Telemedicine: Transforming the
Delivery of Healthcare
Debbie Voyles, MBA HOM
Director of Telemedicine
F. Marie Hall Institute for Rural and
Community Health
June 2013
Texas Tech University Health Sciences Center
F. Marie Hall Institute for Rural and Community Health
Five Core Programs
•
Telemedicine –community-based telemedicine in Texas; one
of 2 correctional programs; one of longest running programs
in nation; 45,000+ consultations
•
TexLa Telehealth Resource Center
•
Rural Research – Project FRONTIER, TARC, Alzheimer’s
Disease
•
Health Education – West Texas Area Health Education
Center (WTAHEC), Hot Jobs, Double-T Health Service
Corps, region-wide community health needs assessment
•
Electronic Health Records – West Texas Health Information
Technology Regional Extension Center (WTxHITREC)
Today’s Discussions:
• Unique challenges for Rural Health Care
• What is Telemedicine
• Benefits to using Telemedicine
• Challenges/Barriers to Telemedicine
• Critical Steps to Implement Telemedicine
• Reimbursement
• TexLa Telehealth Resource Center
US 2010 Census
• Population = 308,745,538
• 9.7% increase from 2000
• 83.7% live in the nations 366 metro areas
(population over 50K)
• 10.0% live in the nations 576 micro areas
(population between 10K and 50K)
• 6.3% live in rural areas (population less than
10K)
US Department of Commerce
Population Distribution and Change: 2000 to 2010
Current Challenges in Rural Health Care
• Workforce shortages
• Geographic isolation – limited transportation
• Diminishing community economics
• Low healthcare margins
• Difficulty recruiting physicians
• Increasing dependence on specialty and
expensive technologies
• Demand for quality
Is this the Future of Healthcare?
Health Professional Shortage Areas
HPSA – Mental Health Designated
Populations
HPSA – Dental Health Designated
Populations
Ratio of Providers per 100,000
Population
Primary
Care
Doctors
Physician
Assistants
Nurse
Practitioners
RNs
LVNs
U.S., 2010
67.4
34.4
22.8
882.5
244.0
Texas, 2011
(2005)
69.5
(68.5)
20.8
(14.7)
25.8
(17.7)
712.7
(628.6)
281.7
(269)
West Texas,
2011
60.8
18
28.5
746.4
415.4
West
Texas/Border,
2011
48.0
13.4
24.82
577.54
193.18
Family Practice Physicians in Rural
Counties
Texas Counties Without a Pharmacists
Lips
com
b
Dallam
Sherman
Hansford
Ochiltree
Hartley
Moore
Hutchinson
Roberts
Hemphill
Oldham
Potter
Carson
Gray
Wheeler
Deaf Smith
Randall
Armstrong
Donley
Parmer
Castro
Swisher
Bris
coe
Collingsworth
Hall
Childress
Hardeman
Bailey
Hale
Lamb
Cottle
Motley
Floyd
Wilbarger
Wichita
Foard
Clay
Cochran
Hockley
Gaines
Andrews
El Paso
Hudspeth
Winkler
Ward
Culberson
Lynn
Terry
Yoakum
Loving
Lubbock
Ector
Crane
Reeves
Dawson
Martin
Midland
Crosby
Garza
Borden
Howard
Glasscock
King
Dickens
Kent
Scurry
Mitchell
Sterling
Knox
Stonewall
Fisher
Coke
Taylor
Upton
Reagan
Tom Green
Irion
Schleicher
Palo Pinto
Wise
Denton
Erath
Brown
Somervell
Henderson
Trinity
Robertson
Burnet
Madison
Milam
Travis
Blanco
Bandera
Lee
Liberty
Austin
Fayette
Caldwell
Chambers
Gonzales
Medina
Fort Bend
Lavaca
Galveston
Wharton
Wilson
De Witt
Jackson
Karnes
Goliad
La Salle
McMullen Live Oak
Calhoun
Bee
Refugio
Aransas
San Patricio
Webb
Duval
Jim Wells
Nueces
Kleberg
Source: Texas Department of Rural Affairs, August
2010
Matagorda
Victoria
Maverick
Dimmit
Zapata
Jim Hogg
Brooks
Kenedy
Starr
Hidalgo
Jefferson
Harris
Colorado
Guadalupe
Frio
Orange
Waller
Bexar
Atascosa
JasperNewton
Hardin
Montgomery
Washington
Tyler
San Jacinto
Grimes
Bastrop
Hays
Comal
Polk
Walker
Brazos
Williamson
San Augustine
Sabine
Angelina
Houston
Leon
Falls
Burleson
Zavala
Nacogdoches
Limestone
Bell
Kendall
Panola
Shelby
Freestone
McLennan
Llano
Harrison
Anderson Cherokee
Coryell
Kerr
Uvalde
Rusk
Navarro
Hill
Bosque
Lampasas
San Saba
Gregg
Cass
Marion
Smith
Ellis
Hamilton
Gillespie
Kinney
Bowie
Titus
Hopkins Franklin
Morris
Camp
Rains
Wood
Upshur
Hunt
Dallas
Kimble
Real
Red River
Kaufman Van Zandt
C
on
McCulloch
ch
o
Menard
Edwards
Val Verde
Collin
Johnson
Eastland
Terrell
Presidio
Lamar
Fannin
Rockwall
Tarrant
Parker
Hood
Mason
Sutton
Brewster
Jack
Stephens
Coleman
Crockett
Grayson
Delta
Comanche
Runnels
Cooke
Mills
Pecos
Jeff Davis
Sh
ack
elfo
rd
Callahan
Montague
A
r
c
h
Young
e
r
Haskell Throckmorton
Jones
Nolan
Baylor
Willacy
Cameron
Brazoria
Dentists in Rural Counties
Presidio, TX
ACCESS
Hospital: 0
Population: 4167
Clinics: 1
Medicaid Enrolled: 705
(nearest 85mi.)
Physicians: 1
Nurses: 2
P.A.s: .5
El Paso to Lubbock:
343 mi. / 7 hrs.
Presidio to Lubbock:
398 mi. / 7.5 hrs.
We know a need exists
If we can dream it – we can do it!
Could healthcare be better?
• If it were available anywhere at anytime to anyone
• Costs were reduced and outcomes improved
• Practitioners could consult with experts and each
other anytime and anywhere
• Chronically ill and homebound patients could be
monitored remotely 24/7/365
• Preventive care could be integrated into work, home,
school, or any environment
With Telemedicine it is possible!
What is Telemedicine?
American Telemedicine Association
• It the use of medical information exchanged from one site
to another via electronic communications to improve
patients’ health status.
• It has evolved to telehealth to incorporate health
education, prevention and anticipatory guidance that does
not always involve clinical services
• It may include videoconferencing, transmission of
images, e-health, m-health, patient portals, remote
monitoring of clinical information, etc.
• It is not a separate medical specialty!
Three Links to Effective Telemedicine
How can Telehealth/Telemedicine
be used?
“Shrinking the distance”
•Medically underserved rural
areas
•
Increasing access
•Health professions shortage areas
•
Bridging the gaps
•
Serving the needs
•Saves travel time / increases
convenience
“Care closest to home”
•Lowers costs
•Aging & chronic conditions
•Special populations (Prisons)
•Disaster response & relief efforts
•Refocus on prevention, teambased community-centric care
How it Works
• Video conference system (SF & RT)
• Various medical peripherals (heart rate, blood
pressure, ekg, dematomes, otoscopes, etc.)
• Connectivity (High-speed T-1 phone lines,
DSL, Wireless, Satellite, Cloud, etc.)
• Consultant – physician or specialists
• Presenter – in Texas any certified healthcare
provider working within the scope of their
license
Telemedicine Components
• Equipment standardization
• Peripherals
•
•

Otoscope
General Exam Camera
•
Dermatology
•
Burn Care
•
Wound Care
Stethoscope
Color
Printer
Telemedicine Components
Digital - Electronic Stethoscope
General Exam Camera
Fiber Optic Otoscope
Electrocardiogram (ECG)
Emerging Technology Applications
Service Lines
•Burn/Wound Care
•
Cardiology
•Dermatology
•Genetics
•Infectious Disease
•Mental Health
•
Endocrinology
•
Geriatrics
•
Internal Medicine
•
Nephrology
•
Oncology/Hematology
•
Pharmacy
•Primary Care
•
Pulmonology
•Pulmonology
•
Urology
•Neurology
•Nutritional
•Orthopedics
Telemedicine Philosophy
• Telemedicine does not alter the practice of
medicine.
• It is only a tool.
Telemedicine Access
Response to:
• Fewer physicians in rural/frontier communities
• Fewer specialists throughout region
• Technology advancements
• Changes to state rules
• Services w/out taking too much time off from work/school
• Reduces escalating (spiking) personal travel costs
• Another way to see a health care professional; comparable to face-to-face
care…
• Meeting increasing need for specialties due to increasing chronic illnesses
(diabetes, obesity, psychiatric, geriatric, cognitive…)
• Expand benefits that health services bring to rural and frontier
communities
• …and patients like telemedicine
Benefits to Using Telemedicine
• Improved access to specialty services and care – “care closest to
home”
• High patient satisfaction –
• improved access,
• reduced travel costs (mileage and travel time)
• reduced time away from home/school/work
• Improved patient outcomes – earlier interventions, reduced
complications, consistent use of evidenced based medicine
• Healthy People/Healthy Communities - better relationships with
rural communities – create, improve and maintain local access to
appropriate high quality care
Challenges/Barriers to
Telemedicine
• Keeping up with changes in technology
• Investment in equipment and training
• Credentialing/licensing (especially across state lines)
• Limits on reimbursement from insurance companies,
Medicare, Medicaid
• Connectivity issues
• Regulatory Restrictions
• Systems implementation and interoperability
• End user adoption and training
Critical Steps to Implementation
• Community Assessment – in person
• Be clear on goals – what are you trying to achieve?
• Identify a telemedicine team – find champions
• Determine how telemedicine will fit into the
organizational structure
• Develop a plan for educating and training
• Continually educate senior leadership, medical staff,
community and state leaders, on performance and
advances
Treat Telemedicine The Same As
Any Other Practice of Medicine
• Apply same protocols, techniques, standards
and style
• Treat patient in the same manner as if they
were presented in the same room
Licensure
• State licensing – does not require a different
license
• Physician must be licensed in the same state
the patient is located
• Federal licensing proposal
Telemedicine Credentialing and
Privileging Requirements
• If seeing patients in a hospital setting must
be credentialed with facility as if seeing
the patient in person
• New CMS rule, which applies to all hospitals that participate in
Medicare, and inpatients at critical access hospitals, upholds
The Joint Commission's current practice of allowing the
hospital or CAH to utilize information from the distant-site
hospital or other accredited telemedicine entity when making
credentialing or privileging decisions for the distant-site
physicians and practitioners.
Effective July 5, 2011
Confidentiality and Consent Forms
• Employee confidentiality forms
• Patient consent to treatment form – same as if
being seen face to face
• Release of medical records forms
Telemedicine Reimbursement
•Medicare
•Medicaid
•Third-Party
•Private Pay
Medicare
Eligible areas include:
• Health Professional Shortage Area (HPSA)
• County that is not included in metropolitan statistical area (MSA)
Eligible sites include:
• Office of physician or practitioner
• Critical access hospital (CAH)
• Rural health clinic (RHC)
• Federally qualified health clinic (FQHC)
• Hospital
• Skilled nursing facility (SNF)
• Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
• Community mental health center (CMHC)
Medicare
Practitioner who may bill:
• Physician
• Nurse practitioner (NP)
• Physician assistant (PA)
• Nurse midwife
• Clinical nurse specialist (CNS)
• Clinical psychologist (CP) and clinical social workers (CSW)
(CPs and CSWs cannot bill for psychotherapy services that
include medical evaluation and management services under
Medicare. These practitioners may not bill or receive
payment for Current Procedural Terminology (CPT) codes
90805, 90807, and 90809)
• Registered dietitians or nutrition professionals
Medicare – Eligible Medical Services
• Office or other outpatient visits (99201-99215)
• Individual psychotherapy (90804-90809)
• Pharmacologic management (90862)
• Psychiatric diagnostic interview examination (90801)
• End stage renal disease related services included in the monthly
capitation payment (90951, 90952, 90954, 90955, 90957, 90958,
90960 and 90961)
• Individual Medical Nutritional Therapy (G0270, and 9780297804)
• Individual and group diabetes self-management training services
(G0108-G0109)
• Neurobehavioral status examination (96116)
Medicare – Eligible Medical
Services
• Individual and group health and behavior assessment and
•
•
•
•
•
•
intervention (96150-96154)
Follow-up inpatient Telehealth consultations (G0406, G0407
and G0408)
Emergency department or initial inpatient telehealth
consultations in hospitals and SNFs (G0425-G0427)
Subsequent hospital care services (but not more frequently
than once every 3 days) (99231-99233)
Subsequent nursing facility care services (but not more
frequently than once every 30 days) (99307-99310)
Individual and group kidney disease education services
(G0420-G0421)
Smoking cessation services (99406-99407, G0436-G0437)
Medicare – New for 2013
• 7/30/12 Proposed Rule to add two codes for “alcohol
and/or substance abuse (other than tobacco)
structured screening (e.g. AUDIT, DAST) and
intervention services”
•
•
•
(G-0396 – 15-30,
G0397 – more than 30 minutes)
(NOTE: not screening services but as part of diagnosis or treatment of an
illness or injury)
• Preventive Services added in 2012 now available.
•
•
•
•
•
G0442-G0443. Annual alcohol misuse screening and counseling,
G0444 Annual depression screening,
G0445 Screening for sexually transmitted infections and counseling,
G0446 Intensive behavioral therapy for cardiovascular disease
G0447 Intensive behavioral therapy for obesity
Medicare
Distant site physicians and practitioners submit
claims for Telehealth services using the
appropriate CPT or HCPCS code for the
professional service along with the Telehealth
modifier GT, “via interactive audio and video
telecommunications system.
Medicare
Originating sites are paid an originating site
facility fee HCPCS Code Q3014. The
originating site facility fee is a separately
billable Part B payment.
Current fee is $24.24
Telemedicine Reimbursement
Medicaid
35 States Reimburse for Telemedicine
Alabama, Alaska, Arizona, Arkansas, California,
Colorado, Georgia, Hawaii, Illinois, Indiana, Iowa,
Kansas, Kentucky, Louisiana, Maine, Michigan,
Minnesota, Missouri, Montana, Nebraska, Nevada,
North Carolina, North Dakota, Oklahoma, Oregon,
South Carolina, South Dakota, Tennessee, Texas,
Utah, Virginia, Washington, West Virginia,
Wisconsin, Wyoming
Texas Medicaid Reimbursement
Current Texas Medicaid
• Started reimbursing in 1998
• One of the first states in the country
• Must be “face to face” interactive video, no
store and forward, except for Tele-radiology
• Patient site bills for a facility fee –
• Code Q3014
• Must use GT modifier, indicating it was a
telemedicine visit
Texas Medicaid Reimbursement
•Eligible areas include:
•Rural county – less than 50K
•Medically Underserved Area (MUA) or Medically Underserved Population
(MUP)
• Patient Site Location
•State hospital
•State school
•Physician office
•Hospital
•Rural Health Clinic (RHC)
•Federally Qualified Health Center (FQHC)
•Intermediate care facility for persons with mental retardation (ICF/MR) that is
not a state school
•Community Center as defined in Health and Safety Code  534.001 or outreach
site associated with a community center
•Local health department
Texas Medicaid Reimbursement
•Patient site presenter:
•
Licensed or certified in this state to perform health care services
•
Qualified mental health professional (QMHP)
• Eligible Medical Services
•
•
•
•
•
Consultations
Office or other outpatient visits
Psychiatric diagnostic interview
Pharmacologic management
Psychotherapy
Private Payers
• States with government mandated legislation
•
California, Colorado, Georgia, Hawaii, Kentucky, Louisiana,
Maine, New Hampshire, Oklahoma, Oregon, Texas, Virginia
• All prohibit payers from excluding services
solely because they are delivered via
telemedicine
Private Payers Providers
Texas Insurance Code (Chapter 1455) generally
requires health care coverage providers to treat
telemedicine consults as if they had occurred in a
face-to-face environment.
JUST BILL THEM
Self Pay
Patients are billed at a discounted rate similar
to what they would be billed if seen in person
TexLa Telehealth Resource Center
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 15 TRCs which
include 12 Regional Centers, all with different
strengths and regional expertise, and 3 National
Centers which focus on areas of technology
assessment, telehealth policy and technical assistance
regarding State policies affecting the use and
deployment of telehealth services.
What does a TRC do?
TRC’s provide technical assistance to health care
organizations, health care networks, and health
care providers in the implementation of costeffective telehealth programs to serve rural and
medically underserved areas and populations
TexLa TRC
Primary Objectives
To provide telehealth technical assistance and resources to new and existing
telehealth programs throughout Texas and Louisiana
To evaluate telehealth programs in Texas and Louisiana for effective delivery
of telehealth services, efficiency, sustainability, and patient satisfaction
To develop an interactive hands-on training center to provide guidance in
telehealth planning, implementation, management and sustainability
To educate policy makers about legislative and regulatory barriers to the use of
telehealth in Texas and Louisiana and work to improve reimbursement for
telehealth services with CMS and third party payors
To collaborate with other regional TRCs to share resources as well as lessons
learned to help promote best practices in telehealth across the United States
Project Oversight
PI – Billy U. Philips, PhD, M.P.H



Executive Vice President and Director
The F. Marie Hall Institute for Rural and Community Health
Texas Tech University Health Sciences Center
Co-PI – John Griswold, M.D, F.A.C.S



Professor and Chairman,
Department of Surgery
Texas Tech University Health Sciences Center
Project Director – Debbie Voyles, M.B.A, H.O.M


Director of Telemedicine
The F. Marie Hall Institute for Rural and Community Health
Site Coordinator, LSU – Ted Lambert



Telemedicine Program Coordinator
Medical Informatics and Telemedicine
Louisiana State University, Health Care Services Division
Funding for Project
This project was made possible by grant number
G22RH24748 from the Office for the
Advancement of Telehealth, Health Resources
and Services Administration, DHHS.
Texas Tech Telemedicine
Q&A
Contact information:
Debbie Voyles, MBA, HOM
TTUHSC Telemedicine
debbie.voyles@ttuhsc.edu
806-743-4440