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HHS Telemedicine HackWeek 3: Workflows & DocumentationAugust 5, 2020

Welcome to Telemedicine (TM) Hack! 10-week learning community to accelerate telemedicine implementation for ambulatory care providersEmphasis on peer-to-peer learning Case studies and discussion boards Modeled after CMS-led learning collaboratives (e.g., Transforming Clinical Practice Initiative) Inclusive All ambulatory care providers invited to participate Designed as 10-week sprint Public health need Optimize telemedicine readiness in anticipation of fall COVID-19 surgeGOAL: At least 90% of participants will have conducted and billed 1 or morevideo-based telemedicine visits by September 30, 2020Saving Lives. Protecting Americans.2

“HHS Telemedicine Hack” CurriculumSession #1: Telemedicine– Where Do I Start?July 22nd, 12-1PM ETOffice Hours # 1July 29th, 12-1PM ETSession #2: Workflows & DocumentationAugust 5th, 12-1PM ETYou are hereOffice Hours # 2August 12th, 12-1PM ETSession #3: Billing & Reimbursement– How to Do It Properly & Ensure ComplianceAugust 19th, 12-1PM ETOffice Hours # 3August 26th, 12-1PM ETSession #4: Clinical Best Practices & the Art of the Tele-Physical ExamSeptember 2nd, 12-1PM ETOffice Hours # 4September 9th, 12-1PM ETSession #5: The New Normal– Making Telemedicine Part of Your Permanent PracticeSeptember 16th, 12-1PM ETOffice Hours # 5September 23rd, 12-1PM ETGOALAt least 90% of participants will have conducted and billed 1 or more video-based telemedicine visits bySeptember 30, 2020Saving Lives. Protecting Americans.3

“Telemedicine: Where Do I Start?” Hack #1—Lead Your PracticeHack #2—Know Your WaiversHack #3—Assess NeedsHack #4—It’s All About Access!Hack #5—Start Today“Top 5 Hacks” is accessible on TRAIN discussion boardsSaving Lives. Protecting Americans.4

Logistics Use Q&A function on Zoom for questions and comments for speakersUse Chat function on Zoom for questions re: technical/logistical issuesThis session is being recorded. Your attendance is consent to be recorded.CME/Continuing Professional Development (CPD) credits—Link will be placed in the Chat at end of session. Link also intoday’s Project ECHO email announcement.Saving Lives. Protecting Americans.5

“HHS Telemedicine Hack” Data Use Project ECHO collects registration, participation, questions/answers, chat comments, and poll responses for this programand shares this data with HHS/ASPR. Your individual data will be kept confidential. These data may be used for reports,maps, communications, surveys, quality assurance, evaluation, research, and to inform new initiativesSaving Lives. Protecting Americans.6

Today’s Agenda Case #1: Gastroenterology Clinic at a Rural Academic Medical Center– Eric Shah, Dartmouth-Hitchcock Medical Center,Lebanon, NH (10 min) Q&A Follow-up (5 min) Documenting Workflows– Fay MacDonnell, Workflow Engineer, CA Telehealth Resource Center, Sacramento, CA (15 min) Q&A Follow-up (5 min) Case #2: Care Coordination at a Federally Qualified Health Center– Tollie Elliott, Dara Koppelman, & Leah Shoval, Mary’sCenter, Washington, DC (10 min) Q&A Follow-up (5 min)A recording will be posted to the TRAIN website. Case presenters and other faculty will be available for Office Hours from 12-1PMET on August 12th to answer your questions about today’s session.Saving Lives. Protecting Americans.7

Case #1: Gastroenterology Clinic at a RuralAcademic Medical CenterEric Shah, MD, MBADartmouth-Hitchcock Medical CenterLebanon, NHSaving Lives. Protecting Americans.8

https://en.wikipedia.org/wiki/History of general anesthesia#/media/File:Southworth & Hawes - First etherized operation (re-enactment).jpgGrigsby J, Sanders J. Telemedicine: Where It Is and Where It's Going. Ann Intern Med. 1998 Jul 15;129(2):123-7.Shah E, Rothstein R. Gastrointest Endosc. 2020 May;91(5):1183-1186.

Shah E, Rothstein R. Gastrointest Endosc. 2020 May;91(5):1183-1186.

The reality of what GI actually lth-statistics/digestive-diseasesPeery, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018. Gastroenterology. 2019 Jan; 156(1): 254–272.e11.Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol 2002; 97: 2812–9.Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS. Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis.Gastroenterology. 2004 Jun;126(7):1721-32.

Reality checkMotility specialistreferral (tertiary care)Visit formotilitytesting2nd visitto discussresults 1,000 to 5,000average per patientannuallyin wasted healthcare costsGI referral( out-of-pocketPrimarycareofficeDiagnosis!No local motility testing availableWalk down the OTC aisleOne procedure at a timeTCAs9 FDA-approved IBS and CIC drugsDiagnosis!Dietician visitsMotilitytestingPsychiatry referralsSecond opinions and repeated testsER visits, hospitalizations, and frustrationcosts, missed work, and missed family health-statistics/digestive-diseasesPeery, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018. Gastroenterology. 2019 Jan; 156(1): 254–272.e11.

Our roadmap for your Motility CenterMotility specialistreferral (tertiary care)Visit formotilitytesting2nd visitto discussresultsDiagnosis!GI referralDirect-access testingTelemedicine consultative programPrimary careofficeDiagnosis!

12001000800600400200Appointments per DayHow far we have 16Telephone Office VisitsTelemedicine Appts

Objectives Cover the basic terminology Healthcare access inequities Discuss scheduling challenges and opportunities Q&A

What istelemedicine?Totten AM, McDonagh MS, Wagner JH. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During theCOVID-19 Pandemic. White Paper Commentary. (Pacific Northwest Evidence-based Practice Center, Oregon Health & Science Universityunder Contract No. 290-2015-00009-I). AHRQ Publication No. 20-EHC015. Rockville, MD: Agency for Healthcare Research and Quality.May 2020

Telemedicine 101TermDefinitionOriginating siteWhere the patient is locatedDistant siteWhere you are locatedFacility feeFor qualifying originating sites onlyParity lawSimilar reimbursement for in-person andtelemedicine visits

Telemedicine 101TermDefinitionSynchronous careReal-time care over audio or videoAsynchronous care Provider-to-provider consults(store-and-forward) Not in real time (i.e. email, photos)

Ensure equitable access to telemedicineNouri, et al. Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic. NEJM Catalyst. May 4, 2020.

Broadband penetration in rural AmericaFewer than 10% of physicians practicein rural communities where 25% of Americans liveBut it takes more than bandwidth1. Licensing restrictions2. Reimbursement policies on“qualifying originating sites”3. Incentives for AMCs for teleeducationDrake, et al. The Limitations of Poor Broadband Internet Access for Telemedicine Use in Rural America: An Observational Study. Ann Int Med. 2019 Sep 3;171(5):382-384.Struminger, et al. Leveraging Telehealth to Improve Health Care Access in Rural America: It Takes More Than Bandwidth. 2019 Sep 3;171(5):376-377.

A learning process for everyoneHealth system-created barriers Requiring patient portal use Inadequate interpreter access Inadequate planning fortechnical/internet access challenges Don’t require patient portal Interpreter access Test visits, video tutorials, shifting staff rolesPatient barriers No access to electrical outlet Living in a group setting No internet Advance planning (social work) Advance planning (social work) Advocate for expanded broadband access Poor digital and health literacy Video tutorials, shifting staff rolesNouri, et al. Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic. NEJM Catalyst. May 4, 2020.

How do I transition my schedule? Start small One or two visits end-of-day Short weekend/after-hours session Longer visits Expect technology hiccups Your practice manager as championShah E, Amann S, Karlitz J. ACG Practice Management Toolbox: Essential Guide to Telemedicine in Clinical Practice: EASY STEPSTO RAPID DEPLOYMENT. April 2020.

What types of visits do I need?1. Telehealth (E/M) (real-time video)2. Telephone calls (audio only)3. In-personShah E, Amann S, Karlitz J. ACG Practice Management Toolbox: Essential Guide to Telemedicine in Clinical Practice: EASY STEPSTO RAPID DEPLOYMENT. April 2020.

How do I create a scheduling process?1) Identify priority patients for telehealth2) Educate patients using a script3) Convert patients to telehealth4) Visit by telehealth but have a back-up planMy telemedicine lifehack is Organize your scheduling workflow

Resources Shah E, Amann S, Karlitz J. The Time Is Now: A Guide toSustainable Telemedicine During COVID-19 and Beyond. Am JGastroenterol. Am J Gastroenterol. 2020 Jul16:10.14309/ajg.0000000000000767. Epub ahead of he Time Is Now A Guide to /pmc/articles/PMC7382421/ ACG Practice Management ToolboxEssential Guide to Telemedicinein Clinical Practice: EASY STEPS TO RAPID ntial Guide to Telemedicine in Clinical Practice.pdf

Gastrointestinal Motility, Esophageal, andSwallowing Disorders CenterGI Motility LabCarol Greeley, RNElizabeth Pelletier, RNEridana Harder, RNMichael Curley, MDAdvanced Motility FellowshipProgram DirectorCatherine Giguere-Rich,RD, LDGI DieticianEric Shah, MD, MBACenter DirectorJamie Sanchez,MSN, APRNRichard Rothstein, MD Jessica Salwen-Deremer,PhDGI Behavioral HealthEmily Sieglinger,MSN, APRNRosemarie AddanteMBA, MPAS, PA-CGI Clinic NursesKathy Del Giudice, RNEridana Harder, RNTammy Wilson, RNSchedulingMariah ConnollyShari McBrideElizabeth r-gastrointestinal-motility.html

Your Telemedicine Questions,AnsweredPlease submit your questions through the Q&A boxSaving Lives. Protecting Americans.28

Documenting WorkflowsFay MacDonnellSenior Workflow EngineerOCHINCalifornia Telehealth Resource CenterSaving Lives. Protecting Americans.29

Saving Lives. Protecting Americans.30

Poll Question #1Please answer using Zoom’s polling function.Saving Lives. Protecting Americans.31

Poll Question #2Please answer using Zoom’s polling function.Saving Lives. Protecting Americans.32

Saving Lives. Protecting Americans.33

What is a Workflow? A workflow is the progression of steps or tasks that make up a work process: Physical and/or mental tasks Performed by various people Over time Across roles, teams, or locations A workflow map shows a picture of who does what, and in which order Tasks can be sequential or olkit/workflowSaving Lives. Protecting Americans.34

ExampleSaving Lives. Protecting Americans.35

ExampleSaving Lives. Protecting Americans.36

ExampleSaving Lives. Protecting Americans.37

Steps to Map a Workflow Identify and name the process Clarify the purpose or outcome of the process Identify a clear start and end point for the process List or draw out the tasks and decision points within the process and put them in order Define and note which role completes each stepSaving Lives. Protecting Americans.38

Basic Workflow Map SymbolsSaving Lives. Protecting Americans.39

Putting It All TogetherSaving Lives. Protecting Americans.40

Facilitating Workflow Conversations Gather your subject matter experts (SMEs) Start with pencil and Post-it notes or dry-erase board Ask questions! “Walk me through your typical “ “What do you do now?” “And then what?” “Who does that step?” “Who makes that decision?” “How do you know to do that?” “Tell me more about ” Watch for assumptionsSaving Lives. Protecting Americans.41

Benefits of Mapping Workflows Defines the tasks inherent in a process and the order in which they occur Establishes who does what within a process, thereby reducing ambiguity and confusion Provides a clear, concise visual document to use as a means of communicating about a process Helps to identify gaps or problem areas within a process, enabling teams to direct improvement effortsSaving Lives. Protecting Americans.42

Long-term Success Strategies Designate a champion for team or clinic workflow development and tracking Designate an owner for each workflow Set a schedule to review and update workflows regularly Make sure that workflows are available in a central location that everyone can access; wiki, team binder, etc. Define a communication strategy for updating staff when a workflow changesSaving Lives. Protecting Americans.43

Saving Lives. Protecting Americans.44

Saving Lives. Protecting Americans.45

Saving Lives. Protecting Americans.46

Thank you!Please visit the National Consortium of Telehealth Resource Centers website atwww.telehealthresourcecenter.org for additional telehealth assistance.This presentation was made possible by grant numbers G22RH20249 and GA5RH37469 from the Office for the Advancement of Telehea lth, Health Resources andServices Administration, DHHS.Saving Lives. Protecting Americans.47

Your Telemedicine Questions,AnsweredPlease submit your questions through the Q&A boxSaving Lives. Protecting Americans.48

Case #2: Care Coordination at a FederallyQualified Health CenterTollie B. Elliott, MDDara Koppelman, RN, MHSALeah Shoval, BSN, RN, IBCLCMary’s CenterWashington, DCSaving Lives. Protecting Americans.49

MARY'S CENTER TELEHEALTH LEADERSHIP Tollie B. Elliott, MD – Chief Medical Officer Received a BS & MD from Howard University and completed his Ob/Gyn residency at Georgetown University Hospital. He has workedat Mary's Center since 2015 and became involved with telemedicine in 2011. He serves as the clinical lead for telemedical ser vices atMary's Center. Disclosures (none) Dara Koppelman, RN MHSA – Chief Nursing Officer Received a BA from University of Maryland in Psychology and Spanish, BSN from Johns Hopkins University in Nursing, and MHSA fromGeorgetown University. She has worked at Mary's Center since 2012 and has overseen the telemedicine team since 2017.Disclosures (none) Leah Shoval, BSN, RN, IBCLC – Director of Care Coordination Received a BA from Boston University in Psychology and Photojournalism, BSN from Georgetown University and is currently pursu ingher MSN PNP-PC at Duke University. She has worked at Mary's Center since 2015 and joined the telemedicine team as its director in2019. Disclosures (none)Saving Lives. Protecting Americans.50

Saving Lives. Protecting Americans.51

Mary’s CenterMary's CenterFQHC in DC and MDServices: 5 full-service community health centers22 school-based mental health programs2 Senior wellness centersPublic Charter School co-located at3 health centersPopulation: Approximately 60,000participants from 50 countriesTELETHERAPYTelehealth Before COVID: Facilitatedtelemedicine - less than 5% of visits, MCOpartnershipsTelehealth Now: Combination of virtual andfacilitated telemedicine - 75% of primary carevisitsTELEMEDICINETELEDENTALMy telemedicine lifehack is MEET PATIENTS WHERE THEY ARE –LITERALLY AND FIGURATIVELYSaving Lives. Protecting Americans.52

CASE STUDY: WORKFLOWBARRIERS TO CARETELEMEDICINEIMPROVED PATIENTOUTCOMES & REDUCED COSTSVIRTUAL&SKIPPED APPOINTMENTSFACILITATEDSaving Lives. Protecting Americans.53

CASE STUDY: TELEMEDICINE DURING COVID Transition from facilitated model to acombination of virtual facilitated Temporary hiatus of facilitated Clinical services Care coordination Support from leadershipSaving Lives. Protecting Americans.54

COMMENTS AND QUESTIONS?Please feel free to contact us directly:Dr. Tollie ElliottTelliott@maryscenter.orgDara KoppelmanDkoppelman@maryscenter.orgLeah ShovalLshoval@maryscenter.orgSaving Lives. Protecting Americans.55

Your Telemedicine Questions,AnsweredPlease submit your questions through the Q&A boxSaving Lives. Protecting Americans.56

TM Hack Updates Discussion Boards 251 registrants New features since last week Top 5 Hacks Q&A Transcripts (Weeks 1 and 2) TRC staff answering questions directly in discussion boards“Bonus Hack” sessions Specific topics outside of telemedicine implementation Same format as TM Hack (2 case studies, 15-min didactic); different day/time; organized by peer champion(s); Entire TMHack community invited Tele-behavioral health “Bonus Hack” tentatively planned late AugustResource mailbox (tmhack@hhs.gov) Use for comments/questions on TM Hack curriculum, format, session materials, suggested Bonus Hack sessions For questions on telemedicine implementation, please use discussion boards or in-session Q&ASaving Lives. Protecting Americans.57

TRAIN is Your One-Stop Shop for TM Hack Resources Visit www.train.org Login if you have an account, or create an account if you don’t have one To access discussion boards, slides, and recordings Click on “Your Profile” (under Your Name on the top right) to access the “Manage Groups” screen Enter “TMHACK” under “Join by Group Code” Save your profile and then click the Discussions tab Click here for the TRAIN User Guide with Step-by-Step instructions Other TRAIN benefits HHS training certificate, if you complete 8/10 TM Hack sessions Access to other public health/clinical trainings, including COVID-19 resourcesSaving Lives. Protecting Americans.58

TRAIN Discussion Boards Discussion Boards (n 11) 8 topical boards Getting Started in Telemedicine (Week 1) Workflows & Integration (Week 3) Regulations, Compliance, and Documentation (Weeks 3 & 5) Billing Policy, Coding, and Reimbursements (Week 5) Scaling Up & Sustainability (Week 9) Equitable Access Miscellaneous Technology Specialty Connect Slides, Recordings, and Session Materials Telehealth Resource Centers (TRCs)Saving Lives. Protecting Americans.59

Discussion Board Etiquette and Best Practices At the start of each post, please indicate the state/jurisdiction where you are from For example, “David from MD ” Many telemedicine issues are state-specific, and this helps ensure your questions are routed appropriately andanswered correctly We encourage the TM Hack community to make “Requests and Offers” of each other Request Assistance—If you have a specific question or need help, ask the community Offer Solutions—If you have successfully implemented telemedicine (fully or partially), go to the Discussion Boardand offer to help a peer(s)Saving Lives. Protecting Americans.60

Start Todaytmhack@hhs.govSaving Lives. Protecting Americans.62

“HHS Telemedicine Hack” Data Use . Telemedicine 101 Term Definition Originating site Where the patient is located Distant site Where you are located Facility fee For qualifying originating sites only Parity law Similar reimbursemen