicit their input and keep them involved in the planning process. In addition, there is need for the formation of a collaborative organization that, with respect to telehealth activities, can provide synergy among stakeholders, assist in seeking funding, address issues related to policy, legislation and reimbursement, and provide some assurance of sustainability of programs.

Telehealth Task Force

To continue its work, the symposium steering committee lobbied [wrong word] for the passage of a legislative resolution. During its 2008 session, the Hawaii State Legislature passed a resolution (HCR 138 HD2 SD1) requesting that the University of Hawaii John A. Burns School of Medicine's Telehealth Research Institute (TRI) form a task force to explore the feasibility of further implementation of Hawaii’s telemedicine system's health care services to benefit Hawaii’s citizens. The complete resolution is available at: http://capitol.hawaii.gov/session2008/bills/HCR138_SD1_.htm

Specifically, the resolution requested the task force to examine the following issues:      (1)  Current use of telemedicine and equipment;     (2)  Costs for expansion;     (3)  Timeframe for full implementation of an expansion project;     (4)  Potential difficulties or problems that may arise during or after implementation; and (5)  Broader issues addressed at the November 15, 2007, Hawaii Telehealth Collaborative

Symposium, including:(A)  Business models;(B)  Reimbursement and funding;(C)  Coordination and collaboration;(D)  Added value and incentives; and (E)  Political will and institutional leadership;

The task force has been requested to submit a preliminary report of its findings and recommendations to the Legislature by December 2008, and a final report of its findings and recommendations, including any necessary proposed legislation, by December 2009.

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See Appendix B for the list of task force and work group members. So far, the task force members have met twice, on August 20 and September 16, 2008. They have reviewed and commented on initial drafts of the task force vision and mission, subject to further review, discussion, and consensus seeking after the preliminary report and after additional research and stakeholder consultation in 2009.

Draft vision:By the year 2015, a robust sustainable telehealth system will connect all the people of Hawaii to health care services. [bold font means words changed or added]

Draft mission:Recommend to the Hawaii State Legislature a state telehealth strategic plan to develop financially sustainable and technologically adaptive telehealth services. [bold font means words changed or added]

Draft scope of telehealth: For the purpose of the task force, not as conclusive definition. Includes: infrastructure (technical and organizational), video-teleconferencing, store-and-forward (e.g., radiology, dermatology, need not be real time), personal health applications, distance learning. Excludes: electronic medical records, personal health records. (exclude from this scope due to immense scope and other ongoing activities; but will need to connect for planning and implementation)

Task force agreed preliminary report should address the following: Telehealth projects: synthesis of project summaries, lessons learned, critical success factors,

critical barriers. Needs assessments: We cannot do needs assessment, not have time or money, can use needs

assessments already done by others on community infrastructure, needs, and disparities in care. Find out where needs assessments have been done, summarize findings.

Telehealth legislation: Strategic thing, go through last few years of legislation, what have legislators been interested in.

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Telehealth Projects in Hawaii :Current use of telemedicine and equipment

[this section from first proposal]There are a number of successful ongoing telehealth programs in the State. For example, every month Continuing Medical Education programs are delivered throughout the state and also to US Affiliated Pacific Islands. In addition, the telehealth network is frequently used for committee meetings and conferences reducing the need for inter-island travel. Teleradiology is used routinely. The rapid transition of imaging to digital technology and the increased bandwidth and transmission speeds allow our radiologists to work from anywhere and anytime, provided they have access to the high quality monitors required to read images. Dr. Nancy Johnson, Chair, Department of Nursing, Maui Community College, successfully demonstrated that home nursing visits can be done via simple home video-conference. Dr. Dan Davis, Queens Medical Center, provides telemedicine visits to fragile adult patients in his private practice through a relatively inexpensive home video-conferencing device that he helped develop. Kapiolani Medical Center provides telehealth fetal ultrasound services to a number of neighbor island providers. Shriners Hospitals for Children, Honolulu, has conducted telemedicine clinics providing pediatric orthopaedic consults to Kauai, Maui, four rural sites on Hawaii, and in the Pacific Basin Regions (e.g., Guam, Saipan, American Samoa, Federated States of Micronesia, and the Republic of the Marshall Islands). Within the scope of this proposal, we are unable to provide a comprehensive list of former and current telehealth projects and programs that have been funded from government and private sources.

[this section from second proposal]a. Develop a resource list of previous telehealth projects in Hawai’i with a brief description,

funding source, involved individuals and organizations and current status. (2 months) b. Identify all current telehealth projects and programs, including project description, contact

information, involved organizations or institutions, and funding source. (2 months) c. Research current clinical networks and telehealth systems in other states and associated

documents related to strategic plans or business models. (4 months and ongoing)

See Appendixes D and E for initial compilations of past and current telehealth projects in Hawaii.

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Potential Barriers: Potential difficulties or problems during or after implementation

Need for of EMR/PHR to provide platform or hub that would allow delivery of telehealth services to be more broadly available. Implies recommendation that state should form separate task force for EMR/PHR to address those needs. Implies recommendation that connections should be formalized between telehealth, HHIE, and broadband task forces. (Christina)

still need to distill info from project summaries on success factors, barriers, and lessons] (Deb/Linda)

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Critical Issue: Business Model

Developing a business plan, which would lay out the reasons a telehealth program is needed and a strategy to start and sustain the program, is critical for the success of any telehealth initiative.

The American Telemedicine Association has an excellent resource, entitled, “Business Plan Template: a document to assist in the business and strategic planning of telehealth programs.” http://www.americantelemed.org/ICOT/sigbusiness.htmhttp://www.americantelemed.org/ICOT/BusinessFinance/Telehealthbusiness%20plan%20template%20for%20ATA%204-14-08.pdf

It lists 15 well-organized components of a business planning process: 1) Executive Summary 2) Introduction and Background 3) Needs and Demand Assessment 4) Services Plan 5) Internal and External Assessment 6) Marketing Plan 7) Technical Plan 8) Management Plan 9) Regulatory Environment 10) Financial Plan 11) Presentation to Stakeholders 12) Training and Testing 13) Operations Plan 14) Evaluation, Feedback and Refinement 15) Conclusions and Recommendations.

For the state of Hawaii as a whole, a successful Business Model has been identified as a critical issue and some priority actions include:

1) Developing and sustaining a high quality, integrated infrastructure that would include rural broadband so more areas of the state have access

2) A change in how telehealth is reimbursed3) Maintaining Act 221, which would enable more investment of high-tech companies in

Hawaii.

Indications of success is that telehealth becomes part of standard of care, more doctors are involved in telehealth, more high-tech companies thrive in Hawaii and more specialties are available for the Neighbor Islands.

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Critical Issue: Reimbursement and Funding

We must explore critical barriers and potential solutions regarding reimbursement and funding from the viewpoints of different stakeholders: patients, physicians, and payers.

Patients:There is ample evidence of satisfaction among patients who do use telehealth services. The Hawaii Community Genetics program has seen high satisfaction among participating families from neighbor islands, who might otherwise choose to forego genetic services if they had to travel to Oahu. Kaiser notes high satisfaction among its members who use telehealth services. Programs to date have shown that in terms of both quality of service and care, patients see telehealth services as equal to face-to-face services.

Physicians:Convenience and compensation are primary considerations for physicians. For some, the marginal benefit is low to substitute telehealth services in place of travel; clinicians may benefit in terms of travel time, cost, etc., for a long day of back-to-back face-to-face office visits on neighbor islands. To switch to telehealth, they would have to overcome, on the other hand, it is taxing to do back-to-back VTC consultations, and on the other hand, it is inefficient to do sporadic VTC if they cannot do so from their own offices. Current workflows and physical set-ups in many practices do not support convenient – and cost-effective – use of telehealth. Many physicians are unclear on how to apply for reimbursement, implying the need for a telehealth reimbursement billing guide, such as is available in Utah.

Payers:Since HMSA already has payment policy for telehealth services, it needs more information on what is not reimbursed and why it continues to experience such low volume of submissions for telehealth services. As a managed care organization, Kaiser does not deal with reimbursement per se, but does track telehealth services by CPT code. An important consideration for payers is whether actual cost savings can be realized by using telehealth, i.e., are telehealth services substitutive or additive to face-to-face services? How can the services and any cost savings be properly documented? And if there are cost savings, what or who should realize that value through reimbursement?

A paradigm shift is needed to address the psychological barriers of both providers and payers, probably through collaboration and financial incentive for both parties. New delivery models beyond VTC, new administrative models to improve efficiency in current practice, ways to improve convenience and cost-effectiveness for providers, ways to document cost avoidance for payers. We need to explore successful programs using telehealth, why they work, and how they can be translated to widespread use in Hawaii.

Telehealth seems to be financially viable in health care systems, for example, prison systems and state- or university-sponsored practices where providers are not in private practice. Eastern Washington has a model where competitors got together [to do what?] Here in Hawaii, Kaiser uses telehealth in certain circumstances with high patient satisfaction, with nurses as

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coordinators working with patients; soon they will expand telehealth to provide rheumatology and cardiology services to their Hilo facility.

Recommended next steps for the collaborative to explore include the following: Examine different modalities – Dissect how it works Report what practitioners are billing and what payers are reimbursing; develop telehealth

reimbursement billing guide like Utah Small collaborative groups: Provider / Risk Management / Telehealth Services; Representation

from many areas – enlist people and gather data; Liaison meet with regional services Gather evidence that payers need; come up with plan / compromise before going to payers

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Sub-Issue: Malpractice and Telehealth

Medical Malpractice provides umbrella coverage for physicians who are practicing within the scope of practice established by each individual state. Most states have legislation that addresses telemedicine, Medicare covers telemedicine and law suites that occur while using telemedicine are covered by malpractice carriers. Below is the description of MIEC coverage, one of the carriers in Hawaii:

http://www.miec.com/basic.htm

The MIEC policy protects physicians: Against claims alleging injury or damage caused by delivering or failing to deliver direct

health care services to patients;  When acting as an independent medical examiner  When providing advice or consultation regarding the health of persons who are not patients  For peer review activities 

Bullet one and three clearly cover telemedicine as there is direct care to patients or advice or consultation regarding the health of persons who are not patients. There is no stipulation either in Hawaii state statue or in the malpractice policy that the service is a face to face visit. In addition, the services are reimbursed adding further weight to the argument that telehealth is covered under standard malpractice contracts.

In the material from the Center for Telehealth & E-Health Law (CTEL) discusses potential increased liability related to telehealth. They raise issue with the event that there is adverse patient outcome when there is equipment failure. This concern occurs in a number of settings using advanced technology and is not unique to telehealth. The discussion does imply that providers using telehealth equipment have some level of responsibility to make sure the system is reliable.

The issue of Malpractice coverage is much more confusing when services are provided across state lines. Basically, there are variations in the scope of practice from state to state. The provider is required to meet the scope of practice in the state that the patient resides. This situation is not the primary focus of the report and is included to be more complete in discussing the Malpractice issue.

Policy Implication:Since the Malpractice coverage is defined by the State’s statute covering the scope of practice, the American Telemedicine Association recommends “"Malpractice Coverage - State requirements to mandate payments for telemedicine service should be accompanied with requirements that insurance carriers provide malpractice coverage for those same services."This recommendation establishes a higher level of certainty that telehealth services are explicitly linked to malpractice coverage and the scope of practice.

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Critical Issue: Coordination and Collaboration

To take full advantage of telehealth, Hawaii needs to have better communication and collaboration among the primary stakeholders who are or would be involved in Telehealth. In other states, e.g., Washington, Alaska, Utah and California (specifically, UC Davis), there are central organizations that collaborate and coordinate efforts for telehealth. Many of these organizations address both the technical issues related to infrastructure and the clinical needs of the community and the health institutions. Hawaii does not need to copy these other models, but does need a far better structure to advance telehealth in Hawaii. [excerpt from first proposal for first grant from HMSAF]

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Critical Issue: Added Value and Incentives

Despite known benefits of telehealth programs in the U.S. and Canada, resistance to widespread adoption in the U.S. continues. For broad based buy-in to occur policymakers and program planners will need to address critical human factors such as provider resistance to change and professional disincentives to utilize new technologies.

Sufficient system support and user training, careful program planning that does not substantially increase provider workload, and providing financial incentives can contribute to bringing about needed change. Further, healthcare delivery systems that favor in-person doctor-patient encounters over telehealth visits will need to change to advance widespread adoption of telemedicine.

[this section needs further development, i.e., "plan to plan" for incentives, including plans for lit search, surveys, focus groups]

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Critical Issue: Political Will and Institutional Leadership

For healthcare system changes to efficiently and effectively have impact on the health situation of our community, policy directives must occur at the state and national levels. Many times, federal policies will ignite the change in state policies and national organizations such as the American Telemedicine Association (ATA), Health Information Management Systems Society (HIMSS), American Medical Informatics Association (AMIA), and the Center for Telehealth Law (CTel) are working to change policy at the national level. However, this takes a long concerted effort as each state is unique in its needs and challenges. Therefore, Hawaii must have a voice in facilitating policy changes to meet the needs of our state.

Findings:Political will and institutional leadership was identified during the 2007 Telehealth Symposium as being one of the top 5 critical issues that needs to be addressed to facilitate the adoption and advancement of Telehealth in the State of Hawaii. During a luncheon meeting/discussion on political will and institution leadership held on May 30th, the participants noted that: Telehealth activities in Hawaii is fragmented, The current leader for Telehealth in Hawaii has been an individual (Senator Inouye) and not

systemic/institutional, There is no succession plan in place for Telehealth issues, and There is a lack in understanding of Telehealth

The participants also commented on the importance of: Identifying advocates with a similar mission and engaging leaders from the community, Educating healthcare providers, patients, legislators on the obstacles of reimbursement,

liability, institutional sharing of information, HIPAA, etc. and offer solutions. Identifying and supporting bills that fit with Telehealth, and Collecting data on the value/benefits of Telehealth to the patient, payor, and the physician.

Recommendations: Formally establish an advocacy group that has government support to bring together multiple

organizations that will work on specified objectives toward a goal of improving patient care and efficiency,

Collaborate and gain support of different organizations and associations, Identify, monitor, and support currently proposed legislation that pertains to Telehealth

and/or issues that Telehealth can address (i.e. physician/healthcare provider shortages, healthcare disparities, medical referrals, continuing education, patient centric care, etc.),

Educate institutional leaders, healthcare providers/organizations, healthcare association, payors, the community, and the legislature,

Draft policies to be submitted to the legislature, and Be a resource and expert advisor to the legislative body.

[See Appendix E for list of current telehealth-related bills; still need to expand App E to include past bills and laws.]

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APPENDIX AHawaii Telehealth Collaborative Symposium November 15, 2007Aggregate Results

Critical Issue: Business Model

Highest Priority Actions Rural Broadband Change Rules for Reimbursement, possible pilot program Maintain Act 221

Key Results Every nursing and foster home would be tele-enabled More doctors involved in telehealth Telehealth becomes part of standard care More high-tech companies in Hawaii More specialties, especially on Neighbor Islands

Critical Issue: Reimbursement and Funding

Highest Priority Actions Address medical malpractice (legislation or other resources) Medicaid and private insurers’ consensus on the recognition of telehealth Developing measurable outcomes (i.e. travel costs vs. telehealth)

Key Results Malpractice is available to cover telehealth All payers reimburse telehealth adequately More programs have measurable outcomes Progress in closing gap between actual utilization and perceived utilization Measurements are in place and data is collected. Outcomes are measured – patient and

provider. (# sites, # referring physicians, # consultations, etc.). Travel costs/distance, types of applications.

Critical Issue: Coordination and Collaboration

Highest Priority Actions Increase awareness an advocacy via multi-system/level approach to all the stakeholders

(including congressional, local, government, etc.)

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Define leadership group with clear mandate and authority to make changes to move forward with clear mandate with broad outline and a long-term plan in place

Seek funding and resources (time, etc.) in collaborative way for shared goals vs. individual attempts

Broad telehealth strategic plan that addresses the healthcare and human service needs (e.g. social services supported by DOH) of the State

Key Results Increased utilization of telehealth services Telehealth priority of DOH and other entities Integrated into the delivery system Leadership group in existence Having obtained adequate funding Provider adoption and consumer acceptance A central strategic plan in place with some activities already in motion This central strategic plan would be used by other entities to develop (refer back to) their

own plan Strong, functional work groups that meet regularly Congressional and legislative support Telehealth integrates EMR/EHR

Critical Issue: Added Value and Incentives

Highest Priority Actions Develop and implement a state strategic plan for telehealth that demonstrated value. Develop and implement a standardized set of legal and regulatory operating agreements

between sending and receiving institutions. Create a clinical group that develops a playbook of telehealth-available serves and

addresses integration with traditional healthcare and HER doctor needs on sending and receiving end.

Key ResultsThis group did not have time to discuss key results.

Critical Issue: Political Will and Institutional Leadership

Highest Priority Actions Advocacy Group

- Formally establish a collaborative- Seek funding to organize and operate- Seek business plan development- Advocacy role is important

Educational Campaign

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- Program activity education campaign targeted to various constituencies (legislators, healthcare leaders, physician, business, employers)

- Program activity- Institutionalizing technical assistance (planning, training, not technology) to

various programs. Strategic Plan

- Develop a strategic plan for the collaborative effort to grow telehealth

Key Results Funding for UH/State telehealth programs Collection of grants, especially those who don’t have any as collaborative members Telehealth included in strategic plan in key organizations Policy leaders are educated, informed, supportive Laws on books to support telehealth Better VTC facilities at hospitals General purpose access patients for telehealth consultations (kiosks) Broader range of telehealth advocates Shared vision for telehealth statewide

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APPENDIX BTelehealth Task Force and Work Group Members

TASK FORCE DESIGNEE WORK GROUPAffiliation Name Title

X Kaiser Permanente Alan Lau, MD M.D., Internal Medicine NephrologyX Hepatitis Support Network Alan Tice - Dr. Humphry M.D., FACPX Psychiatric Medical Association Chad Koyanagi, MD - Val M.D., Addiction Psychiatry, PsychiatryX Dept of Health Chiyome Leinaala Fukino Director, State of Hawaii -Department of Health X X Telecom & Information Policy Group Christine Higa Director, PEACESAT, Social Science Research Institute X X Hawaii Primary Care Association Christine Sakuda Principal Investigator X X American Telemedicine Association Dale Moyen Telemedicine Program ManagerX Hawaii Medical Center Danelo Canete, MD M.D., Cardiology X Telehealth Research Institute Deborah Peters, MD Senior Scientist/Research Manager X X UH JABSOM Deborah Peters, MD Senior Scientist/Research ManagerX Hawaii Primary Care Association Elizabeth Giesting Executive DirectorX Queens Medical Center Gerard K. Akaka, M.D. M.D., FACP X Hawaii Medical Center James Lumeng, MD M.D., Anatomic Pathology, Clinical Pathology, Internal

Medicine, Oncology X Hawaii Rural Health Association Jana Lindsey RN, Telemedicine Coordinator X Shriners Hospital for Children Jana Lindsey RN, Telemedicine CoordinatorX UH JABSOM Jerris Hedges, MD Jerris R. Hedges, MD MS, MMMX American Telemedicine Association Jonathan Linkous Director, ATAX X Telehealth Research Institute Joseph Humphry, MD M.D. Internal MedicineX Hawaii Rural Health Association Judy Mikami Director of Resource Development for Na Pu`uwai X X Queens Medical Center Karen Seth Manager, Neuroscience Institute/Stroke

X Kaiser Permanente Lawrence Eron, MD M.D., Infectious Disease Medicine, Internal MedicineX Department of Human Services Lillian Kohler Director of the. Department of Human ServicesX X Hawaii Medical Services AssociationLinda Axtell-Thompson M.A. X Hawaii Health Systems Corporation Lorna Nekoba MLS, Medical Librarian X Department of Human Services Lydia Hemmings Executive Director of the nonprofit Blueprint for Change X Psychiatric Medical Association Mike Fukuda, MSW MSWX Telecom & Information Policy Group Norman Okamura Specialist, Social Science Research Institute X Dept of Health/CSHNB Sylvia Au MS, CGCX Hawaii Health Systems Corporation Thomas Driskill President/CEO

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APPENDIX CMalpractice and TelehealthReference material only below [need to edit, do not include all]

Malpractice insurance covers telemedicine in providing care for patients. I have been unable to identify a single discussion where telehealth is excluded from coverage. Malpractice insurance is global. Malpractice covers the practice of medicine and does not define situations where they would not cover a case with exceptions that may include illegal activities. Historically, there were early discussions and if one googles “telehealth and malpractice” a substantial number of the initial “hits” are articles the predate 2004. I did not review the historical material as the technology and the coverage for telehealth services have evolved.

Most of the recent discussions related to Malpractice and telehealth deal with interstate telehealth where the practicing physician is not in the state where the patient resides. Malpractice Insurers are licenses in states and may not cover events in states where they are not licensed to operate. Teleradiology is probably the most evolved in this arena as current coverage spans the globe. There are issues both with licensing and with malpractice coverage.

As reviewed in the CTEL risk management presentation, (see below) telehealth does increase risk primarily by using new technology that can fail or malfunction. There is no discussion that existing malpractice insurance does not cover the case provided that the services provided meet the standards established by state law. (I believe that Arkansas made it illegal to prescribe medication to a patient over the internet if there was no existing doctor/patient relationship) If a physician is not practicing within the state law, he/she will also have problems with the state regulatory body (Board of Medical Examiners in Hawaii)

Malpractice insurance covers telemedicine services. The TelMed malpractice insurance endorsed by the ATA is a malpractice policy that covers interstate consultations. It is not a policy that covers telemedicine services. The Campania Group will write a malpractice policy that includes language covering Interstate telemedicine services. One would change carriers rather than have two policies, one for medical malpractice and the other for telehealth. I did not request a quote on their web page, but I would be interested to know if providers in Hawaii can get coverage as they are not currently in Hawaii. MIEC description of coverage is below.

The other strong indicator that telehealth services are covered is that most services are now covered by insurance and have CPT codes. Recognized services are considered as part of the practice of medicine. MIEC clearly covers consultations when there is no doctor patient contact or relationship again reflecting the existing breath of coverage. The only time a provider would need a separate policy is if his malpractice did not provide coverage in a different state.

Campania Group web page:http://www.telmedinsurance.com/product.html

Resources:http://www.presidioinsurance.com/news/?p=22

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Teleradiology Prompts Medical Malpractice Insurance Quandry

Published by Persidio at 12:25 pm under Insurance Issues 8/2008A California Radiology Group plans to hire a radiologist to read films from his home in Colorado.  A practice commonly referred to as teleradiology, a branch of telemedicine. This teleradiology practice raises questions concerning whether the physician is practicing medicine in California or Colorado and subsequently will the California-based insurance carrier extend coverage for this out-of-state exposure?

Technically, the teleradiologist need only maintain a California medical license as only films for California patients will be reviewed (this requirement varies from state to state).  From this we can construe the teleradiologist reading from out-of-state for in-state patients is not providing a medical opinion outside California.  In other words, the physician is practicing medicine in California though physically located outside of California.  So, how does this affect the medical malpractice insurance policy issued by a California carrier not licensed to do business in Colorado?  Reverting back to the premise that the teleradiologist is technically practicing in California, this should pose only a minor obstacle for the group to obtain coverage once the telemedicine exposure is clearly documented and satisfactorily explained.

http://www.miec.com/basic.htm

The MIEC policy protects physicians: Against claims alleging injury or damage caused by delivering or failing to deliver direct

health care services to patients;  When acting as an independent medical examiner  When providing advice or consultation regarding the health of persons who are not

patients  For peer review activities 

http://www.ctel.org/documents/CTel_Presentation_-_Risk_Management.pdf

11MalpracticeDefinitionDeviation from the accepted medicalstandard causing injury to a patient forwhom the provider has a “duty of care”Current policyMalpractice governed by state lawLaws vary as to:duty of caredamagesstandard of care

Has the practitioner formed a provider-patientrelationship via telemedicine?

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§ Who is liable (consulting or referring MD,equipment manufacturer, hub or spoke site)?§ If sued, will the practitioner be presented withsame legal issues as an MD in a standardlawsuit?§ What are the risks and liabilities associated withthe use of telemedicine equipment?§ Where is the practitioner practicing?

13Telehealth Malpractice: Issues§ Technology usually increases liabilityProvides more opportunities for problemsCan be improperly used or not used (notobtained, not installed, not used)§ New technology can change the standardof care – is there a duty to keep up?

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APPENDIX DTelehealth Project Summaries

Summaries are available online at http://www.hawaiitelehealth.net/summary.html

1. Asynchronous Local/Oversees Hospital Academic (ALOHA) System2. eICU3. Heartsounds Tele-Auscultation4. Pacific Asynchronous TeleHealth (PATH) System: Pediatric and Adult Specialty 5. Teleconsultation in the Pacific Region  6. Pediatric Diabetes Education Portal (PDeP)7. Pacific Island Health Care Program8. Low Bandwidth Behavioral Telehealth9. Tele-radiology10. Traumatic Brain Injury Telemedicine (TELE-TBI)11. Telehealth Voice Therapy in Remote Regions in the Pacific Basin12. Shriners Telemedicine Program13. Hilo Telehealth Pilot Project14. HMSA's Online Care15. Nursery Pediatric Tele-Echocardiography16. Ohana Health Home Glucose Monitoring Program17. OHANA18. HOPE19. HMSA Telehomecare Demonstation

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APPENDIX EHawaii Telehealth Projects – August 2008

Organization Name of Project Type of Telehealth Contact Phone # Funding Methodology# of Encounters

Other Description

Daniel Davis, MD, Private Practitioner

Home Telemedicine for Fragile Elderly

Chronic care management

Daniel Davis, MD

888-422-7370 Private pay

Real-time, web-based, one-way video, POTS

Dept of Health Genetics Program

Genetics and Newborn Screening Practice Model

Urgent and follow-up genetics consultations Sylvia Au

733-9063 HRSA MCHB

Real time videoconferencing 12

Also will be starting sessions for Guam.

Dept of Health CSHCN Tele Nutrition

Michelle Maeda

Dept of HealthState Hospital JudiciaryHawaii Health Systems Corporation Teleradiology

Hawaii Pacific Health

Fetal TeleUltrasound

Fetal Tele Ultrasound Dale Moyen

808-535-7190

US Dept of Commerce TOP Grant & Weinberg Grant

Real Time Video Conferencing with live full motion Ultrasound 500+

1999 – 2007. As of 2008 Service only within HPH

Hawaii Pacific Health CME VTC

Pediatric Grand Rounds

Dale Moyen 808-535-7190

Weinberg Grant

Real Time Video Conferencing

Weekly since 2003 Operationalized

Hawaii Pacific Health CME VTC

OB/GYN Grand Rounds

Dale Moyen 808-535-7190

Weinberg Grant

Real Time Video Conferencing

Weekly since 2003 Operationalized

Hawaii Pacific Health CME VTC Noon Conferences

Dale Moyen 808-535-7190

Weinberg Grant

Real Time Video Conferencing

Weekly since 2003 Operationalized

Hawaii Primary Care Association Teledermatology Tele Derm

Christine Sakuda

8085358442 OAT Store-and-forward 20

Hawaii Primary Care Association Holomua

Master patient index and visit registry

Christine Sakuda

8085358442 AHRQ Secure internet 500,000

Hawaii Primary Care association

E Ninau Aku I Ke Kauka Patient outreach Nicole Moore

808-935-8658 VTC, VTC bridge weekly

Hawaii Primary Care association Diabetes 101 Health Education

Department of Native Hwn Health

HPCA VTC bridge host

Hilo Medical Center/Kahi

Behavioral Health Lorna Nekoba

Own organizations

Real-time videoconferencing

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Mohala

Hilo Medical Center/Kapiolani

Tele-Echocardiography

Dale Moyen/Lorna Nekoba

808-535-7190808-974-4795

Own organizations

Real-time videoconferencing

Kalihi-Palama DiabetesDr. J. Humphry

Kaiser Permanente Nephrology Dr. LauKaiser Permanente Dr. Eron

Molokai General Hospital/Queen’s

Oncology Clinic with Dr. Melvin Palalay Oncology Louis Martin

585-5123 MGH/Queen’s

Real-time videoconferencing ?

Molokai General Hospital/Queen’s

Diabetes Management Dr. Aululi

North Hawaii Community HospitalQueen's Neuroscience Institute

Movement Disorder Telemedicine Clinic

Neurology - Movement Disorders Karen Seth

585-5179

Pharmaceutical educational grants

Real-time videoconference 160

Queen's Neuroscience Institute/Hilo Medical Center

Hawaii Neuroscience Telehealth Network

Stroke/Acute Neuro/ER Karen Seth

585-5179

HRSA OAT grant

Real-time, web-based, one-way video, VOIP phone 2

Queen's Trauma Services and North Hawaii Community Hospital Trauma Project Trauma

Marsha Durbin

537-7769

Federal funding TBD

Shriners Hospital for Children, Honolulu

Pediatric Orthopedic Conference

Pediatric Orthopaedics Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

>150Shriners Hospital for Children, Honolulu

Pediatric Orthopedic Consults

Pediatric Orthopaedics Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

607Shriners Hospital for Children, Honolulu

Pediatric Junior Rheumatoid Arthritis Consults Pediatric JRA Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

17Shriners Hospital for Children, Honolulu

Pediatric Myelodysplasic Consults Pediatric Myelo Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

3Shriners Hospital for Children, Honolulu

Pediatric HandConsults Pediatric Hand Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

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Shriners Hospital for Children, Honolulu

Burns/Plastics Consult

Pediatric Burns/Plastics Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

9Shriners Hospital for Children, Honolulu

Spinal Cord Injury Consult

Pediatric Spinal Cord Injury Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

3Shriners Hospital for Children, Honolulu

Pediatric Special Ortho (Genetics)Consults

Pediatric Special Ortho (Genetics) Jana Lindsey

951-3637

Operational Budget

Real-time videoconferencing

29Shriners Hospital for Children, Honolulu SHCIS

Electronic Health Records/Patient Order Entries Ross Imada

951-3730

Operational Budget Intranet

Implemented 2005

System-wide between 22 Hospitals

Tripler Army Medical Center

Pacific Islands Health Care Project

Store-and-forward

UHJABSOM Grand Rounds Grand RoundsReal-time videoconferencing

UH Telehealth Research Institute

UH TIPG

Hawaii Open Vista Application Service Provider (ASP)

Electronic Health Record

Norman H. Okamura

956-2909 Medicaid

UH TIPG

The Hawaii Medicare Rural Hospital Flexibility Program (CAH FLEX) Electronic Health

RecordNorman H. Okamura

956-2909 HRSA

UH TIPG

Rural Health Information Technology Assessment and Training

Assess Rural healthcare Health Information Technology (HIT) and EHR Readiness

Norman H. Okamura

956-2909

Hawaii State Office of Rural health

UH TIPG + Partners

Pacific Broadband Telehealth Demonstration Project

Telehealth/ Telecommunication Infrastructure

Norman H. Okamura

956-2909

Universal Service Rural Health Care Pilot Program

Veteran’s Administration Dr. Saiki

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APPENDIX FHawaii Telehealth Bills and Laws

Doc # Description StatusHB202 HD1 Relating to Telepsychiatry (Green)

Requires and appropriates funds for the University of Hawaii to expand its existing telepsychiatry project to rural Oahu, rural Kauai, and Hawaii, and to involve advanced graduate psychiatric residents in the provision of the services. (HB202 HD1)http://www.capitol.hawaii.gov/site1/docs/getstatus2.asp?billno=HB202

8/27/07 D: Carried over to 2008 Regular Session

SB231 Relating to Telepsychiatry (Chun Oakland)Appropriates funds to expand the telepsychiatry project at the University of Hawaii; appropriates funds for that purpose.http://www.capitol.hawaii.gov/site1/docs/getstatus2.asp?billno=SB231

8/27/07 D: Carried over to 2008 Regular Session

HB2246 Telepharmacy; health care; rural areas (Herkes)Authorizes pharmacies that dispense medications pursuant to section 340B of the United States Public Health Service Act to engage in telepharmacy dispensing of medication subject to rules created by the Board of Pharmacy.http://www.capitol.hawaii.gov/site1/docs/getstatus2.asp?billno=HB2246

1/18/08 H: Referred to HLT/HSH, CPC, referral sheet 3

HCR138 HD2SD1

Health; Telemedicine (Evans)Requesting the University of Hawaii John A Burns School of Medicine’s Telehealth Research Institute to form a task force to review the potential expansion of the current practices and equipment of Hawaii’s Telemedicine System.http://www.capitol.hawaii.gov/site1/docs/getstatus2.asp?billno=HCR138

5/1/2008 S: Received notice of House Agreement and Adoption in House (Hse. Com. No. 822)

SB977 SD1 Primary Health Care Services; Rural Areas (Ige)Appropriates funds to develop a statewide rural training model to provide a pipeline of well trained family physicians to improve health care access and meet the future health needs of the people of Hawaii. (SD1)http://www.capitol.hawaii.gov/site1/docs/getstatus2.asp?billno=SB977

8/27/07 D Carried over to 2008 Regular Session

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