The National Telehealth Webinar Series · E-Consult Workgroup Introduction for NTRC June 15, 2017....

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The National Telehealth Webinar Series June 15, 2017 Presented by The National Consortium of Telehealth Resource Centers

Transcript of The National Telehealth Webinar Series · E-Consult Workgroup Introduction for NTRC June 15, 2017....

Page 1: The National Telehealth Webinar Series · E-Consult Workgroup Introduction for NTRC June 15, 2017. BluePath Health Inc.; Client Proprietary and Business Confidential 27 CCHP and BluePath

The National TelehealthWebinar Series

June 15, 2017

Presented byThe National Consortium ofTelehealth Resource Centers

Page 2: The National Telehealth Webinar Series · E-Consult Workgroup Introduction for NTRC June 15, 2017. BluePath Health Inc.; Client Proprietary and Business Confidential 27 CCHP and BluePath
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Webinar Tips & Notes

• Your phone &/or computer microphone has been muted

• Time is reserved at the end for Q&A

• Please fill out the post-webinar survey

• Webinar is being recorded

• Recordings will be posted to our YouTube Channel https://www.youtube.com/channel/UCOzpvd1OZ221AWBSF3QK-yg

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Moving Knowledge, Not Patients: Re-Thinking the Way Primary Care and Specialists Work Together for Improved Quality, Value, and Patient Experience

Daren Anderson, MD - VP/Chief Quality Officer,

Community Health Center, Inc.

Associate Professor of Medicine, Quinnipiac University, Director, Weitzman Institute

Libby Sagara - Health IT and Management Consultant, BluePath Health

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Moving Knowledge, Not Patients Re-thinking the way primary care and specialists work

together

Daren Anderson, MDDirector, Weitzman Institute

The National Telehealth Webinar SeriesJune 15 , 2017

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Dermatology eConsult

Consultation: 3 months old with severe scalp seborrhea and symmetrically bright red eczematoid cheeks that she scratches, protected by gloves, and generalized body atopy. refer to be seen for management of severe apparent eczema/atopy.

13127250

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Community Health Center, Inc.

Transforming Primary Care at the Community Health Center

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A research and innovation center supporting practice transformation for Safety Net Practices across the country

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Dermatologist Response

Diagnosis: seborrheic dermatitis and atopic dermatitis.

Recommendation:

Scalp: Dermasmoothe FS oil at bedtime under occlusion over night, wash off in the morning, daily for 3 days then 2-3x/week as needed.

Rest of body: Hydrocortisone cream 2.5% BID to all affected area with wet dressing: warm water bath, pat skin dry gently, apply HC 2.5% to affected area, then put on wet warm cotton pajama or towel over, wrap baby with warm dry blankets over, leave it on for 30-45mintutes, then take off wet wraps, apply moisturizer cream (Aveeno, CeraVe, Vanicream, etc.) all over. Start wet wraps daily for 3-5 days, when skin improving, use medicated cream BID while decrease wet wraps to 1-2 x/week as needed.-----------------------------------------------------------------------------------------------------------------------------------

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• 10/19/2016 09:29 AM To: Orthopedist

• 32 yo male w/ ACL tear approx 4 years ago treated w/ steroid injections, and several rounds of PT, but never fully improved. XR shows tricompartmentalarthritis. Pt perseverative on getting an MRI now and deeply concerned about need for surgical consult. Reluctant to re-engage with PT until after orthopedic consult. Please review XR and consult on appropriate next steps for imaging and/or therapies. Thank you!

• 10/19/2016 11:13 AM Orthopedist To: 32 year old gentleman with a left knee deficient ACl. It is well known that with the lost of an ACl 4 years ago this candidate may not be suitable for surgical reconstruction. We know well that loosing an ACL will create rotational instsbility specially on the lateral aspect of the knee joint. It is now too late to have any ACL reconstruction. Arthroscopic debridement can be helpful for a while but will not remove the instability.

• There is not really a need to have a MRI since it is well known that there is a deficient ACL knee and it is expected that early DJD will set up but if there is any mechanical locking MRI can be usefull to check further meniscal injury. Otherwise Quad and Hamstring rehabilitation remain the key for improving knee fucntion.

• Good Luck

Orthopedic eConsult

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Target population• Primary Care Providers:

PhysiciansNurse Practitioners/PAs

• Providers EXCLUDED from the study:Pediatric OnlyPart-time

Study Design • Prospective, randomized controlled intervention trial• Blocked randomization• One-year intervention• Clinical, demographic, and utilization data for patients - at

baseline, during the intervention, and for six months after the intervention. Pre/post providers’ perceptions

CHC-UCONN Cardiology eConsult Trial

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eConsults

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Clinical End Points

Intervention Control

TotalN=229

Traditional Pathway N=109

eConsults PathwayN=120

N=361

no. (%) no. (%)

Death from any Cause 0 0 0 1 (0.3)

Death from Cardiovascular Causes 0 0 0 0

Myocardial Infarction 0 0 0 0

Coronary Artery Bypass Surgery 0 0 0 0

Catheterization with Stenting or Angioplasty 3 (1.3) 1 (0.9) 2 (1.7) 2 (0.6)

Diagnostic Catheterization 1 (0.4) 1 (0.9) 0 6 (1.7)

ED Visits with Possible Cardiac Symptoms* 4 (1.7) 3 (2.8) 1 (0.8) 21 (5.8)

Hospitalization for Arrhythmia 2 (0.9) 2 (1.8) 0 5 (1.4)

Hospitalization for Atypical Chest Pain 6 (2.6) 4 (3.7) 2 (1.7) 10 (2.8)

Hospitalization for Syncope or Near Syncope 0 0 0 4 (1.1)

Hospitalization for Congestive Heart Failure 2 (0.9) 1 (0.9) 1 (0.8) 0

* p= 0.02 for ED Visits with Possible Cardiac Symptom. No other end points were statistically different.

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Key lesson: eConsults Achieve theQuadruple Aim

1. Improved outcomes

2. Reduced Cost

3. Satisfied clinicians

4. More convenient for patients

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Specialty Care: Reducing costs/Improving Access

• Providing a High Value Referral Network and Process

– Link primary care providers with specialists electronically

– Reduce the cost of care and expand scope of primary care

– Reduce utilization of expensive specialty care, testing, procedures

– Evidence-proven short term savings

• Reduce Variation in Treatment Patterns, Improve Assessment, Diagnosis and Care Coordination

– Enhance complex care management

– Increase scope of practice for primary care

– Improve integration of physical and behavioral health Increase access to care for medically underserved members

• Improve Member Experience

– Reduced need for face to face visits

– Increase continuity with primary care/PCMH

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CeCN

Provider EHR

eFax

DirectMessaging

Secureemail

?remote access

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21

CeCN Specialty Network Offerings

Cardiology Rheumatology

Dermatology Pediatric Cardiology

Endocrinology Pediatric Endocrinology

Gastroenterology Pediatric Pulmonary

Nephrology Orthopedics

Neurology Pain Management/Medicine

Adult Psychiatry Child Psychiatry

Adult Behavioral Health Child Behavioral Health

Addiction Medicine Urology

Ophthalmology Retinal Screening

Infectious Disease Travel Medicine

Complex Primary Care

Coming Soon

Transgender care Pediatric neuropsychiatry

Pediatric Neurology ENT

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One year referral rates for approximately 54,000 members

1 Year

Adult

Referrals

1 Year

Adult

eConsults

No F2F

Needed

F2F

Needed

%F2F

Avoided

Total

Consult

Reductio

n

Cardiology 1062 316 288 28 91% 27%

Dermatology 1956 834 636 198 76% 33%

Endocrinology 820 360 316 44 88% 39%

Gastroenterology 2312 320 142 178 44% 6%

Infectious Disease 106 44 30 14 68% 28%

Nephrology 374 148 92 56 62% 25%

Neurology 1252 392 358 34 91% 29%

Orthopedics 2340 654 440 214 67% 19%

Pain Medicine 952 56 56 0 100% 6%

Total 11174 3124 2358 766 75% 21%

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Weitzman ECHO Learning Community

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Using ECHO totackle “Hot Spots”

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Weitzman ECHO/eConsult Learning Network

◎ 207 practices

◎ 591 ECHO sessions

◎ 2,115 case presentations

◎ Primary care providers from 25 states

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Center for Connected Health Policy (CCHP)E-Consult Workgroup Introduction for NTRC

June 15, 2017

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CCHP and BluePath Health work to facilitate the E-Consult Workgroup and support complementary efforts across the state

• Facilitate annual CCHP E-Consult Workshops to further reimbursement discussions among DHCS, MCPs and DPHs

• Work to obtain approval for e-consult CPT codes based on time spent (published in 2014 by California Academy of Family Physicians)

• Work with MCP stakeholders within pilot regions to discuss potential reimbursement of specialist e-consults

• With BSCF pilots and MCPs, share incentive plans to engage PCPs at CHCs/FQHCs

• Emphasize e-consult successes in addressing specialty care timely access requirements following Covered California expansion

eConsult Definition and Incentives Engagement and Collaboration

DHCS and DMHC DPHs CHCs/FQHCs

• Provide opportunities for BSCF pilot DPHs to share best practices in implementing e-consult to optimize Waiver programs and reporting, aligning measures with BSCF pilot requirements

• Facilitate collaboration and participation in CAPH educational events (e.g. PRIME webinars)

• Facilitate FQHCs, BH/MH and social services in pilot regions in pursuing GPP programs, utilizing e-consult as appropriate to meet program goals

• Seek opportunities to engage FQHCs in waiver programs which value alternative (specialty care) touches and avoidable utilization of high-cost health care services

• Follow progress in FQHC APM pilots planned for 2018 to determine how e-consult programs can be incorporated

MCPs

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California’s reimbursement for store and forward telehealth services

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Organizations participating in CCHP E-Consult WorkgroupOrganization Name

AARP Julie Bates

Alameda Health System Evan Seevak

Blue Shield of California Foundation Rachel Wick

California Department of Health Care Services Neal Kohatsu

California Health & Wellness/Health Net Greg Buchert

California Health Care Foundation Chris Perrone

California Medical Association Lishaun Francis

California Primary Care Association Mike Witte

California State Rural Health Association Christine Martin

CAPH/Safety Net Institute David Lown

Central California Alliance for Health Elizabeth Murphy

The Children’s Partnership Liliana Velazquez

Colorado State Medicaid JD Belshe

Community Health Center Network Ella Schwartz

Community Health Partnership of Santa Clara County Paul Nguyen

Covered California Allie Mangiaracino

Inland Empire Health Plan Matthew Wray

Kaiser Permanente, CO Ted Palen

LA County Department of Health Services Hal Yee

LA County Department of Health Services Paul Giboney

Local Health Plans of California Caroline Davis

Open Door Community Health Center Bill Hunter

Partnership Health Plan Lyle Smith

San Joaquin Medical Center Jeff Slater

San Mateo Medical Center Carolyn Senger

UC Davis Medical Center Tom Nesbitt

UCSF/Zuckerberg SF General Delphine Tuot

UCSF/Zuckerberg SF General Nwando Olayiwola

Valley Medical Center Kenneth Soda

Weitzman Institute, CHC Inc, CT Kevin Massey

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Workgroup FindingsFrom Statewide Electronic Consult Program Efforts

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Key Tenets of Electronic Consult

E-consult directly impacts patient and provider satisfaction. E-consult related surveys report overwhelming improved satisfaction from both patients and providers.

E-consult is the standard of care. E-consult in no longer in pilot stage. There is a significant experience base that has demonstrated lasting results.

E-consult improves access to specialty care and network adequacy. E-consults optimize face-to-face visits and satisfy specialty access standards. Improved access is demonstrated through:

• Decreased wait times for specialty care

• Decreased repeat appointments

• Decreased no shows

E-consult promotes health homes and builds PCP capacity. Over time, E-consult is shown to expand the ability of the PCP to care for the patient, keeping him/her within the health home.

E-consult is not an electronic referral. E-consult is separate and distinct from an electronic referral. The two processes should not be subject to the same regulatory requirements.

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A standard definition has been accepted for electronic consultation

An electronic consultation is an asynchronous dialogue initiated by a physician or other qualified health care professional seeking a specialist consultant's expert opinion without a face-to-face patient encounter with the consultant.

To capture the service rendered, the specialist will report a code for interprofessional consultation (e.g. 99446). Electronic consults provided by consultative physicians include written report to the patient's treating/requesting physician/qualified health care professional.

(Approved by CA E-Consult Workgroup 2016)

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E-consult programs across California are supporting the safety net

Program Lead Description

Community Health Center Network (CHCN) and Alameda Health System

AHS using EHR to support internal e-consults, partnering with Community Health Center Network (FQHC) who also utilizes a remote specialist network

Community Health Partnership of Santa Clara County

Participating in e-consult exchange with Valley Medical Center serving over 10 specialties

California Health & Wellness

Incorporating e-consult as part of telehealth pilot in 3 counties with selected high demand specialties

Central California Alliance for Health

Beginning pilot with selected PCPs and specialists in Santa Cruz, Monterey and Merced counties

LA Care Health Plan

Following MMC/county MOU, beginning eManagement program for MH/BH (on top of e-consult platform)

Los Angeles Department of Health Services

Los Angeles County CHCs and FQHCs partner with Health Care LA IPA specialists

PartnershipHealth Plan

Partnering with FQHCs with 6 specialties across Humboldt and Marin counties, rolling out in additional counties across the state

USCF/ZuckerbergSF General

eReferral program results in approximately 20% of requests adequately cared for by PCP, and 50% drop in wait time for specialty clinics

Early Pilot/Planning:• Contra Costa RMC• Inland Empire Health Plan• Kern Health System• San Joaquin General• San Mateo Medical Center• Ventura County

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A standard set of CPT codes exists for e-consult

Program Finding Supporting Data

The standard set of e-consult CPT codes mustbe considered by State Medicaid programs

• Referring and consulting clinicians participating in e-consults will use approved CPT codes specific to interprofessional consultation.

• These codes should be incorporated into the list of approved codes for DHCS specialist reimbursement.

*JAM, Effective January 1, 2014

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E-consults are being reimbursed at actuarially-sound rates

Program Finding Supporting Data

MCPs are paying specialists actuarially-sound rates for e-consult which must be acknowledged in Medicaid rate setting

• Pilot programs have demonstrated successes with e-consult, and will report more data over longer periods of time to show eConsult sustainability.

• Reimbursement would require the use of CMS/Medicaid-accepted CPT codes for interprofessional consultation with codes and rates tied to time spent per encounter.

• When fee-for-service rates apply, they are based on a percent of the provider’s face to face hourly Medicare rate, adjusted for electronic consults of up to >10, 10-15, 15-20 and >20 minutes.

Improving Access to Chronic Pain Services Through eConsultation: A Cross-Sectional Study of the Champlain BASE eConsult ServiceClare Liddy MD, MSc, CCFP,FCFPCatherine Smyth MD, MSc, FRCPC

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E-consult supports efforts toward timely access

Program Finding Supporting Data

E-consult supports MCPs in efforts to meet timely access requirements

• Providers are working to meet timely access requirements through use of alternative specialty care touches (e.g. electronic consult) as part of the referral process.

• PCPs can complete eConsults with specialists “within fifteen business days of the request for appointment…” through participating in electronic consultations in which a standard response time of a specialist is 7 calendar days.

Olayiwola, J, Anderson, D et alElectronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically UnderservedAnn Fam Med 2016;14:133-140. doi: 10.1370/afm.1869.

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E-consult supports network adequacy efforts

Program Finding Supporting Data

E-consult allows plans to expandtheir networks of specialists to support network adequacy efforts

• MCPs contract with local specialists who respond to E-Consults as a first step to a referral request. The e-consult may provide the PCP with the advice needed to treat the patient. If a face-to-face visit with the specialist is needed, it will be scheduled according to the patient’s needs.

• In geographical areas where specialists do not exist (within 10 miles or 30 minutes of the member) or do not accept Medicaid patients, the MCP may contract with a remote network of licensed specialists who can offer e-consults when appropriate to address the network adequacy requirement, avoiding unnecessary travel for the member.

• E-consults are used as part of the process of specialty care -- not just as an alternative used when providers have “exhausted all other reasonable options”.

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Gaps exist in financial support for electronic consult programs

Stakeholder Source of Support Current Gaps

FQHC

• GPP

• County Specialty Care Budgets

• WPC

• APM

• APM and WPC pilots are limited. Program will not scale to support additional FQHCs until 2018.

• Incentive payments to PCPs are taken out of the clinic’s PPS rate during reconciliation

ManagedCare Plan

• DHCS

• DMHC

• Contracts do not acknowledge the use of electronic consults as a means of delivering specialty care

• eConsult is not considered a solution to network adequacy and timely access requirements

County

• GPP

• County Specialty Care Budgets

• GPP is a potential funding source for uninsured, yet specialist must be reimbursed at (minimum) Medicare rates

• Works with partners (e.g. LADHS working with CA DSH, community and university providers)

District and Public Hospital

• GPP

• County Specialty Care Budgets

• PRIME payments made based on mid-year and annual reporting of metric target achievement: referral reply turnaround rate, specialty care touches, receipt of specialist report

• GPP incents DPHs to provide non-traditional/technology based services to increase primary and preventive services

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Next Steps

Activate leadership from consumer and payer associations demonstrating support for a potential solution to access to specialty care

Create case studies from mature e-consult programs that are now demonstrating cost savings through avoided unnecessary visits, travel, ED visits, duplicate tests and labs

Obtain examples of e-consult program cost savings from across the country

Share examples at October 2017 CCHP E-Consult Workshop in Sacramento

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The National Telehealth Webinar Series

3rd Thursday of every month

Next Webinar:

Telehealth Topic: Chronic Disease Remote Patient Monitoring Project Presenters: Kim Schwartz and Becky Lundgren – Central Oregon Telehealth Network

Date: Thursday, July 20th

Times: 8:000AM HST, 10:00AM AKDT, 11:00AM PDT, 12:00PM MDT, 1:00PM CDT, 2:00PM EDT

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Your opinion of this webinar is valuable to us.

Please participate in this brief perception survey:

https://www.surveymonkey.com/r/HTT97R9

TRC activity is supported by grants from the Office for the Advancement of Telehealth, Federal Office of Rural Health Policy, Health Resources and Services Administration, DHHS