AcuteCare Telemedicine Blog


Looking Backwards to See Ahead – Part 4: Running the Business

This is another blog in a series chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at 2011’s Annual Meeting of the American Telemedicine Association (ATA). What follows is an amalgam of facts, experience and opinions culled from that fantastic symposium and honed by hindsight. Today’s blog will focus on several issues relevant to establishing and running a telemedicine service.

There are myriad of issues confronting physician-entrepreneurs when establishing a telemedicine service. Often these are not immediately evident, although some may be the focus of business development meetings. This blog reviews the topics of business size, communication/documentation, ROI considerations, and coding/billing issues.

The size of a company will directly impact its ability to stay true to its mission. Our firm belief is that the future of telemedicine is in regional providers partnering with both local hospitals and government or not-for-profits. There are larger providers of teleneurology, and their scale may be a corporate advantage; a large staff of part-time physicians to fractionate call burden as well as development of proprietary hardware & software (the cost of which is hidden in a monthly service charge). However, their size is not beneficial to patients and hospitals. In reality, the size of these “McTelemedicine” services paints them as something hospitals fear; impersonal, computerized doctors. The need to focus on healthcare solutions tailored to the specific needs of the healthcare region has been addressed in a recent blog.

Communication must occur in a timely fashion. Otherwise, the telemedicine consult is for naught. Dictating is necessary for documentation of the initial encounter in the permanent medical record, but will be delayed even if transcribed as “priority.” Faxing or emailing is faster, but not always practical. In order to reduce error & liability, especially for critical care issues, direct communication with the local treating physician and nurse is paramount. In cases of acute stroke, providing the medical opinion of whether tissue plasminogen activator (tPA) should be given is sufficient. The actual order for administration of tPA should be given by a physician actually present to review that the dose was properly calculated and administration was expedited.

Return on investment (ROI) will depend on maximizing revenue and avoiding costs – this is relevant to any business. The perspective of both the telemedicine provider and the client hospital must be taken into account. For example, revenue may come to the client hospital through the increased use of value added ancillary services (e.g. radiology, PT, Rehab). One must also identify cost drivers, areas of poor market share (e.g. EMS bypass), obstacles to access, and obstacles to productivity (e.g. difficulty luring a local neurologist because of ER coverage responsibilities). The telemedicine provider may also benefit from the addition of value added services such as reading neurophysiology studies (EEG, sleep, EMG) or lateral expansion through the development of ancillary specialties such as tele-ICU, telepsychiatry or telecardiology.

Coding or billing expertise is not typically required for remote presence consultation, as it is a service provided to the hospital and reimbursed by the hospital accordingly.  Proven increases in revenue and improved patient outcomes absolutely justify this business model. However, in some situations, a physician may bill directly for their services, for example, if the hospital is rural or designated a disadvantaged Metropolitan Statistical Area (MSA). When coding these encounters, Medicare regards telemedicine as face to face time. Using a GT modifier prevents charge bumping if a patient is subsequently seen by a community physician on the same day. Records must also state “Services provided by telemedicine.” One cannot bill Medicare Advantage in an MSA unless there is a contract with the Medicare Advantage carrier.

Medicaid may reimburse encounters within an MSA, but Medicaid does NOT have to follow Medicare rules. Treat them like a third party payer. Keep in mind, the Medicaid staffer handling your reimbursement issues may require education. Finally, follow up telemedicine visits can be billed for 1 visit every 3 days.

Considering these issues, most of which were not immediately evident at the outset, has helped AcuteCare Telemedicine create impact in the market place. ACT not only hightlights the clinical value of its physicians but also addresses the comprehensive business needs of the organizations it serves.



Regional Solutions Are Best for a National Health Care Problem

Stroke affects every community in the United States. However, the risk varies by region (consider the “Stroke Belt” of the southeastern US), and the resources available for treatment have historically been unevenly distributed. Much of the disparity is cultural, but some is political. In the 18th and 19th centuries, where a river or mountain range limited travel, state boundaries were created. At the time, those natural boundaries impeded communication, but 21st century technology breaks those barriers with ease.  The federal government’s recent institution of 12 new telehealth regions takes into account the latest technological advances while maintaining regional autonomy. New broad-band internet availability in rural parts of the country now allows telehealth to provide high quality medical care in areas where geographical obstacles once prohibited.

Rapid stroke-specific care can be accomplished at any local hospital within a telehealth region. No longer does a zip code determine the quality of healthcare available to its residents. Fortunately, regionalism, an inherent aspect of human nature, is preserved, and for good reason when providing healthcare. Each region, unlike some individual hospitals, has all the specialty services needed, but still provides a manageable focus for organizing and monitoring quality of care. Compared to national approaches, regional telemedicine providers have knowledge of and experience with regional medical care and resources, making it easier to understand each region’s specific needs.

The Federal Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS), created the Office for the Advancement of Telehealth (OAT) to promote the use of telehealth technologies for health care delivery, education, and health information services. Each region is managed by a regional Telehealth Resource Center (TRC). OAT provides a list of the current TRCs on their website as well as a map of their catchment areas.

The Georgia Partnership for Telehealth is a leader in the Southeastern Telehealth Resource Center, providing reliable and cost effective high speed internet service to medical sites in Georgia, Alabama and South Carolina, all of which are located in the aforementioned “Stroke Belt,” where incidence of stroke is highest. Linking a region’s medical resources to maximize patient care is a race against the clock (which in the case of stroke is a race towards saving brain), and telemedicine consultations now take just minutes. Simply put, an internet connection traveling the speed of light is a significantly more efficient means of linking these resources than an ambulance driving at full speed or a helicopter flying at 120 miles per hour. This is the power of 21st century technology.

 



AcuteCare Telemedicine Shares Teleneurology Insights at 2012 GPT Conference

Dr. Matthews Gwynn, Partner, AcuteCare Telemedicine (ACT) delivered a presentation discussing the future of teleneurology in the next decade during the 2012 Georgia Partnership for Telehealth (GPT) Conference at the Ritz-Carlton, Reynolds Plantation in Lake Oconee, GA on Thursday, March 15th.

The conference attracted physicians, nurses, administrators, and other healthcare industry professionals and covered a wide variety of topics related to telehealth, including recent innovations, advocacy and education, policies and regulations, and case studies. GPT’s mission is to improve and promote the availability and provision of specialized healthcare services in rural and underserved parts of Georgia through telehealth technology. Presenters including healthcare network Optum, telecommunications provider USAC, and others addressed a variety of ways to overcome barriers that exist for patients living in rural parts of the state at a distance from medical facilities.

Dr. Gwynn’s presentation, visible in its entirety on the GPT website, was entitled “Beyond tPA: Teleneurology for This Decade.” Dr. Gwynn began by discussing the prevalence of stroke, and covered a brief historical outline of the integration of telemedicine technologies in cutting edge neurological care. He then offered case studies demonstrating the value of teleneurology in creating a higher standard of stroke care in the future. Dr. Gwynn illustrated that teleneurology will not only improve care, but also play a vital role in helping healthcare providers meet changing standards and tightening budgets.

“The partners of ACT truly believe that teleneurology is forging a path through a new frontier in medicine that will ultimately result in better patient care with a lower associated cost,” said Gwynn. “Presenting ACT’s outlook at the GPT Conference was an outstanding opportunity to share our vision with other industry leaders. Both healthcare providers and our patients benefit from this exchange of knowledge.”

For more information about Dr. Gwynn and ACT, visit www.acutecaretelemed.com.

 



Insomnia: Limiting the Use of Sedatives and Hypnotics

Insomnia is the most commonly encountered sleep disorder or complaint, with a wide prevalence range reported to be between 10 and 40 percent  (the variance is due to differences in the definition of insomnia). Suffice it to say, millions of individuals are affected by insomnia at some point in their lives. Because of the significant increased rate of comorbidity associated with insomnia, the burden placed on society by way of increased utilization of health care resources, poor work performance, and missed work days, it is essential that insomnia is appropriately and efficiently managed.

Individuals who suffer from insomnia frequently seek help from medical professionals and this help is often provided in the form of a sedative/hypnotic medication. Significant risks are associated with the use of sedatives and hypnotics, such as dependency, falls (particularly in the elderly), and even an increase in cancer and death rates, as shown by a recent study. Prescription medications do have a role in the treatment of some individuals with insomnia, as well as those with conditions and situations that may call for temporary use, such as time zone changes and jet lag. However, these medications are often over prescribed and/or misused due to insufficient patient evaluation.

It is well understood that when evaluating a patient with complaints of insomnia, an underlying medical and or psychiatric disorder should be considered. Ruling out and treating underlying etiologies is requisite. With resolution or control of the causative medical or psychiatric condition, the insomnia will often times abate. When thorough evaluations are performed in the setting of insomnia, sedative use can be potentially limited, if not completely avoided.

Complaints of insomnia may also be indicative of another (primary) sleep disorder such as restless leg syndrome (RLS) and periodic limb movements (PLMs), delayed sleep phase disorder (DSPD), or obstructive sleep apnea (OSA). Sleep onset and maintenance difficulties may be the result of both PLMs and OSA. The inability to fall asleep at the desired sleep time will be seen in individuals with DSPD. Patients with the above conditions will frequently complain of daytime sleepiness, a complaint not usually expressed in individuals with primary insomnia. These sleep disorders can all be treated without the use of sedatives. Furthermore, the use of sedatives in these cases will only serve to mask and possibly exacerbate the primary sleep disorder, leading to increased morbidity and mortality rates.

In the July 2010 issue of SLEEP, a study was published showing that the prevalence of sedative use in the general Canadian population had more than doubled between 1994 and 2003. Interestingly, this increase had occurred moreso in men, non-elderly, and obese individuals. The study concluded that “the greater odds of sedative medication use found among morbidly obese men may reflect the presence of underlying obstructive sleep apnea, which may in turn serve to explain in part the known relationship between sedative medications and mortality.” When patients with untreated sleep apnea are prescribed sedative/hypnotic medications, apneic events typically worsen, setting up for poorer outcomes and placing them in danger of respiratory arrest.

When underlying etiologies of insomnia have been ruled out and sedatives are needed, they should be used sparingly and temporarily. When possible, alternative treatment modalities such as cognitive behavioral therapy should be employed to avoid or limit the use of sedative and hypnotic medications.