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Oregon Telehealth

Gaps and Opportunities

Report

Prepared for:

Oregon Health Authority

By:

Telehealth Alliance of Oregon

September 30, 2015

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Table of Contents

Executive Summary Page 3

Introduction and Background Page 4

Outcomes and Findings Page 6

Conclusions and Recommendations Page 17

Appendix 1 – Methodology Page 21

Appendix 2 – Participants Page 24

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Oregon Telehealth

Gaps and Opportunities

Summary Report

Executive Summary

Telehealth in Oregon is evolving rapidly. In order to better understand the Telehealth landscape

within Oregon, the Oregon Health Authority (OHA) asked the Telehealth Alliance of Oregon

(TAO) to undertake three tasks:

1. Create a comprehensive, easy to understand Law and Policy Review with on-going

quarterly updates;

2. Develop a portal where telehealth providers can share information regarding the types of

services being offered and to whom; and

3. Conduct a telehealth gaps and opportunities assessment and follow it up in a year with

another assessment that will help determine how those gaps and opportunities are being

addressed.

This report discusses the Telehealth Gaps and Opportunities Assessment (TGOA) conducted by

TAO throughout the State in August 2015. There were five focus groups covering five separate

regions, and additional individual discussions with several key informants who were unable to

participate in the focus groups. In addition, TAO conducted a quick, informal scan of telehealth

services currently being provided in Oregon. Through the focus groups and the scan, TAO found

that a wide variety of specialty services are being delivered by large urban providers to acute care

settings such as rural and regional hospitals. Ambulatory care is being delivered by both urban

and regional hospitals to clinics and directly to patients in their homes, schools and workplaces.

Home monitoring services are just beginning to be offered. Distance education and knowledge

sharing, between providers at separate sites, between providers and community groups, groups

of patients, or individual patients occurs], but not is always acknowledged as telehealth.

While focus group participants and key informants could envision the opportunities offered by

telehealth, they believed that significant barriers would need to be removed in order to facilitate

continued expansion of telehealth services. Barriers were classified into four categories: cultural

(including education and knowledge sharing); operational (including funding); technical; and

regulatory/policy. Cultural barriers appear to present the biggest challenge to implementing or

expanding telehealth in the different regions.

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Participants provided insights on the kinds of support that are needed to expand telehealth in

Oregon and offered some excellent suggestions for education and knowledge sharing. TAO will

conduct another assessment in a year to determine how barriers have been addressed for the

participants, and if some of the requested supports were provided and proved helpful.

This project is funded through the Oregon Health Authority’s federal State Innovation Model

(SIM) grant. The SIM grant supports projects that advance Oregon’s health system

transformation efforts.

Introduction and Background

Within the last few years, there has been an exponential increase in the demand for telehealth

services both in the United States and globally. Telehealth was first introduced to Oregon by the

RodeoNet project in 1992, a collaborative grant project between Oregon Health and Sciences

University (OHSU) and Eastern Oregon Human Services Consortium. Telehealth grew slowly, as

telecommunications and equipment costs at the time were very high. There was no

reimbursement and many states banned the practice of telemedicine. Organizations such as the

American Telemedicine Association (ATA) at the national level and the Telehealth Alliance of

Oregon (TAO) at the state level worked to reduce the policy barriers and to convince payers,

including the Centers for Medicare and Medicaid Services (CMS), to begin reimbursing for

telehealth services. Telecommunications and equipment costs declined through the decades. In

2009, Oregon received $21 million in grants through the Federal Communications Commission’s

first round of telehealth broadband awards. This funding allowed telecommunications providers

to extend broadband to many rural healthcare facilities. The Affordable Care Act, signed in 2010,

provided another impetus to the expansion of telehealth. Hospitals were required to meet the

goals set forth in the Act, and telehealth became a promising way to help achieve those goals.

According to OHA, telehealth is an important and growing way for medical providers to extend

their reach geographically and increase their capacity. Telehealth covers a broad variety of

technologies and strategies to deliver virtual medical, health, and education services. Telehealth

includes video conferencing for medical consultations at a distance, monitoring patients

remotely through electronic devices and the related use of mobile devices in medical care. These

technologies are quickly expanding in use and have the potential to extend medical services to

more people and in new ways, particularly in Oregon's rural areas. 1

Stakeholders and the state of Oregon have been very active in developing policy that will allow

telehealth to grow with this new demand. Policy in Oregon has been developed in two ways. The

1 http://www.oregon.gov/oha/OHIT/Pages/Initiatives.aspx

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first has been through collaboration between providers and state agencies to change or develop

policies that allowed providers to move forward with their telehealth program (examples include

Grande Ronde Hospital working with the Oregon Medical Board to change their cross-state

licensure protocol so that Grande Ronde could more easily use out of state consultants to provide

needed services. Another example is the work done between TAO and the state Medicaid office

to develop the state’s first protocols regarding Medicaid payment for telehealth services.)

Telehealth policy in Oregon has also been developed through legislation. In 1999, Senate Bill (SB)

622 was passed. It allowed US West to build six interconnected broadband rings throughout the

state with funds that would have been used to pay a significant fine from the Public Utility

Commission. These rings were to be used by education and healthcare. In 2003, House Joint

Resolution (HJR) 4 was passed. The bill expressed legislative support and encouragement for

telemedicine and for reimbursement for services delivered telemedically. In 2009, SB 24 was

passed mandating that health benefit plans cover telemedicine services between health care

organizations without consideration for urban and rural designations. In 2013, SB 569 was passed

requiring the OHA to develop a uniform documentation requirements for credentialing providers

of telemedicine services. Finally in 2015, SB 144 was passed. The bill modified health benefit

plan coverage of telemedical services to include coverage of direct provider to patient services

regardless of where the patient was locate. It also required the Oregon Educators Benefit Board

(OEBB) and the Public Employees Benefit Board (PEBB) to cover telemedicine services. Yet, to

date there has been a lack of comprehensive information about the current landscape of

telehealth services in Oregon, including: who is offering services; who is receiving services; what

types of services are offered; and who is paying for services. There is also no comprehensive

review of the laws and policies governing telehealth in Oregon compiled into a single place. First-

hand information about the gaps in telehealth services and the actions necessary in order to

address these gaps and needs has been limited. Efforts are scattered across multiple

organizations, agencies, providers, systems, and individuals throughout the state. A

comprehensive vision for expansion and exploration of telehealth opportunities within the state

does not currently exist.

Seeking to bridge the gaps listed above, the Oregon Health Authority utilized State Innovation

Model Funds to gain a comprehensive view of telehealth in the state, so that a vision for the way

forward for telehealth can be developed. In order to support the expansion of telehealth

throughout Oregon, OHA is funding TAO to implement three tasks:

1. Create a comprehensive, easy to understand Law and Policy Review with on-going

quarterly updates;

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2. Develop a portal where providers of telehealth can share information regarding the types

of services being offered and to whom; and

3. Conduct an initial telehealth gaps and opportunities assessment, with a follow--up

assessment after a year to determine how those gaps are being addressed and

opportunities are maximized to advance telehealth in Oregon.

This report is the initial Telehealth Gaps and Opportunities Assessment, providing information on

the current state of telehealth through a scan by TAO, five regional focus groups across the State,

and key informant interviews. It contains several recommendations on how barriers might be

addressed.

While we attempted to gather as much information as possible to make this a comprehensive

report based just on the input from the focus groups, there were some challenges. The mix of

participants sought for the focus groups was representatives from CCOs, telehealth providers,

providers not currently practicing telehealth, and Innovator Agents. There were representatives

from hospitals and health systems, clinics, CCOs, private providers, telecommunications

providers, and healthcare associations. The representatives were physicians, nurses, telehealth

directors, IT staff, hospital, health system, and clinic administrative staff, CAC members, and CCO

staff. In all but one of the groups, attendance was low. In some, there was a lack of knowledge

about what kinds of telehealth services were being offered in the region outside their own

particular facility, and finally, some of the groups did not have a lot of background in telehealth.

The solution was to conduct some private phone interviews with others in the region that were

unable to attend the focus group, and with others from large urban providers who provided

services to the region and were familiar with the gaps and opportunities. TAO and the Office of

Rural Health (ORH) also provided information on the background and history of telehealth and

for the culture of each region for this report based on the current knowledge of working with

those regions.

Outcomes/Findings

The overarching findings on barriers and opportunities were similar among the focus groups. However, each focus group placed different emphases on which barriers and opportunities were most significant to them.

Rural participants found value in telehealth when it directly addressed existing barriers to healthcare. In larger, more urban areas where telehealth programs are growing rapidly, there is greater emphasis on developing capacity to meet demand and removing the regulatory and policy barriers that kept the full potential of telehealth from being realized.

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Participants from all focus groups believed that increased information about telehealth was necessary, ranging from very basic information about what telehealth is to very sophisticated information regarding security, scope of practice issues, and billing. Another common theme was that current provider and patient cultures surrounding telehealth are the biggest barriers to telehealth development. In the current culture, originating site providers (providers at the patient location) worry that telehealth providers at distant sites (locations where the telehealth provider is located) will take away their patients, or that telehealth is a way for other providers to oversee and attempt to manage their practice. For telehealth providers, they are uncertain about receiving reimbursements and there are difficulties with getting licensed and credentialed to provide services. Patients have concerns that they will be getting sub-standard care not tailored to them as individual patients. With so much of the healthcare culture changing, participants expressed that it seems overwhelming to take on changing telehealth culture as well, though all agreed that providing more educational opportunities would be the key to changing the culture for both providers and patients.

The following is a summary of findings from all five focus groups for each question that was posed

to them:

Barriers to Care

1. What are the barriers to accessing healthcare services (physical, dental, and behavioral)

in the region?

System capacity

a. There is too long a wait time for patients to access services, especially for

ambulatory services. The large number of patients that need to be seen in clinics

does not allow the providers to practice “good medicine”.

b. Shortages in nursing were reported in most areas. Rural areas report provider

shortages, as well as difficulties in recruitment and retention. Many providers,

including primary care providers and dentists, are not willing to practice in remote

areas, as there are low numbers of clients with infrequent visits, no hospital

affiliation and no telemedicine services.

c. Larger providers are dealing with high demand for specialty care, including

pediatrics. The shortage of specialists makes it more likely that the uninsured,

Medicare and Medicaid patients and Hepatitis C patients have long waits to

receive services.

d. Behavioral health service providers are in demand everywhere. Emergency

Departments are filled with behavioral health patients. Residential services are

needed, especially for teens. Residential beds for alcohol and drug patients, as

well as dually-diagnosed patients, are also needed.

Distance and lack of transportation to services

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a. Patients in rural areas often lack transportation to primary care services. Some

need to travel over 50 miles to receive those services. Specialty care can be several

hundred miles away. There is not always funding to help pay for transportation

costs until the need for care becomes acute.

b. Many urban patients also lack the resources for transportation to receive care.

Operational problems

a. Billing processes can be confusing and sometimes information is conflicting.

b. Problems with integrating EHR systems.

Lack of Information for both patients and providers

a. Navigating the system – knowing which provider to call or where to access

services.

b. Understanding insurance – knowing what services are covered and which

providers can be used.

c. Providers lack information of available resources, especially for children and rural

patients.

d. Patients perceive barriers that are not there. There may be a lack of information,

incorrect information or other cultural issues that lead to this perception of

barriers.

e. Some patients do not understand the CCO configuration.

Cost of care

a. Insurance does not cover the cost of some testing and medical supplies.

b. In some instances, ambulatory care services are not offered to Medicare patients

due to lack of reimbursement.

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The table below shows the similarities and differences in the barriers stated above

between urban and rural providers:

Barriers to Care Urban Rural

System Capacity

1. Long wait time to access services X X

2. Nursing and primary care shortages X

3. Demand for specialty care increases likelihood that less advantaged patients will be seen

X X

4. Lack of behavioral health providers X X

5. Lack of dental providers X

6. Difficulty recruiting and retaining providers

X

Distance and lack of transportation to services

1. Distance to care X

2. Lack of transportation to care X X

Operational problems

1. Billing processes can be difficult or confusing

X

2. Problems with EHRs X X

Lack of information both patients and providers

1. Navigating the system X X

2. Understanding insurance X X

3. Providers lack information about available resources for children and rural patients

X X

4. Patients perceive barriers that don’t exist X

5. Some patients don’t understand the CCO configuration

X

Cost of care

1. Insurance doesn’t cover cost of testing and medical supplies

X X

2. Ambulatory care services not being offered to Medicare patients due to lack of reimbursement

X X

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2. Is telehealth (current or potential) a solution for addressing barriers in this region?

Participants expressed that significant challenges would have to be overcome before

telehealth could be better utilized to address healthcare barriers. This was especially

true for rural areas. It was pointed out that certain telehealth programs established

in the past had failed, particularly in rural areas, because the cultural, regulatory,

operational and technical barriers outlined in question #4 below had not been

addressed.

Participants felt telehealth has the potential to:

a. Increase access to specialty care for patients in rural areas. That care could or does

include dermatology, pediatric ICU, other pediatrics services, cardiology,

psychiatry, mental health, interpreter services, orthopedics, and gastroenterology

b. Decrease the cost of some services particularly direct provider to patient services

c. Allow physicians to provide support to other clinicians

d. Reduce long wait times for care

e. Save lives

f. Triage care

g. Keep patients from being readmitted to hospital care

h. Increase access to primary care by:

o utilizing direct physician to patient care

o creating centers for telemedicine service in school-based health centers

(SBHCS)

o using mobile solutions to provide direct services

o providing services during disaster

i. Provide more Extension for Community Healthcare Outcomes (ECHO)2 programs

to more providers

j. Monitor patients with chronic diseases in their homes

Telehealth Implementation

3a. Is telehealth currently being used to provide services in the region?

Currently, the majority of services are provided by the larger urban hospitals and

systems, mostly located in the Portland area, to smaller regional hospitals, small rural

hospitals and clinics located in both urban and rural areas in all regions. Specialty

consultative services tend to be provided by the urban hospitals to larger regional

2 Project ECHO (Extension for Community Healthcare Outcomes) is a collaborative model of medical education and care management that empowers clinicians everywhere to provide better care to more people, right where they live. The Project ECHO model was developed at the University of New Mexico and the model is now used in many sites throughout the United States. http://echo.unm.edu/about-echo/

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hospitals in all regions. The regional hospitals also provide some services to smaller

rural hospitals and clinics. With the advent of private payer reimbursement for direct

physician to patient services, there is rapid growth of telemedicine services for non-

urgent primary care to patients in their homes, schools and work places. More rural

hospitals, clinics, and single providers will use this type of service to care for their

patients. These direct physician to patient services area occurring in most regions,

with the highest volume in the Portland metropolitan area and the Willamette Valley.

The growth of services is currently unknown and should be monitored to see if there

is growth in other regions when private payer reimbursement becomes available after

January 1, 2016.

It is important to note that the standard of care is the same whether delivered in

person or using telecommunications technology. Care may consist of the distant site

providing services directly or of assisting originating site staff in service provision

when originating site staff have limited capacity for that service skill set. Telehealth

can also be used to determine that the patient needs to be transferred to the distant

site.

Focus group participants discussed telehealth services as natural groups divided into

four types: acute care; ambulatory care; home monitoring; and education/knowledge

sharing.

a. Acute care (inpatient) services are the most developed of all telehealth

services. They are delivered by the large urban hospitals and health systems

that have resources to develop sophisticated specialty services. Usually the

urban site (distant site) is assisted in providing the care by the staff at the

originating site. Some of the most commonly used offerings are: strokes care;

cardiology including cardiac critical care; pediatric and adult intensive care

services; hospitalist care; and neonatal care.

b. Ambulatory care is emerging as more hospitals and clinics are finding niche

markets. One of the largest emerging services is behavioral health. Despite its

growth, demand still exceeds supply. Dental services are growing especially in

SBHCs; Community Health Centers (CHCs); and Federally Qualified Health

Centers (FQHCs).

c. Home monitoring services for chronic care are offered only by a few

organizations: Asante, Mosaic, and OHSU. To date, neither CMS nor private

insurers have offered reimbursement for home monitoring services. This is

beginning to change, as hospitals and insurers are realizing that home

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monitoring can reduce their readmissions, particularly for patients with

multiple conditions. Hospital systems such as Rogue Regional Medical Center

are paying out of pocket for these services. Congress and organizations such

as the American Telemedicine Association are applying pressure on CMS to

reimburse for home monitoring.

d. Education and knowledge sharing was the least cited service, not because it is

not happening, but because providers do not always acknowledge it as a

telehealth service. One of the most prominent education/knowledge sharing

services is the ECHO project. ECHO projects provide didactic education and

team consultation for cases presented by providers throughout the country.

This model was developed at the University of New Mexico and is being

replicated by different organizations at sites throughout the country. In

Oregon, the Project ECHO model is being used by OHSU for psychiatric

medication management. Often Continuing Education Units (CEUs) are

offered for participation. OHSU also provides monthly educational brown bag

lunches to sites where the primary care provider does a face-to-face

introduction of a patient to the behavioral health specialist to which he or she

is being referred (commonly referred to as a warm hand-off). Grande Ronde

Hospital receives cardiology and ER grand rounds, and perioperative training.

3b. What are the opportunities for telehealth in the region?

This question was not a part of the original structure. At the first focus group meeting,

one of the participants suggested that this question should be included to balance the

question regarding barriers. It was then included in all of the focus groups. The

information provided was very helpful to the assessment.

Participants from the urban areas provided responses that reflected that they were

farther along the continuum of telehealth implementation than their rural

counterparts. Rural responses consisted of services that they would like to see in their

facilities and regions such as:

Drug and alcohol services

Diabetes management

Specialist consultation services to emergency rooms located in smaller

hospitals

Cardiology

Psychiatry and mental health

ECHO programs

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Dermatology

Home health services

Pediatrics

Interpreting services

Gastroenterology for Hepatitis C

Orthopedics

Chronic disease management

Connecting providers to each other and to patients within medical homes

Development of telehealth centers, particularly in SBHCs

Remote patient monitoring post hospital discharge

Primary care services to patients in remote areas

Building capacity with out-of-area telehealth providers until the capacity can

be built locally

Responses from urban participants indicated opportunities to create more advanced

services such as:

Better use of wearable devices to monitor patients with chronic conditions

Follow-up for renal transplant services

Better monitoring of renal dialysis patients

Diagnosis of diabetic myopathy

Better use of wearable devices to monitor patients with chronic conditions

and improving health care processes such as:

Better population health

Better intervention methods

Establishment of telehealth clinics

Inclusion of more providers such as educators and therapists

Establishment of patient-centered medical homes

Chronic care education programs

Better care coordination

4. What are the biggest challenges (current and potential) for implementing telehealth in

this region?

The challenges stated by participants can be separated into four categories – cultural,

operational, technical, and regulatory. The greatest numbers of challenges seen by

participants were cultural, followed by regulatory, technical and operational.

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a. Cultural (includes education and training)

Participants believed that the lack of education and training is at the core of

provider resistance to telehealth. Providers and administrators who do not

understand telehealth or see its benefits do not fully commit to making it happen

in their organizations. This lack of commitment results in underutilization of

services offered by distant providers, and ultimately failure of the program. It

takes a lot of time and resources to bring telehealth into an organization, and a

great deal of education and re-education regarding benefits, as well as operational

realities, is needed to keep administrators and providers motivated and moving

forward. Provider champions within organizations who are willing to share their

telehealth successes with their colleagues are needed to promulgate telehealth

within the organization. Organizations successful in providing telehealth services

that are willing to serve as role models and share their experiences with other

organizations can also help break down resistance to using telehealth.

Incorporating telehealth can be very challenging to many providers who believe

that a successful examination cannot be conducted without touching the patient;

who do not want “outsiders” providing services in their region; who view

telehealth as a replacement for their services; and who see telehealth as a “big

brother” mechanism (ex. The larger “parent” hospital uses telehealth to watch the

smaller hospital and judge its performance).

b. Operational (includes funding)

All too often, an organization begins a telehealth program using soft funds without

developing a sustainability plan, and many times without any idea of the overall

costs of a telehealth program and what it takes to make it sustainable. Care is not

always taken to find and match the right resources with the needs of the

community, and soft funding no longer allows the “learn as you go” method of

developing a sustainable plan.

In Oregon’s most remote areas, the low population equals no opportunity for

funding or services. Infrastructure is cost prohibitive to build and maintain, and

there are insufficient subsidies for these areas.

Billing and coding can be challenging for clinics and smaller hospitals that are

unfamiliar with telehealth codes and such processes as GT modifiers and

originating site fees. As they are small, there are often no resources for them to

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learn the codes and processes other than by trial and error, which can prove very

frustrating.

The capability to input information on telehealth services into electronic health

records (EHRs) remains a problem in some systems, with limits on information

automatically entered into the EHR. Participants from larger organizations or that

are using some developed systems did not report this concern, as there can be a

greater variety of options available for seeking solutions

c. Technical

In addition to the lack of telecommunications infrastructure in some rural areas,

there is also a lack of coordination for existing infrastructure. Often there is no

consideration for using broadband that is installed for one organization, such as a

school district, to be used for a hospital or mental health clinic as well.

Despite the fact that broadband does exist in most rural hospitals, it does not

extend to patient homes, particularly those who live outside of the community

boundaries. This makes it very difficult for hospitals to provide services to patients

in their homes. Internet connectivity to these homes is non-existent or not

suitable to use when providing healthcare services.

There is insufficient technical support in rural areas. Often there is a lack of

information technology staff with telehealth expertise immediately available to

help a small clinic in a rural area with technology that is not performing reliably.

Either clinics receive no assistance or need to wait for assistance to arrive from

outside the area.

d. Regulatory

Understanding the regulatory issues involved in providing telehealth services is

daunting, and not just for rural providers. Focus group participants in all of the

regions expressed the need for more understandable and consistent information

regarding risk management, reimbursement, credentialing and privileging, privacy

and security, licensure and scope of practice for telehealth.

Support for Telehealth

5. What kinds of support are needed in order to successfully increase the use of

telehealth in the region?

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Four types of support were requested by participants: funding,

education/communication, regulatory/policy, and technical. The majority of requests

were for better education and communication regarding telehealth.

Funding

Rural areas requested funding support. These requests included additional funding

for telecommunications infrastructure in frontier areas (both installation and on-

going); a grant writing specialist for telehealth; and funding to establish community

telehealth clinics in SBHCs or other suitable community facilities.

Education/Communication

Participants had many requests for education/communication support. The request

that stood out as a possible solution for enabling many of the other requests was to

develop a telehealth learning collaborative for Oregon. The collaborative could be the

convener to bring together providers, CCOs, hospitals, clinics, state agencies,

legislators and patients to discuss and share knowledge regarding telehealth.

Some of the other education support requested was for: reimbursement and billing;;

benefits of telehealth; how best to remove cultural barriers; Standards of Care/Best

Practices for telehealth; resolving credentialing and privileging issues for telehealth;

how to build telehealth into an organization’s vision; how to market telehealth

services; and identifying good telehealth role models.

It was suggested that a ‘simple’ manual be developed that would explain what is

needed to start and sustain a telehealth program specific to Oregon. A directory of

telehealth services in Oregon was also suggested.

Regulatory/ Policy

Participants requested that Congressional support be sought for legislation to

increase Medicare expansion of services eligible for payment beginning with

Oregon’s Congressional delegation.

They also requested improved processes for licensing and credentialing out-of

state providers.

Technology

Technology support requests came primarily from rural participants. They

included: more IT/IS support for telehealth; guidelines for easy to use patient

portals; guidelines; and support for selecting reliable technology; and better

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coordination of technology resources (possibly a regional or state-wide telehealth

IT group).

Conclusions and Recommendations

OHA has contracted with TAO through September, 2016 for several deliverables to strengthen

the telehealth landscape in Oregon. One of the deliverables under this contract is a Law and

Policy Review that will provide on-going information on laws and policies that affect Oregon’s

telehealth providers. The Review will be posted on TAO’s website and will be updated on a

quarterly basis. TAO plans to continue the updates after the contract expires.

Under this contract, TAO will also provide an inventory on the telehealth services offered

throughout the state, a new telehealth services portal will open in December. This portal enables

telehealth providers to enter information on available services into a searchable site. Parties

interested in accessing telehealth services can then search based on type, location,

reimbursement, and other factors.

Based on the information gathered from the focus groups, TAO would make the following

recommendations for each of the four areas where challenges were noted. These

recommendations also align closely with the four areas for which support was requested.

Recommendations for resolving cultural challenges:

1. Consideration needs to be given to developing a telehealth learning

collaborative for Oregon. Partnerships should be developed between those

organizations that can bring their expertise to the collaborative – TAO, OHA,

Oregon Association of Hospitals and Health Systems, Oregon Medical

Association, Oregon Medical Board, established telehealth providers and

others who want to contribute their telehealth knowledge to the

collaborative. The collaborative should use its expertise to increase awareness

and understanding of telehealth throughout the State, bringing those with

expertise together with those who are just learning about telehealth or who

may have misconceptions about it.

2. Create events (conferences, webinars, etc.) and/or take better advantage of

existing ones that highlight the excellent work of telehealth programs

throughout the State, and present provider champions who can inspire and

challenge their peers to engage in telehealth.

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Both of these recommendations would help to increase knowledge about telehealth,

reduce misconceptions and encourage those not currently involved in telehealth to

consider doing so.

Recommendations for resolving operational challenges

1. Develop a webinar/course on planning and developing a telehealth program

that includes a long term sustainability plan. This course would be primarily for

small hospitals and clinics and would include plans for offering and receiving

telehealth services. It would also offer information on how to develop

telehealth partnerships or collaborations with other organizations.

2. Develop a specific course for billers and coders who are dealing with telehealth

services. Ideally, there would be a resource person who could teach the course

and offer support to billers and coders when they needed additional help.

Both of the courses above would make available information a resources to

those starting telehealth programs that would help give smaller organizations

confidence to develop a program and help them avoid costly mistakes that

often cause new programs to fail. The course would give existing programs an

opportunity to strengthen their program operations.

3. There is no easy or cost-effective solution for inputting information on

telehealth services provided or received in an EHR that does not already have

that capability built-in. Costs to develop one can be prohibitive, as can

changing the EHR program. Organizations that are starting a telehealth

program should discuss the need for the interface with their EHR software

provider.

Recommendations for resolving technical challenges

1. A state-wide telehealth IT group should be formed to better integrate

telehealth technology throughout the state and to contribute knowledge to

the learning collaborative. It should be made up of vendors, healthcare

technical support, and other key stakeholders, including from the State. The

group should have a clear charge for dealing with technical challenges and

propose strategies for resolving them.

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2. This same group should also consider solutions for rural areas that still do not

have appropriate telecommunications to support health care in their

hospitals, clinics and homes.

3. Consideration should be given to developing a state-wide technical support

call center or rotating hotline that could assist small and rural providers who

do not have on-site technical staff with problems as well as offer assistance

with technology selection.

Recommendations for resolving policy and regulatory challenges

1. To help with providing more understandable and consistent information

regarding regulatory and policy issues, TAO, with funding and support from

OHA, has developed a Law and Policy section on its website at

http://www.ortelehealth.org/content/law-and-policy that offers information

on state and national laws and policies and many resources for better

understanding them.

2. When issues arise with a law or a policy in Oregon, putting together a work

group (similar to the Oregon Senate Bill 144 work group in 2014) of those

affected has proven valuable. A work group can determine how best to resolve

the issue, and develop and carry out the strategy for resolution. The resolution

does not always require legislation.

3. When issues arise with law or a policy at the national level, it is important to

build collaborations at regional and national levels such as the Telehealth

Resource Centers (Oregon belongs to the Northwest Telehealth Resource

Center) and organizations such as the ATA. Joining together creates a much

larger voice with which to approach Congress or CMS. Creating the

relationships with these organizations, as well as with Oregon’s Congressional

delegation, before an issue arises is helpful. State organization such as TAO,

Oregon Association of Hospitals and Health Systems, and Oregon Healthcare

Information and Management Systems Society (HiMSS), have staff that can

assist with this.

The participants in the focus groups were interested in and enthusiastic about telehealth. For the

most part, participants from urban areas had a greater amount of knowledge and experience

with telehealth than their rural counterparts. All of them thought that telehealth was a means to

improve access to primary and specialty healthcare services. Most thought it had the potential

20

to reduce costs. All of the participants thought it would be a permanent part of the healthcare

landscape.

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Appendix 1

Methodology

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Methodology

TAO conducted the focus group surveys with the help of the Oregon Office of Rural Health.

Regions

The State was divided into five regions, with attention paid to amount of travel time involved for

participants and attempting to keep most of the counties in each Coordinated Care Oregon (CCO)

together (This was not the case for Eastern Oregon Coordinated Care Oregon (EOCCO), as the

area covered was too large.) The five regions and the counties involved are as follows:

Region I – Clatsop, Tillamook, Yamhill, Clackamas, Columbia, Washington,

Multnomah, and Hood River Counties;

Region II – Lincoln, Linn, Marion, Benton, Polk, and Lane Counties;

Region III – Coos, Douglas, Jackson, Curry, Josephine, and Klamath Counties;

Region IV – Wasco, Jefferson, Crook, Lake, Sherman, Deschutes, and Wheeler

Counties; and

Region V – Morrow, Umatilla, Union, Wallowa, Grant, Baker, Harney, and Malheur

Counties.

Participants

A total of 36 participants were involved in the focus groups. TAO and OHA determined that there

should be participation from each of the following groups in each focus group:

(1) the group’s regional CCO staff/board;

(2) regional providers currently practicing telemedicine;

(3) regional providers not practicing telemedicine; and

(4) the clinical innovator for the region’s CCO(s).

The names of the participants and their representational breakdown are included in the

individual region reports located in the appendices to this report.

On a state-wide basis representation was as follows:

16 participants represented urban telehealth providers

10 participants represented CCO staff, board or community advisory councils (CACs)

11 participants represented rural areas

1 participant represented a telecommunications provider

1 participant represented the OHA Transformation Center

2 participants were independent providers (both rural) using telehealth

Eighteen of the participants attended the focus groups in person. Thirteen of the participants

used audio or videoconferencing to attend the conference. Seven participants were privately

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interviewed. Of the participants who gave private interviews three of them are from hospital

systems that provide services throughout the state. They were interviewed to fill in some of the

information gaps in the areas where they provide services.

Focus Group Structure

The focus groups were held at the Legacy Health System Office in Portland, Asante Center for

Outpatient Health in Grants Pass, Mosaic Medical Center in Prineville, and St. Anthony Hospital

in Pendleton. The focus group that was scheduled for Peace Health in Eugene was conducted via

audio and videoconferencing, as no one could attend in person.

Each focus group was scheduled for two hours. The following set of questions was asked of each

group:

Barriers to Care

1. What are the barriers to accessing healthcare services (physical, dental, and behavioral) in this

region?

2. Is telehealth (current or potential a solution for addressing barriers in this region?

Telehealth Implementation

3a. Is telehealth currently being used to provide services in this region? What kinds of services

are being provided?

3b. What are the opportunities for telehealth in this region?

4. What are the biggest challenges (current or potential) for implementing telehealth?

Support for Telehealth

5. What kinds of support are needed in order to successfully increase the use of telehealth?

All of the focus groups and private interviews were conducted by Robert Duehmig, Oregon Office

of Rural Health and Cathy Britain, Telehealth Alliance of Oregon. Information was captured in

written and audio formats and later used to create the reports

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Appendix 2

Participants

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Participants in the focus groups

Region I

Participants attending in person: Christy Burton, OHSU Dustin Zimmerman, Innovator Agent

Jean McCormick, OHSU Theresa Nute, Teladoc

Bryan Cochran, OHSU Len Bergstein, Zoom+

Miles Ellenby, OHSU Danielle Coates, Tuality

Lori Wakashige, Legacy Thanh Nguyen, Providence

Chris Burns, LS Networks Susan King, Oregon Nurses Association

Kristin Bork, OHA (Observer)

Participants attending via phone or video: Susie Fisher, Providence Jim Rickards, Yamhill County CCO

Region II

Participants who attended via phone or video:

Pam Hood Szivek, Corvallis Children’s Therapy, Corvallis Dan Reece, OHA Transformation Center, Salem Lynnea Lindsey Pengelly, Trillium, Eugene

Region III

Participants attending in person: Jeff Caulley, Asante, Medford Participants attending by phone or video: Natalie McFarland, Umpqua CCO, Roseburg Dr. Bitter, Umpqua CCO (board chair), Roseburg Anne Alftine, Jackson Care Connect, Medford

Region IV

Participants attending in person: Sharon DeHart, Deschutes Rim Clinic, Maupin JoDee Tittle, St. Charles Pioneer Memorial Hospital, Prineville

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Andy Eck, Mosaic Medical, Prineville

Region V

Participants attending in person:

Cheryl Pearce, CHI St. Anthony Hospital

Ben Eckstrom, GOBHI

Participants attending via phone or video:

Maria Vargas, Valley Family Health Care (CAC member)

Crystal Clifford, Lifeways (CAC member)

Anne Brauer, Norco, Inc. (CAC member)

Ray Gibbons, St. Alphonsus Medical Center Baker City

Participants who were interviewed privately

Participants were interviewed privately when they were unable to attend their regional focus

group or when they had knowledge of more than one region because they provide services in

those regions.

Mark Lovgren, OHSU for all regions Susie Fisher, Providence for regions II, III, IV and V Dan Casares, Peace Health for region II Bob Power, Samaritan Health for region II Bob Adams, Bay Area Hospital for region III Lori Wakashige, Legacy for region IV Monica Schulz, St. Charles (Bend) for region IV Doug Romer, Grande Ronde Hospital for region V Tiffany Whitmore, St. Alphonsus (Boise) for region V