Perinatal Telemedicine

Telemedicine is the delivery of medical care or services from a distant site. Telemedicine provides two-way, communication between a patient and healthcare provider at a distant site. The communication is supported by audio and video equipment that allows a physician at the main hospital/office to see the patient and/or sonogram.

Telehealth refers to a broader scope of remote services than telemedicine and refers to a collection of means or methods for enhancing health care or health education using telecommunications technologies. While similarities exist between health information technology (HIT), health information exchange (HIE) and telehealth, neither HIT nor HIE are considered to be telehealth.

TYPES OF TELEHEALTH SERVICES

Synchronous or live, interactive videoconference consultation: this occurs when a physician and the patient communicate in real-time but are not in the same geographic location. Typically the specialist is often in a special telemedicine facility or in his or her office. The patient is at a different location, such as a clinic or hospital, and may be accompanied by her local provider or a telemedicine facilitator at that location. Communication is facilitated typically by using secure videoconferencing in which the physician’s image is captured by a video camera, digitized and transmitted over secure, broadband speed telecommunications lines to the patient’s location where it appears on a video screen and viewed by the patient. At the same time, the patient’s image is captured by a similar secure process and transmitted to a video screen viewed by the physician. The audio aspect of the conversation between the patient and the physician is captured and transmitted in the same way. Broadband speeds must be sufficiently fast to enable conversations as if they were in the same room, hence the descriptor “live, interactive” for these types of consultations. Telemedicine specialty consultation provides care to patients or advice to other medical providers in a particular medical subspecialty or healthcare specialization in cases in which the recipient of that service is located in a different geographic location from that of the provider. The provider is typically reimbursed in the same amount that he or she would receive if the patient had been seen in the provider’s office. The Federation of State Medical Boards has also promoted the adoption of a special purpose license to cover telehealth interactions.

Store-and-forward consultation: this is one in which information is captured from the patient at one time and location and evaluated by a provider at another time and location. It derives its name from the fact that information is captured and “stored” in a digital file at one location and then transmitted or “forwarded” to another location for evaluation

Hybrid consultation blends synchronous and store-and-forward consultations.

Benefits of Perinatal Telehealth

• Increase access to specialty care

• Improve efficiency

• Extend the scope of obstetric practice

• Improve pregnancy outcomes

• Reduce costs in the healthcare system

• Reduce travel burden and related costs to the patient

Uses of Perinatal Telehealth

• Provider-to-provider consultation (e.g. perinatal, genetic, diabetes, hypertension, etc.)

• Provider-to-patient consultation

• Tele-ultrasound and tele-echocardiogram

• Remote patient monitoring

• Non-stress tests

• Postpartum management (depression, weight loss, follow-up visits, etc.)

• Research

• Patient education

Originating sites recognized by Medicaid (HHS, CY 2015)

• Physician or practitioner offices

• Hospitals

• Critical access hospitals

• Rural health clinics

• Federally qualified health centers

Models of Telehealth

Telehealth Services comprise three components with overlapping responsibilities – (1) clinical care, (2) technology support, and (3) administration. In a membership organization, providers and consumers of telemedicine services function as a network, matching the need for services with those providing the service. Independent businesses can provide telemedicine consultation services comparable to organizations that arrange physician locum tenens services, whereas the business recruits physicians into its network who then agree to provide telehealth services.

Building your team

• Telemedicine endeavors can range from single originating and distant sites to networks comprising many originating and distance sites, delivering any number of Maternal-Fetal Medicine services. In most cases, existing clinical, administrative, and technology staff members can receive training to incorporate telemedicine consultation into their daily practice.
• Ensure your telemedicine network is HIPAA- compliant.
• Ensure your telemedicine network provides reliable connections with sufficient bandwidth to support real-time interaction between the originating and distant sites to ensure the best quality of care.

Each organization would deploy a unique program that includes Inpatient (Consult driven, 24/7 billable), and Outpatient (Teleconsult specific for perinatology and inclusive of a multispeciality clinic). Patients currently cannot refer themselves directly or initiate Perinatal Telemedicine consultations. Requests for consultation need to come from the originating site via a medical provider. Both the originating site and distant site have to be approved to provide telehealth service to avoid claim denial. Prior authorization is required in order to bill for telehealth services at both the originating and distant sites. The Federation of State Medical Boards requires that physicians engaging in telemedicine be licensed in the State in which the patient is located.

Once the initial encounter is established via telehealth, a follow-up encounter can then be established via telehealth or with an in-person consultation. The patient has the option to decline telehealth at any time and request an in-person encounter. The originating and distant sites have to be approved to provide telehealth services, such as the accreditation provided by the American Telemedicine Association. In order to select your telemedicine cart, it is necessary to work with your technology department and your State’s directory of resources. The directory lists companies providing telemedicine carts and ancillary services (e.g. patient education and language interpretation) through telemedicine to healthcare providers such as hospitals, clinics, private practices and urgent care centers. The Society for Maternal Fetal Medicine does not endorse any specific vendor for telemedicine resources. Market growth will be bolstered with the expansion of telemedicine services and increased awareness and implementation of standards for reimbursement.

The following lists team members typically seen at originating and distant sites:

Originating Site Team

• Local provider

• Sonographer (providing tele-ultrasound)

• IT Personnel / Technologist

Scheduler / Distant Site Team

• Distant Specialist

• IT Personnel / Technologist

• Scheduler

Telemedicine Network Team

• Medical / Clinical Director

• Project Manager

• Outreach Coordinator

• Telemedicine Coordinator

• Telemedicine Troubleshooting Hotline/ Telemedicine Technologist

• Patient Call Center

Telehealth Action Plan Worksheet

 What are your jurisdiction’s clinical and educational needs that can potentially be addressed through telehealth?

 How will you use telehealth to address those needs?

 What will be the funding and/or revenue streams from your telehealth practice?

 Will that funding be adequate for provider participation and sustain the program?

 Have you identified and formed partners at the originating and distant sites?

 How does your organization culture deal with change?

 Who is (are) your telehealth champion(s)?

 Will your organizational decision makers support the use of telehealth?

 What are your current technical capabilities (i.e. equipment, bandwidth, firewalls, technical infrastructure, and support staff)?

 What are your goals and timeline?

Physician Reimbursement Models in Telehealth

Telemedicine consultations will require the same elements as those required in regular face-to-face consultations, that is (1) request, (2) opinion, and (3) written report. Reimbursement may include Fee for Service, Pay for Performance/ACOs, Global or Bundled Payments, or Episode of Care Reimbursement. The provider is typically reimbursed the same amount as if the patient had been seen in the provider’s office. The Federation of State Medical Boards promoted the adoption of a special purpose license to cover telehealth. Modifier 95 (Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system) debuts in the 2017 CPT manual to presumably take the place of Medicare’s modifier GT. The communication of information exchanged during the course of the synchronous telemedicine service must be sufficient to meet the key components and/or requirements (i.e., time) of the same service when rendered face-to-face with the patient. CPT provides a list (located in Appendix P) of services that are typically performed face-to-face, but may be rendered via synchronous telemedicine. Modifier 95 may only be appended to the services listed in Appendix P. The services are also identified with a “” symbol next to the individual CPT code in the manual. Services that may be reported with modifier 95 include office and inpatient Evaluation and Management codes, Patient Self-Management Training, Medical Nutrition Therapy, and Genetic Counseling services. For a full list of applicable CPT codes, see Appendix P of the 2017 CPT-4 coding manual.

Obstacles to Telemedicine

Those who have never used telemedicine may be skeptical of its feasibility and effectiveness or concerned about the potential loss of the doctor-patient relationship that is fostered with in-person care. Some specialists perceive their time as already fully booked and do not feel they have the availability to see patients via telemedicine. Local providers may perceive that specialists providing telemedicine could “steal” patients away from their community. Most physicians believe they will not be reimbursed for telemedicine services. The best way to address these concerns is a comprehensive community outreach program combined with internal and external marketing that raises awareness on the purpose and benefits of telemedicine.

Talking points and FAQs

• Do the telemedicine providers have to be credentialed at the facility where they are located? YES

• Do telemedicine providers have to be credentialed at the facility where the patient is located? YES, per current Medicaid requirements. Exception applies when a physician provides advice to another physician in a remote facility via telemedicine and the remote physician retains responsibility for the care of the patient. Under these circumstances, consulting specialists do not need to be specifically credentialed at a remote facility if they are credentialed at their own institutions. These Joint Commission standards allow for the option of credentialing and privileging by proxy.

• Do providers need to be specifically covered for telemedicine by their malpractice insurance? YES. Every physician or medical/clinical specialist who provides telemedicine consultations should have malpractice coverage that specifically includes telemedicine. In those cases, an insurance rider to supplemental insurance specifically for telemedicine may be obtained.

Download the PDF

_RESOURCES

_{1. American Telemedicine Association – www.americantelemed.org/home}

_{2. Telemedicine Resource center and Buyer Guide –www.telemedicineresourcecenter.org/getProducts.cfm?searchmode=home&dir=251DAE&expCats=true}

_{3. ATA Accreditation – www.americantelemed.org/ata-accreditation}

_{4. State Policy Resource Center (standards, licensure, reimbursement, etc.) www.americantelemed.org/policy-page/state-policy-resource-center}

_{5. Center for Telehealth and E-Health Law – www.ctel.org}