Nina M. Nina M. AntoniottiAntoniotti, RN, MBA, PhD, RN, MBA, PhDMarshfield Clinic Marshfield Clinic TeleHealthTeleHealth
Thursday, April 13, 2011Thursday, April 13, 2011Washington, D.C.Washington, D.C.
National Conference of National Conference of State LegislatorsState Legislators
““Transforming Health Care Transforming Health Care Through TechnologyThrough Technology””
MARSHFIELD CLINIC
SERVICE AREA
Mission of Provider TeleHealthMission of Provider TeleHealth
To improve access to specialty and To improve access to specialty and primary services for populations with primary services for populations with unmet needs by reducing the burden of unmet needs by reducing the burden of time and distance for the patient; time and distance for the patient;
To improve organizational efficiency and To improve organizational efficiency and effectiveness through reductions in costs effectiveness through reductions in costs of providing care; andof providing care; and
To improve provider access and To improve provider access and communications with patients at a communications with patients at a distancedistance
TELEHEALTHTELEHEALTH
Extends high quality, advanced health Extends high quality, advanced health care electronically to situations in care electronically to situations in
which the physicalwhich the physicalpresence of a provider or consumerpresence of a provider or consumer
is not feasible, practicalis not feasible, practicalor is unnecessary.or is unnecessary.
Mission of Consumer Mission of Consumer TeleHealthTeleHealth
To be patientTo be patient--centriccentric
To reduce the burden of accessTo reduce the burden of access
To reduce out of pocket costsTo reduce out of pocket costs
To assist with changing health To assist with changing health behaviorsbehaviors
To collaborate with primary careTo collaborate with primary care
TeleHealth is a tool for improving TeleHealth is a tool for improving access and attaining quality access and attaining quality metrics that influence and metrics that influence and change population health care change population health care beliefs and behaviors.beliefs and behaviors.
Health Care Provider
Patient and Family
Health Care Relationships
Base TeleHealth On…..
Employer
Payers
Marshfield Clinic TH ServicesMarshfield Clinic TH ServicesAllergyAllergyAudiology Audiology Burn CareBurn CareCardiologyCardiologyCardiovascular SurgeryCardiovascular SurgeryChild PsychiatryChild PsychiatryConcussion ClinicsConcussion ClinicsDentistry Dentistry DermatologyDermatologyDiabetes ManagementDiabetes ManagementDisease ManagementDisease ManagementEndocrinology Endocrinology ENTENTGeriatricsGeriatricsInfectious DiseasesInfectious DiseasesJail Primary CareJail Primary CareMedical GeneticsMedical GeneticsNephrologyNephrology
Mobile Retinal ScreeningMobile Retinal ScreeningNeurology Neurology Seizure, Parkinson, Seizure, Parkinson, GeneralGeneral
Nurse TriageNurse TriageNutrition ServicesNutrition ServicesObstetricsObstetricsOncologyOncologyOrthopedicsOrthopedicsOphthalmologyOphthalmologyPain ManagementPain ManagementPathologyPathologyPediatric NutritionPediatric NutritionPediatric Pediatric
EndocrinologyEndocrinologyPediatric NephrologyPediatric Nephrology
Pediatric Neurology Pediatric Neurology PharmacyPharmacyPlastic SurgeryPlastic SurgeryPrimary CarePrimary CarePsychiatry Psychiatry Pulmonary MedicinePulmonary MedicineResearch StudiesResearch StudiesSkilled CareSkilled CareSleep Studies Sleep Studies Speech PathologySpeech PathologySocial Worker Social Worker
TherapyTherapySupport Groups Support Groups UrologyUrologyWound TherapyWound Therapy
Where is Where is TeleHealthTeleHealth??
Physician Offices/Rural Centers
Skilled Nursing Facilities
Hospitals
Indian Health Centers
Head Start Centers
Clinics
Clinician Offices
Hospitals, SNFs, Outpatient Centers
Clinical Exam TechnologiesClinical Exam Technologies
Patient Exam CameraPatient Exam Camera
Digital Electronic StethoscopeDigital Electronic Stethoscope
FiberFiber--optic optic OtoscopeOtoscope
FiberFiber--optic Ophthalmoscopeoptic Ophthalmoscope
Digital CameraDigital Camera
Document CameraDocument Camera
IntraIntra--oral Cameraoral Camera
Laser Caries DetectorLaser Caries Detector
Computer or NoComputer or No--Computer??Computer??
TelePathologyTelePathology
FormForm--based patient symptom based patient symptom and medical history data captureand medical history data capture
Video and still digital camerasVideo and still digital cameras
Remote controlled microscope with Remote controlled microscope with remote slide viewingremote slide viewing
Digital MicroscopeDigital Microscope
Microscope slide scannerMicroscope slide scanner
Internet connections Internet connections
Mobile Retinal ScreeningMobile Retinal Screening
NonNon--MydriaticMydriatic FundusFundus CameraCamera
Digital Image CaptureDigital Image Capture
Network Archived Similar to PACSNetwork Archived Similar to PACS
Read by Centrally Located Retinal Read by Centrally Located Retinal SurgeonSurgeon
http://visitors.reachmcg.com
TeleStroke Systems
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Sterile Sterile Products Products Pharmacy Pharmacy
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MERCERMERCER
MINOCQUAMINOCQUA
Retail Pharmacy
ICAA ICAA Head StartHead Start
2006 2006 –– 20072007
Oral Health Needs Oral Health Needs of Children and of Children and TeleHealthTeleHealth
Marshfield Clinic Research FoundationMarshfield Clinic Research FoundationNational Farm Medicine CenterNational Farm Medicine CenterBiomedical Informatics Research CenterBiomedical Informatics Research CenterNational ChildrenNational Children’’s Centers Center
North American Guidelines for North American Guidelines for ChildrensChildrens Agricultural Tasks (NAGCA)Agricultural Tasks (NAGCA)
Epidemiology Research CenterEpidemiology Research CenterCenter for Human Genetics Center for Human Genetics Personalized MedicinePersonalized MedicineMarshfield Clinic Education FoundationMarshfield Clinic Education Foundation
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Barriers to TelemedicineBarriers to Telemedicine
PhysiciansPhysicians–– Lack of Lack of reimbursementreimbursement–– Lack of organizational readiness Lack of organizational readiness –– good business good business
planplan–– Broadband costs for private practicesBroadband costs for private practices–– Technology costs Technology costs –– internal infrastructureinternal infrastructure–– Lack of standardsLack of standards–– Lack of Venture Capital and reasonable Lack of Venture Capital and reasonable
transmission coststransmission costs
PatientsPatients–– Lack of access through Lack of access through TeleHealthTeleHealth–– Lack of awarenessLack of awareness
Medicare and Medicaid: Medicare and Medicaid: What Needs to be Done?What Needs to be Done?
1.1. Make all services currently covered by Medicare Make all services currently covered by Medicare eligible for payment if delivered by eligible for payment if delivered by TeleHealthTeleHealth..
2.2. Make all Medicare certified practitioners eligible for Make all Medicare certified practitioners eligible for payment.payment.
3.3. Make all Medicare certified facilities eligible for the Make all Medicare certified facilities eligible for the Medicare facility fee payment.Medicare facility fee payment.
4.4. Delink the facility fee from the practitionerDelink the facility fee from the practitioner’’s s payment.payment.
5.5. Put Put TeleHealthTeleHealth technology costs on the cost reports technology costs on the cost reports as allowable costs.as allowable costs.
6.6. Allow Allow TeleHealthTeleHealth visits in the PPS calculations for visits in the PPS calculations for home health.home health.
7.7. Pay for episodes of remote monitoring when used as Pay for episodes of remote monitoring when used as a part of a comprehensive health team approach to a part of a comprehensive health team approach to chronic conditions. chronic conditions.
How can the Federal Government be used to How can the Federal Government be used to spur broadband investment in telemedicine?spur broadband investment in telemedicine?
Continue to fund service grants Continue to fund service grants –– broadband is broadband is infrastructure, not serviceinfrastructure, not service
Continue to fund USAC and increase funding levels Continue to fund USAC and increase funding levels
Develop incentives for carriers to build out the Develop incentives for carriers to build out the ‘‘last last milemile’’ –– perhaps under USACperhaps under USAC
Change the NTIA, RUS, BTOP, and TOPS programs to Change the NTIA, RUS, BTOP, and TOPS programs to be more service orientedbe more service oriented
Include Urban populations in funding programsInclude Urban populations in funding programs
Fix the rural definition problem!!!!!!!!!!!!!!!!!Fix the rural definition problem!!!!!!!!!!!!!!!!!
Health care reform must include Health care reform must include TeleHealthTeleHealth provisionsprovisions
““No reimbursement or other barriers to access to care No reimbursement or other barriers to access to care through through TeleHealthTeleHealth””
What Can the State Legislators What Can the State Legislators Do for Do for TeleHealthTeleHealth??
Rural Health Care Division Rural Health Care Division –– USACUSAC
Federal Communications CommissionFederal Communications Commission Proposed Changes to the Rural Health Proposed Changes to the Rural Health
Care Division, USACCare Division, USAC WC Docket Proceeding No. 02WC Docket Proceeding No. 02--6060
“Proposed Changes often Put the Clinicians and the Carriers on Opposite Sides…”
1)1) Health Care Broadband Infrastructure Health Care Broadband Infrastructure ProgramProgram
Marshfield Clinic Marshfield Clinic TeleHealthTeleHealth believes that believes that diverting funds from the current health care diverting funds from the current health care program which supports the deployment of program which supports the deployment of telecommunications equipment for the telecommunications equipment for the purposes of direct patient care, purposes of direct patient care, improvement of access to health care improvement of access to health care services, and the reduction in the burden of services, and the reduction in the burden of illness and disease of remote and disparate illness and disease of remote and disparate populations populations SHOULD NOTSHOULD NOT be part of the new be part of the new guidelines for use of funds under the Rural guidelines for use of funds under the Rural Health Care Program. Health Care Program. Example: FCC Pilot Example: FCC Pilot ProgramProgram
Question: What happens to excess capacity?Question: What happens to excess capacity?
2.2. Rural Health Care Primary Program Rural Health Care Primary Program (RHCD Support Program)(RHCD Support Program)
Valuable, critical program for most organizations Valuable, critical program for most organizations –– lifeline for lifeline for manymany
Works well, streamlined application, helpline support staffWorks well, streamlined application, helpline support staff
Expansion of the Primary RHCD program is the most valuable use Expansion of the Primary RHCD program is the most valuable use of funds of funds
Increase # of applicants through proIncrease # of applicants through pro--spectivespective assistance from assistance from carrierscarriers
Expand Eligible Health Care Entities Expand Eligible Health Care Entities –– SNF, Dialysis Centers, SNF, Dialysis Centers, SchoolSchool--based Clinics, Communitybased Clinics, Community--based Residential Facilities, based Residential Facilities, CBRFsCBRFs, Head Start Clinics, rural dental centers, county jails, , Head Start Clinics, rural dental centers, county jails, public health offices, free standing emergency departments, public health offices, free standing emergency departments, emergency transportation services offices, data warehouses that emergency transportation services offices, data warehouses that are a part of a larger health care delivery system (not are a part of a larger health care delivery system (not HIEsHIEs))
Ensure that all Medicare, Medicaid, and underserved populations Ensure that all Medicare, Medicaid, and underserved populations have access to health care through broadband supporthave access to health care through broadband support
((concon’’tt))
Definition of Rural and Grandfathering Definition of Rural and Grandfathering ConditionsConditions–– Adopt a consistent and legitimate definition Adopt a consistent and legitimate definition
of rural that does not significantly impede of rural that does not significantly impede rural health care providers from receiving rural health care providers from receiving support under RHCD for broadband access.support under RHCD for broadband access.
Go back to USDA grandfathering provisions Go back to USDA grandfathering provisions due to expire this year and use definitions of due to expire this year and use definitions of rural that are based on population of actual rural that are based on population of actual community and not proximity to urban community and not proximity to urban areas. areas.
((concon’’tt))
Changes in Support CalculationChanges in Support Calculation
Marshfield Clinic Marshfield Clinic DOES NOT SUPPORTDOES NOT SUPPORT any new calculation strategies that any new calculation strategies that reduce support. The 50% calculation reduce support. The 50% calculation would significantly reduce Marshfield would significantly reduce Marshfield ClinicClinic’’s support. s support.
3) Health Broadband Services Program3) Health Broadband Services Program
Agree to rename Internet Access Fund to the Agree to rename Internet Access Fund to the Health Care Broadband Access FundHealth Care Broadband Access Fund
Increase support to 50% for an eligible rural Increase support to 50% for an eligible rural health care providerhealth care provider’’s monthly recurring s monthly recurring internet costsinternet costs
Include any advanced telecommunications Include any advanced telecommunications platforms that provide pointplatforms that provide point--toto--point access to point access to broadband (cellular, mobile, satellite)broadband (cellular, mobile, satellite)
Analyze low utilization before making any Analyze low utilization before making any changes that reduce or divert fundingchanges that reduce or divert funding
NO MINIMUM BANDWIDTH REQUIREMENTSNO MINIMUM BANDWIDTH REQUIREMENTS
NO MINIMUM SPEED REQUIREMENTSNO MINIMUM SPEED REQUIREMENTS
(con(con’’))
Do not support requirement for lowest Do not support requirement for lowest bidder bidder
No requirement for evergreen status of No requirement for evergreen status of contractscontracts
4) Data Gathering and Performance 4) Data Gathering and Performance MeasuresMeasures
Support requirements for formal Support requirements for formal performance measures for participants in performance measures for participants in all of the proposed programs in the all of the proposed programs in the proposed changes with the exception of proposed changes with the exception of the Infrastructure Program (Marshfield the Infrastructure Program (Marshfield Clinic does not support this program)Clinic does not support this program)
Thank you! Nina M. Antoniotti, RN, MBA, Ph.D.
Director, Marshfield TeleHealthEmail:
715-389-3694
