The National Telehealth Webinar Series
Presented by
The National Network of Telehealth Resource Centers
Telehealth Resource Centers
http://www.TelehealthResourceCenters.org
• California Telemedicine & eHealth Center (CTEC)
• Great Plains Telehealth Resource & Assistance Center (GPTRAC)
• Heartland Telehealth Resource Center (HTRC) • Mid Atlantic Telehealth Resource Center (MATRC)
• National Telehealth Policy Resource Center (CCHP)
• National Telehealth Technology Assessment Resource Center (TTAC)
• Northeast Telehealth Resource Center (NETRC)
• Northwest Regional Telehealth Resource Center (NRTRC)
• Pacific Basin Telehealth Center (PBTRC)
• South Central Telehealth Resource Center (SCTRC)
• Southeastern Telehealth Resource Center (SETRC)
• Southwest Telehealth Resource Center (SWTRC)
• TexLa Telehealth Resource Center (TEXLA)
• Upper Midwest Telehealth Resource Center (UMTRC)
Comprehensive Telemedicine: A Practical Approach
Presented by: TexLa TRC
Speaker: Kim Dunn, M.D., Ph.D.
Your Doctor Program, L.P.
Houston, Texas
Thursday, October 16, 2014
(8:00AM HST, 10:00AM AKDT, 11:00AM PDT, 12:00PM MDT, 1:00PM CDT, 2:00PM EDT)
Comprehensive Telemedicine:
A Practical Approach
Kim Dunn, MD, Ph.D.
[email protected]
Talk overview
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»
»
»
What are the standards of care today?
Medical home
Comprehensive telemedicine
Leadership development for value based care
Current reality
FINANCIAL / REGULATORY
PATIENT OWNERSHIP
QUALITY MANAGEMENT AND SERVICE
Current reality cont.
Current information management
Clinical Documentation
Subjective
Objective Assessment
Doctors paid on
what document in
subjective and
objective, not
assessment, plan.
Current EMRs
follow the money
and also do not
incorporate
outcomes nor
telemedicine.
Patient Outcomes Payment
Plan Variables
So the most
important
is…….
Genetics
Not
automated
Not integrated
outside of
doctor office
Social
Environ
Data
not easily
obtained
Not
actionable
Disjointed
Used as a
surrogate
for quality
Value based service
Quality
Value =
Cost
Quality attestation
Quality
Population health
• Ambulatory: Age, sex, disease
specific PQRS/measures adjusted
for social / clinical factors /
adherence
• Inpatient: Required regulatory
Patient experience
• Satisfaction / patient education
• Improve access via telemedicine
Cost / Payment
• Payment for telemedicine
• Real time claims management
• Point of service payment via
quality attestation
Value-based Care
Strategy
Save lives and money
through engaging
physicians in
telemedicine and quality
and patients in their care.
Partners
CME: Texas Medical Association
CNE: Care Track, LLC, State of California
Payers
KDunn and Associates, PA
Value based contracting for patient centered,
telemedicine based care.
We assure
The Physician Quality Standard TM is met
via peer review and practice-based CME-CNE.
Primary: Business
Insist on The Physician
Quality Standard TM
Secondary
•
Payers: What does
The Physician Quality
Standard TM mean?
•
Consumers: How we
assure your care is
coordinated, safe, and
effective if you do your
part.
Patient
Your Doctor Program, L.P.
Schull Institute, a 501 C 3
Training and support for telemedicine, medical home,
population management, and clinical integration.
De-identified data analysis
Accomplishments since
commercialization
» Comprehensive
reimbursable
telemedicine model
» Feedback from
patients to improve
service and
decrease liability
Quality
» Saved lives with two pilots in
high risk populations (dual
eligible) and homeless (1.5%
mortality reduction
» Established program for quality
that overcomes physician
barriers for engagement
»
Patient
»
Service
Cost
• Defined CME / CNE Program
• Defined market for employer community
Eliminate ED visits
for primary care
Reduced
readmissions 75%
Our value summary
KDunn and Associates, Standards for Value Based Care
Your Doctor Program for
Quality attestation
for point of service
payment for Value
Based Care
Accountable Communications
Benefits
Total quality
management
Use of The
Physician Quality
Standard TM by
practitioners
meeting standards
Patient centered,
telemedicine based
service delivery
Patients / Payers
Providers
Service Products
Save money
Healthcare in Your Hands
Care is coordinated, safe, and
effective
Leadership development for quality,
service, and effectiveness
Medical Home in a Box
Accountable Care in a Box
Technical integration to standards
Paid for telemedicine
Engagement for prevention
and disease management
Paid faster via quality attestation
model
Improved access and save
time / money via
telemedicine
Save money via medmal reductions
Board Re-Certification
* KDunn and Associates, P.A., dba HealthQuilt, is a practice association for value based care contracting. We use a patented
process for total quality management via peer reviewed program for standards of practice for a patient centered, telemedicine based
care delivery model.
Value improvement via
total quality management
Ongoing value improvement
» Quarterly value improvement peer comparison reports
» Population health: Top five clinical quality adjusted for patient
adherence and patient social / clinical risk factors.
» Patient experience: Service and patient engagement
» Cost: Total cost with emphasis on devices, total costs, readmissions
» Annual value improvement
» Population health: Top five clinical quality metrics adjusted for patient
adherence and patient social / clinical risk factors.
» Patient experience: Service and patient engagement
» Cost: Total cost with emphasis on devices, total costs, readmissions
Medical home
HEALTH HOME
* Patent pnd
Clinical Centered Model
Encounter Type
Consumer Centered Model
Key actions
Billing Event
In Person
Annual /
Population
healthdata
Annual visit with medical home
Med Home: In person / episodic
Ongoing:
Eight
in
person
Sign MH / Info mgt agreements
Credit card on file
Training on tool / download application
Establish pt's doctor network
Establish / update care plan /allergies
Select one prevention goal: Need Smoking Cessation / Weight
Reduction?
Disease specific goals / contracts
Health Risk Assessment
Update living will / mpoa
Preparedness plan given
Patient card sent
In Person
X
X
X
X
X
xxxx: Prevention
xxxx: Patient teaching
xxxx: HRA
Upload encounter note / labs / imaging
Define tasks
Send encounter survey
Trip claim
Update care plan
xxxx: Encounter note
Upload encounter note / labs / imaging
Define tasks
Send encounter survey
Trip claim
Care plan updated and all patient records updated
Messaage / fax referral request
Order
Patient take care plan with them with request
Care plan recommendations updated
xxxx: Encounter note
Note / data uploaded vs. faxed back to medical home
Care plan updated
Define tasks
Send encounter survey
Trip claim
Care plan updated
Message / fax referral request
xxxx: PMPM or PCO
Patient take care plan / card with them
Define tasks
Send encounter survey
Patient take care plan / card with them
Note /data uploaded vs. faxed back to medical home
xxxx: DME/Pharmacy
In Person External Referral Specialist /
Lab
Referral for DME / Pharmacy
Home Health
Ongoing:
Six telemed
in care plan
* documentation
inside the care
plan
Note / data uploaded vs. faxed back to medical home
Care plan updated
Define tasks
Send encounter survey
Patient care plan managed by home health with oversight from
medical home
Patient Take Care plan, instructions, and card to visit.
Request care plan update and encounter data faxed /
uploaded
X
X
Patient Take Care plan, instructions, and card to visit.
Request care plan update and encounter data faxed /
uploaded
X
X
Care plan updated
Define tasks
Send encounter survey
Patient take care plan / card with them / Care plan managed by
nurse as inpatient and attending physician assumes medical
home care oversight role
1. Attending / staff
2. Consultant / staff
3. DME / Meds
Patient Take Care plan, doctor instructions, and card to
visit. Request care plan update and encounter data faxed /
uploaded
X
X
X
X
X
X
X
X
Patient Take Care plan, doctor instructions, and card to
visit. Request care plan update and encounter data faxed /
uploaded
X
X
X
X
xxxx: PMPM or PCO
Emergency / Urgent Care
Hospital / Nursing facility based
X
X
X
X
X
X
Patient Take Care plan, doctor instructions, and card to
annual visit. Request care plan update and encounter data
faxed / uploaded
X
X
X
xxxx: PMPM or PCO
Patient Take Care plan, instructions, and card to visit.
Request care plan update and encounter data faxed /
uploaded
X
X
xxxx: PCO
Telemedicine
Messaging
Med Home: Telephone during Office
Hours
Med Home: Telephone after Office
Hours / Oncall
Curbside: Med Home-Specialist
LIV: Patient-MH or Specialist
Biomonitoring: Patient-Medical Home
Part of care plan for administrative purposes
Update care plan
Document telemed encounter note / labs / imaging
Define tasks
Send encounter survey
Trip claim or credit card payment
Update care plan
Document telemed encounter note / labs / imaging
Define tasks
Send encounter survey
Trip claim or credit card payment
Update care plan
Message request
Phone conversation
Specialist document encounter recommendation
MH Update care plan
Define tasks
Send encounter survey
Trip claim or credit card payment
Update care plan
Message request
Video call in system
Specialist documentation encounter in system
MH Update care plan
Define tasks
Send encounter survey
Trip claim or credit card payment
If patient does not have FOR A, gets daily message to enter their
data per the disease protocol
If can get FORA
Training on tool
Sync with mobile app
Uploads daily
Threshold established for patient
Above threshold triggers alert to clinical support to call the
patient
Care plan updated
Define tasks
Send encounter survey
If not already PMPM, trip claim for PCO
xxxx: Encounter note
xxxx: Encounter note
xxxx: Encounter note
xxxx: PMPM or PCO
Done inside the Care Plan Management, documentation,
billing at the point of service delivery completion or per
contract
xxxx: Encounter note
xxxx: PMPM or PCO
xxxx: PMPM or PCO
Point of
Service
Payment /
via Quality
Attestation
1. Care
Plan /
Tasks
2. Upload
data
3. Send
Survey
4. Ongoing
CME/
CNE
Trip claim to
rendering
physician
Healthcare in Your Hands TM
Patient centered care automation
Comprehensive telemedicine
» Care plan (all records available and
translated into an integrated care plan)
» Messaging for administrative tasks
(prescription refills, schedule appointments,
call center support)
» Biomonitoring for patient engagement
» HTN: Blood pressure, weight
» Diabetes: Glucose, exercise, diet
» Weight loss
» Smoking cessation
» Telephonic / live interactive visits
» Medical home / primary care
» Specialists
Medical home / specialists for
clinical integration
Physician Care
Oversight
Outpatient: Medical
Home
Methodology
•
•
•
•
•
Inpatient:
Attending as
“Temporary
Med Home”
•
•
Base standard
CME / CNE to customize
treatment preferences
Primary care manage
care plan including risk
factors and patient
tasks
Curbside from specialist
to primary / attending
Population health via
Annual Health Risk
Assessment
Defines patient
engagement tasks
Quarterly feedback
Specialists
Outpatient :
Defined by medical
home
Inpatient:
Defined by
attending
physician
What it means for a patient
» One phone call
» 24 / 7 access to a doctor via telemedicine
» Care coordinated via care plan and
telemedicine, working with home health
» Care transitions eliminated
» Service follow up all encounters
» Care coordinated, safe, and effective
Telemed: care plan / messaging
Population health
» Prevention Visit: Annual age, sex, disease
specific health risk assessment that
attributes physician ownership / risk
adjustment
» Disease management tracking
Health risk assessment
Disease Tracking /
Biomonitoring
Patient agreement
Patient tracking, many devices
for electronic tracking
Telephonic / Live interactive
» Primary care: $50 if established care
» Specialist “curbsides”: $75, applies to
deductible if need in-person, part of
clinical integration program
» Live interactive
» Per doctor for second opinion
» Hospital care transitions using care plan
management process and home visits for
telemedicine via physician care oversight
Encounter
Documentation
» 15 encounter type
templates
» Linked to CPT /
transaction codes
» Survey follow up 3
days after service
delivery with provider
attribution
YDP card and
Secure online access
Front of card
» Identifies your primary doctor
contact for information
» Access for your doctors to
your care plan through the
Quick Response (QR) code
» HIPAA compliant QR reader
Back of card
» Your name
» Instructions to your doctors to
follow information management
standards
» Financial strip
Smartphone Application
Supports communication
and biomonitoring Personal QR reader
takes you and a doctor
to your care plan
Medical Home in a Box TM
Train the trainer model
» Teach medical home,
telemedicine, clinical integration
» Policies / procedures
» Training manuals
» Online training
» Patient contract reviews
» Branded card printing
» License of Healthcare in Your
Hands integrated into care
delivery
» Marketing plan for The Physician
Quality Standard TM
90 Day Team for Value Based Contracting to
The Physician Quality Standard TM
» Kim Dunn, MD, Ph.D.: Physician leadership development,
telemedicine, medical home, preparedness and disaster
response
» Sandra Petersen, DNP, Ph.D.: Nurse leadership development,
patient engagement for self management, hospice, policies/
procedures
» Karen Garmin: Policies / procedures
» Jay Stowers: Liability management
» Justice Kennedy: Financial management
» Kevin Dunn: Marketing with The Physician Quality Standard TM
» Adi Kadapa, MD, MS: Technical integration lead
90 day initiation
Month 1
» Initiate physician leadership / business plan
» Policies and procedures for value based contracting to The Physician Quality Standard TM
» Network / Leadership Development
» Video production for specialist “baseline protocols” for primary care / patient education
» Primary care / Emergency / Hospital physician agreements for Peer Review with KDA
» Co-branding / Marketing plan for cards / employers / MCOs
» Initiate technical integration roadmap via YDP care plan framework
» Initiate FTC Letter of Determination for Clinical Integration based on policies and procedures
Month 2
» Medical Home in a Box TM: Physician Care Oversight for Patient Centered Care / Quality
» Outpatient
» 2 day onsite consulting, workflows, tasks, go-live with HIYH Info Kiosks, NCQA application / 90 day
reporting period
» Inpatient (Temporary medical home)
» 2 day onsite consulting, workflows, tasks, go-live with HIYH Info Kiosks, clinical integration
» Initiate employer marketing campaign
Month 3
» Finalize technical integration
» Initiate peer comparison report program
» Expand employer marketing campaign
Initiation
STAFF TRAINING
PHYSICIAN LEADERSHIP DEVELOPMENT
» Content
»
»
»
»
»
»
»
»
Standards for information management
Clinical integration / Accountable care
Medical home
Telemedicine
Liability reduction
Patient engagement
Care plan / regulatory management
Care transitions
» Activities onsite with nursing staff
» Practice assessment- clinical, business
» Document treatment preferences
» Telemedicine training
» Takehomes
» Clinical quality improvement plan
» Secure IT / Risk infrastructure
» Quarterly reviews
» Annual PDCA
» Content
»
»
»
»
Policies / procedures
Workflows / tasks
Communication / telemed standards
Preparedness
» Activities
» Workflows / tasks
» Takehomes
»
»
»
»
Checklists for workflows / task lists
Policies / procedures
Ready for reporting
Satisfaction / Education improvement plan
90 day timeline
Month One
Deliverables
Wk1
Wk 2
Month Two
Wk 3
Wk 4
Wk1
Wk 2
Month Three
Wk 3
Wk 4
Wk1 Wk 2 Wk 3
Wk 4
Physician leadership development for clinical integration, medical home, telemedicine
Telespecialists
Agreements
Peer review agreements
with all doctors in pilot
Online customized CME /
CNE training program
YDP baseline protocols
customized to XXXX
Disease management /
telemedicine established
Film, edit
Peer review agreements
XXX Physician
/ Nursing
Leadership
Training
Ongoing Practice based CME /
CNE
Customize training platform / content with XXXX
Rapid medical home to
NCQA Level 3 / FTC Clin Int
Train the
Trainer Medical
Home Program
for 90 day
reporting
period
Customized to XXXX
Policies and Procedures: Clinical integration, medical home, telemedicine, quality, risk management
Assessment, evaluate
Proposed changes
Complete customized policies
Transition
Training and Support Manuals for patients, doctors, staff, specialists, nursing
Technical integration plan
Technical
assessment
Co-branding / marketing
program
Marketing to SIE
Financial/ regulatory models
Proposed changes
Phase 1 implementation: Data
submission / presentation layer
Materials developed:
website, card, printed
ID Targets
FTC Clinical Integration
Letter / Value based care
Review
Codes defined
Ongoing Support: Card field
printers, patient application
Co-marketing to SIE/ Business community
Consulting Team for 3 Month Clinical Integration / Licensing Initiation
Staff
Leadership
Policies
Training
Dr. Kim Dunn
Dr. Sandi Petersen
Jay Stowers
Kevin Dunn
Justice Kennedy
Sean Harkins
Karen Garmin
Dr. Adi Kadapa
**
*
*
*
*
*
*
**
**
*
*
*
Technical
assessment
*
*
Branding
**
*
*
**
Marketing to
Employers
*
Financial /
regulatory
*
*
*
**
*
**
*
*
Hours
480
130
120
480
480
480
150
480
Total for Initiation 2800 hours
Example business proforma
Actual
New Revenue by Population Health / Value Based Contracting
• $2.8 M annual revenue
• 6 physicians
• Active patients: 34750
• Average pts / doctor / day: 18
Daily
Monthly
Average per day per doctor
Number of doctors
Total Visits
18
6
108
2160
Acuity Level of patients
Level 1
Level 2
Level 3
P4P
26,461
6289
2000
Annual
1 visit
Telemedicine
2 telephonic / day / practitioner
/ 5 oncall
PCO/ QM / Biomonitoring
(50/50 split)
2.5
5
12.5
Comprehensive
Annual YDP new
wellness / disease
Annual
management /
visits
preparedness
not
model for service
covered
delivery model
with increase of
$100
Physician care
Telephone visit
plan oversight: payment during Clinically
Info / Quality
day 2/ doctor Integrated
management /
plus on call 4, Specialists:
Biomonitoring: total daily is 16 /
$50
2.5/5/12.5 PMPM
day $30
8830
INCREASED
ANNUAL
883000
2646100
628900
200000
883,000
Current
model
200
100
YDP
model
300
100
0
60
0
60
300
520
Phone calls
NP extender for annual visits home and wellness
/ office
visits
3,475,000
793830
377340
300000
1,471,170
793830
188670
60000
1,042,500
6,871,670
Definition of a computer
One who computes…….
The patient……
And their doctors…
Lifelong patient ownership
365 / 24, all situations
•
•
•
•
•
•
Self management
Education
Accountability
Wellness
Biomonitoring
Social support
Disaster
preparedness
Engaging physicians in quality
Framework transition
»
»
»
»
Current model
Model: Episode based,
financial based, not
patient accountable
Communication: Fax,
voice mail, no follow up
Documentation: Review
of Systems / Exam
Payment: Episode of
care with challenges of
denials, lack data
»
»
»
»
YDP model
Model: Quality based,
patient centered, data
integration
Communication: Care
plan, telemedicine
Documentation: Care
plan, outcomes, tasks
Payment: Paid for
telemedicine / point of
service completion
How we work with employers
» Insist on
» standards for information and quality management
» Telemedicine
» point of service payment via quality attestation
» Meetings with all contracted insurers / managed care
»
»
»
»
Define target populations
Pre-adjudicate claims
Pay for comprehensive telemedicine / in person
Pre-post impact on quality, service, cost for shared savings
programs
Benefits
Providers: Physicians / Hospitals / Nurses
» Rapid clinical integration
» Rapid medical home
» Payment at point of service completion via quality attestation starting with telemedicine
» Get in charge of quality, service, and efficiency for all required CME / CNE and Board Re-certification
» Clinical integration
» Hospitals: Reduce 30 day readmissions, regulatory information management, liability
» Ambulatory: Pay for wellness, telemedicine, improve revenue cycle management, reduce regulatory information
management, liability, all P4P
» Technical integration to support current technology
Employees / Consumers / Patients
» Improve access via telemedicine
» Remove hassles for administrative requests
» Frustration of duplication of data to different doctors
» Improve safety of healthcare system
» Ownership of their wellness and care
» Emergency management service and travel medicine support
Employers Save 3-7 % on healthcare costs with no new cost outlays
» Patient knowledge of their responsibilities to own care
» Practitioner ownership of quality and cost reductions
» Emergency workers have access to core patient data
» Decreased costs via telemedicine
» Improved worker compensation
» Eliminate fraud
Next steps
» Enroll in “Train the trainer” program for
leadership development
» Identify physician, nursing, pharma, IT,
financial, marketing leaders for initiation
» Approve project plan
» Initiate 90 day project to value based
contracting via medical home,
comprehensive telemedicine and total
quality management
Contact
»
»
»
»
Kim Dunn, MD, Ph.D.
[email protected]
713-981-6125 (o)
832-752-1635 (c)
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Date: Thursday, November 20, 2014
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