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In Partnership

This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. This material is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment. 12SOW-QIN-QIN-04/29/20-3676

© 2020, Telligen, Inc.

Pamela Ballou-Nelson, RN, MSPH, CMPE, PhD Health Care Consulting Inc.

Kellyn A Pearson, RN, MSN Learning Community Manager Department of Family Medicine

Jennifer Halfacre, Health Care Program Manager / CHITADepartment of Family Medicine | Practice Innovation Program at University of Colorado

TelehealthPath to Implementation COVID-19 and Beyond

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Disclaimers

• Today’s content and answers to participants’ questions reflect Telligen’s best understanding based on currently available information about COVID-19 as of Monday, May 11, 2020.

• However, COVID-19 is an emerging, rapidly evolving situation. Therefore, it remains critically important to continually check the CDC’s most up-to-date guidance, as well as the guidance from your state/local health department. CDC guidance for COVID-19 may be adapted by state and local health departments to respond to rapidly changing local circumstances.

• Colorado: https://www.colorado.gov/cdphe• Illinois: http://www.dph.illinois.gov/• Iowa: https://idph.iowa.gov/• Oklahoma: https://www.ok.gov/health/

• The views expressed by the speaker do not necessarily reflect the views of Telligen or The Centers for Medicare & Medicaid Services. Presentation content is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment.

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What word comes to mind when you think of virtual learning?

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Path to implementing virtual health through telehealth: • Identifying a need• Benefits of telemedicine • Preparing the team• Defining success• Evaluating the vendor• Designing the workflow • Implementation • Partnering with the patient• Evaluating success• Resources

Objectives

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• Before embarking into telemedicine, it’s important to understand why you want to pursue it and to outline specific goals and objectives for the service. Then you will be in a good position to address how it should be implemented for maximal benefit.

• Importantly, you should have a vision about the value it can bring to your practice, not just because of COVID-19 but beyond.

• Taking the time to answer these preliminary questions will inform other decisions you make during implementation and will serve as a guide to you and your staff.

• The goal is to be interested in making telehealth a sustaining feature of your practice. Yes or No?

Identify the Need

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• Flexible schedule: With telehealth you can have secure, real-time two-way communication with your patients anytime and anywhere. You can conduct sessions during times that best fit your schedule (and your patients). You do not have to be confined to a 9-to-5 schedule if it does not fit your lifestyle

• Convenience: You can provide your services from your office, your home, or even while traveling. With telehealth you are no longer constrained by your physical location, you can easily connect with your patients as long as you have an internet connection and a camera

• Greater access: Telehealth can make health services more accessible and convenient—increasing health treatment outcomes

• Patients may also seek care earlier if they have the option to get help without leaving their homes

• Additionally, telehealth also gives rural patients and patients with limited mobility increased access to healthcare they may not have had access to otherwise

• Increased income: Telehealth gives you the opportunity to offer additional hours in which you may be available

• Improved quality: Countless studies over the last decade have consistently shown that telehealth provides quality of care that is on par with traditional in-person services.

Benefits

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• Check with your malpractice insurance carrier to ensure your policy covers telemedicine before you proceed.

• Form a small team with at least one clinical person and one non-clinical person to lead the decision making.

• Determine your budget and factor in fees for one-time purchases as well as ongoing maintenance, upgrades and refreshes.

• Discuss “must have” features and “nice to have” features. • Conduct mock telehealth services video to determine gaps.

Prepare the Team

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• What does success look like for you?• What are your barriers to your success?• What data will you collect to measure success?• Does you practice have shared leadership to realize and

support your idea of success?

Define Success

Technology

Evaluate the Vendors

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• During the COVID-19 emergency, you can use any mobile computing device or technology such as a smart phone, tablet or laptop that has audio and video capabilities for two-way real-time interactive communication. Examples include FaceTime, Skype, Google Hangouts video and Zoom.

• HIPAA violation penalties will be waived when this technology is used as long as providers exercise good faith. You must ensure the technology is secure; therefore, applications on public platforms such as Facebook Live, Twitch and TikTok cannot be used.

• Telehealth technology platforms offered by IT and EHR vendors can also be used, but there may be fees involved.

Evaluating the Vendor

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Post COVID-19 Public Health Emergency Consider

Evaluating the Vendor

• If you have an electronic health record (EHR), contact your vendor to see if they offer telehealth functionality.

• If considering commercial telehealth technology, research and compare each platform’s capabilities and costs and analyze how each fits into your business plan.

• Consider asking peers or medical associations for recommendations. Inquire if the vendor will provide timely technical support when needed.

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Zoom seems to be a good fit for many practices at this time due to simplicity, pricing structure ($200/month for 10 users), and the fact that it is an established company with presumed ability to scale their technical infrastructure. Zoom offers more of a video-conferencing product, rather than a true telehealth platform. Workflow for some items such as patient consent will need to be addressed. It is worth considering a product developed specifically for telehealth if practices are looking into a long-term telehealth solution. Doxy.me and Spruce Health are smaller but more healthcare specific platforms that are still affordable ($50/provider/month). Some advantages over Zoom for these platforms include credit card processing via Stripe, online consent forms prior to visit, and basic waiting room/queuing capabilities. SnapMD is a very established healthcare specific platform with great reviews, proven reliability, and a ton of functionality. a. Price is higher than other options due to expansive functionality but would be worth consideration for a practice wanting to put forth a full effort toward telehealth.

Vendor Selection

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Vendor Selection

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Vendor Selection

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Vendor Link

• eVisit 2.0 is the next version of the eVisit Virtual Care Platform. It’s highly configurable and incredibly simple to use.

• I like this site. It gives you the names, price and information about each platform.

• https://www.softwareadvice.com/telemedicine/

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Computer, phone or tablet with internally integrated speaker, microphone, and camera

Headphones (if your device does not have high quality speakers integrated or if you want more privacy)

Ensure you have access to a high-speed internet connection. Use Google’s speed test to test the quality of your internet. If either your download or upload speed is below 3 Mbps, you should consider upgrading your internet connection. Additionally, before your session, close all other browsers and applications to ensure a better connection.

Although Wifi is compatible with most telehealth platforms, when possible we recommend using a wired Ethernet connection instead of using Wifi. Wired internet provides a better connection that is more stable. If your computer does not have an ethernet port, you can purchase this ethernet adapter to switch to a wired connection.

Technology Checklist

Designing Workflow

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• Who is my patient?• Know your patient populations • Can you identify your high-risk patients? • Explain how you notify patients, when it is time to be seen • Explain your care management services for your high-risk

patients

Designing the Workflow

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• Decide if you want to offer scheduled visits, virtual “walk-in” hours or both.Services normally provided in-person can be provided via telehealth during the COVID-19 emergency. This includes common office visits, mental health counseling and preventive health screenings.

• Create an office policy that includes: – Triage protocol: A list of medical conditions, complaints and visits that you

agree are amenable to telehealth – A process to identify patients with chronic conditions so that you can offer

telehealth appointments to ensure there is not a lapse in their healthcare needs

• Guidelines on appointment length (for example: initially schedule 20-30 minutes per telehealth visit to work out technology issues, then decrease time as everyone gains experience)

• A process to refill prescriptions• A process for referrals

Designing the Workflow

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Setting your Schedule • Consider grouping your telehealth visits in a block. The workflow

associated with a telehealth visit is different than seeing a patient in the office.

• You should adjust your schedule accordingly to group telehealth visits. This will enable your staff to assist you so that the logistical aspects of the encounter are properly distributed to your office staff.

• Consider the time block required and the optimal times to meet with patients remotely – both from your perspective and the patient’s. Grouping telehealth visits together can increase efficiency when they are your sole focus during that time.

Designing the Workflow

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• Many Medicare beneficiaries do not have a smart phone or computer or know how to use one effectively. If patients are unable to obtain assistance from a family member, neighbor or friend to use audio and video technology, then other methods of virtual healthcare can be used:

• Virtual Check-in: A patient can contact you by telephone, text, e-mail or the patient portal to discuss whether an office visit is necessary.

• You can remotely evaluate a recorded video and/or image if provided one.• The medical issue discussed cannot be related to a visit within the

previous 7 days or lead to a visit within the next 24 hours (or first available appointment).

• During the COVID-19 emergency, this service can be provided to both new and established Medicare patients.

• E-Visit: An established patient can contact you via the patient portal. The e-visit covers communication during a 7-day period.

What if my patients don’t have a computer or smart phone?

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• CMS is waiving the video requirement for certain telephone evaluation and management services and adding them to the list of Medicare telehealth services. As a result, Medicare beneficiaries will be able to use an audio-only telephone to get these services.

• This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.

Telephone Visits Billing -Medicare

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• CMS is increasing payment for audio-only telephone E/M services (CPT codes 99441-99443) such that they are paid at the same rate as similar office and outpatient E/M visits, resulting in increased payments from $14-$41 to $46-$110.

• CMS believes that the resources required to furnish these services during the PHE are better captured by RVUs associated with level 2-4 established office/outpatient E/M visits.

• CMS is not increasing payment for CPT codes 98966-98968, which are intended for practitioners that cannot separately bill for E/M.

• This policy is retroactive to March 1, 2020.• For telehealth services other than CPT codes 99441-99443 and 98966-98968 (now

added to the list of covered telehealth services), Medicare continues to require modalities that have both audio and video capabilities.

• CMS is forgoing its typical rulemaking process to add new services to the list of Medicare services that may be furnished via telehealth. Instead, CMS will add new telehealth services on a sub-regulatory basis to speed up the process of adding codes to the list.

May 1 Update: Telephone Codes

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Payment Updates

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• Pre-Session Prep• Prepare yourself: Test out your telehealth platform before your first

appointment, to ensure your devices and connection are ready to have a smooth teletherapy session. Send a practice link to a friend and ask them to hop on quickly so you know what the process looks like. This also allows you to make sure all of your equipment is working properly and lets you catch any problems before your real appointment.

• Prepare your client: Inform your client about what they should expect during their telehealth session. Let them know what platform you will be using to conduct your sessions and inform them ahead of time if they need to download any additional applications.

Designing the Workflow

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• Privacy: Select a space for your online therapy sessions that is private and free of distractions. You want to make sure that no one else can hear the conversation between you and your client.

• Noise Level: Ensure that there are no noises that could be distracting to you or the client during your session. This includes doorbells, noises from outside, TVs, radios, and other conversations.

• Visual Distractions: Your background in the camera should be free of all clutter. We recommend having a neutral colored wall, so it does not distract your client.

• Lighting: Try to maintain a consistent light source throughout your online therapy session. Avoid having light sources behind you as this can cause your face to be shadowed. Make sure your face is fully lit and in the frame during your session. We recommend placing lights around the room or ensuring you have good natural light in your space. Try to keep windows and curtains closed if they are behind you, both to ensure you have consistent lighting and also to protect the privacy of your clients. Check out this lighting guide for more details.

Designing the Workflow

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• Clothing: Even though you may not be leaving your home, dressing professionally during your telehealth sessions is important. Wear clothing that is in contrast with your background but try to avoid patterns because they can be visually distracting and cause eye strain for your clients.

• Eye Contact: Maintaining eye contact during your online sessions is imperative. You want your client to feel as if they have your full attention. Avoid doing other work, looking at other screens, or taking notes for long periods of time. It can be distracting, and even unnerving, for your clients if they see you constantly looking away. Be mindful of your eye contact and explain to your clients why you are looking away when it is necessary.

Designing the Workflow

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• Consent Documents: Whether you need to provide your clients with consent documentation or not depends on your state regulations. Some states do not require any consent documentation, while others require verbal or written consent.

• During COVID-19 verbal consent documented in the chart is all you need.

Designing the Workflow

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• Documentation: Same as if visit was face-to-face• Documentation Guidelines and key components of

E/M Services:S Level of HistoryO Level of Exam A P Level of Decision Making

Level of Service

Designing the Workflow

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Back-up plan• Create a plan when there are technical difficulties and you are

unable to use audio and video during the scheduled time. One option is to have a telephone call, which is covered by Medicare during the COVID-19 emergency.

• If multiple clinicians are in the office providing telehealth services simultaneously, it may exceed your office’s Internet or Wifi capabilities, which degrades the quality of the video. Consider having some clinicians provide telehealth from their home.

Designing the Workflow

Telehealth

Implementation

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Implementation

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Implementing the Visit

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• Collect co-payment (if applicable). This is waived for Medicare patients during the COVID-19 emergency.

• Ask patient the reason for the visit and enter the chief complaint in EHR.

• Ask patient if they took their temperature, BP, pulse or weight prior to visit and if so, document.

• Review medications. • Notify clinician that patient is ready to be seen.

Implementing the Visit

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• MA/nurse will tell clinician when the patient is ready. • Review the patient’s complaint and medical record, then

begin the clinical portion of the visit. • Provide care as you would during an office visit. Based on the

patient’s complaint, assess to see if they look ill, appear to be in pain, have labored breathing or have a physical issue they can show you, such as swollen feet, a contusion, a rash, etc.

• Determine if a face-to-face office visit is warranted based on observations. If not, continue with the visit.

Implement Visit Workflow Clinician

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• Complete documentation, including orders, updating the care plan and charges.

• Include location of patient and clinician during the visit: “Virtual visit completed by clinician located in office and patient located in their home.”

• Include wording to note technology used and limitations: “History reviewed and examined patient with limitations acknowledged due to nature of virtual visit through a synchronous telecommunications system.”

• Include wording about follow-up: “Discussed circumstances under which a face-to-face office visit would be appropriate versus a telehealth visit.”

• Verbalize and clarify next steps, such as if a follow-up appointment is necessary and review care plan and prescription orders.

• Notify administrative staff/nurse when finished so they can check the patient out.

Implement Visit Workflow

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• Clinical staff schedule follow-up appointment if appropriate (office or telehealth).

• Check patient out.• Send patient a visit summary. • Consider sending a feedback survey so you can improve your

telehealth process.

Implement Visit Workflow

Telehealth

Partner with the Patient

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Partner with Patient

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Partner with Patient

Ask patient to write down the questions that they have for the provider or nurse ahead of time.

Ask them to have all of their medications with them.

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Script for Patients Who Want to Cancel Their Routine Appointment Due to COVID-19 (Not Routine Physicals)

Scripts

• Patient: Due to COVID-19, I want to cancel my appointment.• PIM: Yes Ma’am/Sir. I understand your concerns. Let me

change your appointment to telemedicine and walk you through getting access to this program so that you do not have to come in the office.

• Patient: Great! Thank you!

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Script for Patient Who Want to Cancel Their AWV

Scripts

• Patient: Hello, I am in the high-risk category for COVID-19. I think it is best I reschedule my Medicare AWV.

• PIM: Yes Ma’am/Sir. I understand your concerns. In that case, we need to schedule you for a telemed appointment in order for your physician check in with you to continue to refill your medications. When would you be available? We will reschedule the complete physical for a different day.

• Patient: I feel fine. I do not need to have the AWV portion right now.• PIM: Mr./Ms. Patient, I totally understand your concerns. However, this current

environment is not a time to put your healthcare on hold. Your doctor wants to touch base with you at the very least and refill your medications until he/she is able to see you in the office. Let me get you scheduled to speak with him/her or our PA or NP so we can be proactive about your health.”

• Patient: Okay, please walk me through what I need to do to proceed with an AWV telemedicine appointment.

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Script for Patients Who Wants to Cancel Their Routine Physical

Scripts

• Patient: I need to cancel my routine physical until this whole COVID-19 situation blows over.

• PIM: Mr./Ms. Patient, I totally understand your concerns. However, this current environment is not a time to put your healthcare on hold. Your doctor wants to touch base with you at the very least and refill your medications until he/she is able to see you in the office. Let me get you scheduled to speak with him/her or our PA or NP so we can be proactive about your health.

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• It is critical during this stressful time to check on the well being of families and children.

• Parental depression screening for moms with infants. Depression screening in children as well.

• You want to continue to provide young patients with timely immunizations well visits and check ins for mental health. Therefore, continue to offer well care and immunizations for children 5 and under, as well as immunizations for 11-year-olds. Offer virtual visits for adolescents.

Wellness

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• Face-to-face well visits and vaccines should be scheduled for 3-day, 2-week, 2-month, 4-month, 6-month, 12-month or 18-month-old and children up to age 5. If families have concerns about this care or want to delay their visit, they are encouraged to schedule a telephone or virtual visit with their child’s Primary Care provider (PCP).

• Depression screening for caregiver should continue.• Questions about and assistance for families with food and

other social needs should receive community outreach/referrals.

Pediatric Wellness

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Site Visits

Site Visits

Provide masks for family members and children entering any medical office, as a way to protect both sick and well patients.

Limit the number of adults and children coming to the visit. For pediatrics, one adult with a child in the exam room, no other children, not being seen, should come to the visit.

Spread out appointments based on your waiting room space to maintain 6 feet separation.

Curbside visits not telehealth codes

Measuring Success

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• It should be understood by everyone that it takes commitment to do things differently.

• Ask for and seek staff and patient support.• Time otherwise spent in delivering care prior to COVID-19

now can be focused on building the systems and processes that will enable more efficient care delivery in the future.

Measuring Success

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• Data collected – Number of visits via telehealth – Staff satisfaction – Patient satisfaction – Reimbursement

Measuring Success

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Action Plan

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Thank you!

• Action Plan give us some examples

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How useful was today’s session for you?a. Extremely usefulb. Usefulc. Moderately usefuld. Somewhat usefule. Not useful

Poll

Chat In What is one thing you will try this week, as a result of this session?

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How satisfied are you with today’s session? a. Extremely satisfiedb. Satisfiedc. Moderately satisfiedd. Somewhat satisfiede. Not satisfied

Poll

Chat In What do you need us to cover in upcoming sessions to help you?

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Bring your questions about this series!

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• Tips for keeping your practice in business during the COVID-19 pandemic: https://www.ama-assn.org/delivering-care/public-health/tips-keeping-your-practice-business-during-covid-19-pandemic

• COVID-19 State of Emergency Changes to Telemedicine Services for Medicaid: https://www.colorado.gov/pacific/hcpf/provider-telemedicine

• Respond to Coronavirus (COVID-19): https://www.aafp.org/patient-care/emergency/2019-coronavirus.html?intcmp=nCoV_car_2019-nCoV_promo_pos1

Resources

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• Relief for Clinicians, Providers, Hospitals and Facilities Participating in Quality Reporting Programs in Response to COVID-19: https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting

• Center for Connected Health Policy/Public Health Institute:https://www.cchpca.org/info@cchpca.org

Resources

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Thank you!