Melinda Trimble RPSGT, RST

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1 Melinda Trimble RPSGT, RST

2 Conflict of Interest Disclosures for Speakers I have no Conflict of Interest on this topic I would like to disclose that I do work for Philips Respironics

3 Objectives Review how telemedicine and technology factor into future models of care in sleep medicine; and Review the different roles that will be necessary in telesleep in the future Discuss opportunities for technologists in telemedicine

4 Sleep Medicine Realities Regulatory changes Cuts to codes Decrease in payment for diagnostic reimbursement OCST utilization Preauthorization

5 Sleep Medicine Realities Totally Challenged: How does sleep medicine remain relevant? Totally Fluid: Who will pay? How much will they pay?

6 Standards of Practice (CPGs) Screening Diagnostic Evaluation Accredited Sleep Center with Board Certified Sleep Physician (BSCMP) Interpretation Testing and Interpretation Treatment Initiation Early Management DME Primary Care Practitioner or Non- Sleep Specialist Long Term Management Only performed by accredited sleep practice (board certified sleep physician and sleep team) Quality Metrics Performed by accredited sleep practice and/or primary care provider/non-sleep specialist

7 Telemedicine - Why Sleep? Sleep Physicians : 7,500 Persons in US with: OSA: 18,000,000 RLS: 30,000,000 Insomnia: 30,000,000 Ratio: 10,400 : 1

8 What is Telemedicine? The exchange of a patient s medical information from one site to another via electronic communications to improve a patient s clinical health status.

9 Telemedicine - Why Now? Imagining our Future Emphasis on Patient Management Influx of New Patients Decreased Reimbursement Reaching Rural Populations Patient Directed Care Collaborative Care

10 Development of a Strategy Evaluate if telemedicine is right for your center Identify your target audience Select a model that is right for you Center to Home (C2H) This model uses the patients own technology laptop or cell phone Center to Center (C2C) This model is usually at a medical office or clinic

11 Strategy Cont. Identify hardware and software needs Evaluate financial considerations How do I get paid How much does it cost Capital for new equipment Development of new procedures

12 Strategy Cont. Personal needs Training of new and old personnel Clinical Space Advertising IT staff Access to supportive and knowledgeable IT staff is indispensable in developing and using telemedicine Understand the regulatory, legal and ethical considerations

13 Things to ask yourself Are we comfortable with technology? Are we willing to adapt to a new communication skill set? Do patients need improved access and/or is there a remote patient need? Are referring providers and /or patients adaptable to telemedicine visits?

14 Reimbursement for Service Private Insurers Coverage rules vary based on the originating site s state. Most states require that insurers reimburse telemedicine visits the same as (a parity with) in-person visits based on Evaluation and Management coding rules. Several additional states are considering similar parity laws. Up-to-date, state specific information can be found at American Telemedicine Association telehealthpolicy.us/state-laws-and-reimbursement-policies The National Telehealth Policy Resource Center Sleep Telemedicine Implementation Guide American Academy of Sleep Medicine

15 Medicare Medicare only reimburses real-time video teleconferencing (C2C) when the originating site is in a Health professional shortage area, as defined by the US Office of Management and Budget. It also excludes home-based telemedicine, significantly limiting patient eligibility. You can find out if a particular site is eligible for Medicare coverage at: datawarehouse.hrsa.gov/telehealthadvisor/telehealtheligibility.aspx US Department of Health and Human Services If an originating site is Medicare eligible, the Centers for Medicare & Medicaid Services (CMS) provide up-to-date coding guidelines for clinical encounters at: Network-MLN/MLNProducts/ downloads/telehealthsrvcsfctsht.pdf Centers for Medicare & Medicaid Services Sleep Telemedicine Implementation Guide American Academy of Sleep Medicine

16 Medicaid Similar to private insurer parity laws, Medicaid coverage for telemedicine visits is state specific. Additionally, individual states put restrictions on which type of telemedicine visit can be covered (e.g., real-time video telemedicine visit only). Two particularly useful Medicaid-related sources are: American Telemedicine Association National Conference of State Legislatures Sleep Telemedicine Implementation Guide American Academy of Sleep Medicine

17 Patient s out of pocket fees There is evidence that patients are willing to pay outof-pocket costs for telemedicine services. Nevertheless, viability of this funding source depends on careful analysis of the population served. Additional expenditures may be incurred due to enhanced marketing, advertising, and direct-topatient billing. Sleep Telemedicine Implementation Guide American Academy of Sleep Medicine

18 Equipment

19 Data Transmission Security and Stability issues may be challenging Private site to site commotions Major broadband networks High speed internet T1,T3 dedicated fiber, DSL, Cable Shared internet line- less reliable Webcam Mobile examination camera HIPPA-Compliant,encrypted software

20 Physician EMR Telemedicine Goals 1. Improved Access 2. Cost Efficiencies 3. Improved Quality TXT Office Visit Patient Video Visit Kiosk Home Tablet Auto-matic Process Essential Components 1. Remote capability 2. Automated care processes 3. Self-directed care 4. Integrate end-toend care

21 Telemedicine Mechanisms in Sleep Medicine

22 Home Sleep Testing Sleep Provider

23 Automated care processes Self-directed care mechanisms Remote mechanisms Comprehensive End-to-End Care Model Integration Systems Team-Based Care Educate Patient Insomnia App CPAP App Video Visit TXT HST PAP (modem) Sleep Center Integration system Communi-cation system PA Physician RN MA Therapist/ techs Other Devices EMR

24 Role of Non-Physician Personnel Create Policies and Procedures: Front Office/Scheduler or designee: Gather information for clinician to determine appropriateness of TM prior to scheduling Provide information about the limitations of telemedicine Provide and obtain the Informed Consent for Telemedicine Consultation

25 Role of Non-Physician Personnel Cont. Medical Assistant, RT, Sleep Technologist, RN: Obtain the vitals prior to the consultation Obtain any necessary clinical assessment paperwork and transmit electronically Introduction of the patient to the clinician Let the patient know if there are issues to open the door and request assistance

26 Current Roles of the Sleep Technologist Remote Scoring Technologist: Scoring of sleep studies via Secure HIPAA compliant methods Requirements are under the federal and state requirements (RPSGT and State Licensure) Pros: It s a good option for facilities that need support on a full time or flex time for periods of high volume or short staffing Cons: Typically contractual arrangements (no benefits, professional liability insurance, and tax liabilities)

27 Current Roles Cont. CPAP Setup For patients that don t have a local DME to provide the CPAP setup Demonstrate use and fitting of same equipment that s been shipped to the end point of service Troubleshooting with mask fits (have the patient demonstrate fit)

28 Current Roles Cont. PAP Compliance Officer: Responsible for day to day monitoring of adherence through wireless uploads Identify compliance trends: hours of usage, leak, and AHI Compliance can be predicted as early as days 3-7 Be proactive and leverage this data to enhance PAP adherence

29 Wireless Modem

30 Automated care mechanisms Modem Office Visit Telephone Enc Modem + Automated Platform (Usleep or Sleep Mapper Sleep Seeker) TXT Automated algorithms Em ail

31 Future Roles Cont. Real time tech support: Patient can contact a 24 hour CPAP support service where the patient can download the cloud based app and have a live F2F encounter

32 Considerations Automated educational systems Encourage use of automated self-directed CPAP follow-up (ie. Wakeuptosleep.com, Sleep Mapper) Internet based insomnia CBT Direct EMR integration versus External integration system Explore built-in EMR capabilities (auto-link to appts, smartphrases) Screening strategies for primary care physicians and other providers

33 Considerations Conflicts of interest Be mindful of federal regulations such as those that are explicitly noted by the Stark Law Privacy issues and data security Be knowledgeable of applicable aspects of the Health Insurance Portability and Accountability Act (HIPAA) Physician-patient interactions Structure sessions in accordance with local state policy Telepresenter be mindful of scope of practice issues regarding the provider performing the telepresenter role according to local state policy Informed consent Check with your legal experts on verbiage Licensing Determine what licensing requirements are, both for where you practice and where your patient will be, according to state policies Internet prescribing Check with state medical boards and pharmacy boards as well as local and state policies Malpractice Check with insurance provider to make sure the policy covers telemedicine and coverage extends Sleep Telemedicine Implementation Guide American Academy of Sleep Medicine

34 Resource Guide

35 Conclusion Future success requires: A highly trained sleep team under the direction of a BCSMP Collaborative relationships with primary care Monitoring of outcomes and focus on quality Incorporation of new technologies to reach more patients and provide them with better care

36 Thank You

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