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At NewYork-Presbyterian, Virtual Health is Transforming How Care is Done

February 13, 2018
by Rajiv Leventhal
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A full suite of digital health services has put NYP on the leading edge of virtual care offerings

In a recent survey on telehealth, conducted by Baltimore-based healthcare research firm Sage Growth Partners (SGP) and inclusive of some 100 industry executives, about half of respondents said they have adopted telemedicine in some form, and of the non-adopters, most said that they see it as a priority. The survey findings also revealed that mobile apps and outpatient care are the “next frontier for telemedicine use.”

Indeed, hospitals across the U.S. are starting to embrace telemedicine initiatives more now—albeit at a slow space still—and in a healthcare landscape that is prioritizing cutting costs and keeping patients out of the hospital, this type of remote care has carved out a niche. At NewYork-Presbyterian Hospital, a New York City-based academic medical center, and at its affiliates, including Columbia University Irving Medical Center and Weill Cornell Medical Center, also based in New York City, leveraging telemedicine has become a priority. But as Peter Fleischut, M.D., senior vice president and chief transformation officer at NYP, contends, the institution’s digital health portfolio is inclusive of various virtual care offerings.

In 2016, NewYork-Presbyterian announced the rollout of NYP OnDemand, a new suite of digital health services that included an array of innovation initiatives, including: Digital Second Opinion, a service in which NYP specialists from both ColumbiaDoctors and Weill Cornell Medicine can offer their clinical expertise for second opinions to patients around the country through an online portal; Digital Consults, which connects patients at NYP’s regional network hospitals to NYP hospital specialists; a digital emergency and urgent care program (Express Care), in which visitors to the NewYork-Presbyterian/Weill Cornell ED have the option of a virtual visit through real-time video interactions with a clinician after having an initial triage and medical screening exam; and finally, Digital Follow-Up Appointments, which provides patients a virtual follow-up option, instead of asking patients to come back to the office in person.

Fleischut, who served as NewYork-Presbyterian’s chief innovation officer prior to being named senior vice president and chief transformation officer last May, says that NYP’s core vision was to build a comprehensive suite of telehealth services, rather than just one program. In that sense, the organization has succeeded; to date, there are more than 50 telehealth programs in all. And in total, there have been approximately 15,000 of these virtual care encounters to date, with the care being delivered by any one of 700 providers, Fleischut says.

“We have had 600 percent growth in the past year in telehealth,” he says. Taking just Express Care as an example, patients coming in could wait up to two-and-a-half hours from admission to discharge for an [ED] visit, but with Express Care, in that same window—admission to discharge—patients are seen in approximately 31 minutes. And this is with same levels of patient satisfaction and outcome,” Fleischut attests.

Peter Fleischut, M.D.

Of course, the Express Care program is meant only for patients with minor complaints, but in such cases, after ED patients go through triage—when a physician assistant or a nurse practitioner performs a medical screening exam—those who are judged to be in stable condition with no life-threatening injuries or symptoms are given the option of seeing an emergency room physician via a videoconference in a private room. Fleischut notes that even if the patient initially chooses video visits, he or she can still back out for any reason and switch to an in-person visit instead. “It really comes down to patient preference, but we find that patients prefer [the video visits] in many different [scenarios],” he says.

What’s more, NYP is also partnering with Weil Cornell and ColumbiaDoctors on a telepsych initiative. The motivation for this project, as Fleischut explains, is that in some of NYP’s hospitals—just like across the country—there simply is a shortage of qualified behavioral health specialists. As such, a patient can wait up to 24 hours to see a psychiatrist in certain hospitals. But now with the telepsych program, NYP allows for peer-to-peer visits and can connect patients to psychiatrists within an hour, says Fleischut. And that leads to reduced transfers and reduced admissions, he adds, also pointing out one recent case in which a telepsych patient was scheduled for an in-person follow-up encounter, but then called NYP and said he actually preferred doing the visit from home.

Furthermore, the same process applies with NYP neurologists; there merely aren’t enough experts available. Enter the organization’s telestroke program, which uses video conferencing and data sharing that allows for 24/7 coverage for acute stroke care with rapid evaluation by a neurologist. This can save up to 7 minutes of treatment time, or about 14 million brain cells, as approximately two million brain cells die every minute during a stroke. To this end, NYP also has a mobile stroke unit, in which ambulances are equipped with a CT scan machine to diagnose and treat the patient in the ambulance prior to coming into the hospital, Fleischut says.

Despite the success that NYP has had with this digital suite of services, Fleischut does note one specific challenge that he sees as a major obstacle right now. He gives an example of a patient who comes in, is seen by a provider, and then it’s determined that a follow-up visit is needed. In this case, that doctor has an established relationship with the patient, so if the patient goes back home, that provider can do a follow-up visit with him or her without any issue. But if the patient happens to cross state lines, that provider is no longer able to do a follow-up video visit with that patient; per telemedicine regulations, only a telephone follow-up would be permitted.  

But Fleischut expressed frustration in this scenario since the technology (the video visit) is now innovative enough to the point in which it provides higher-quality care than a phone encounter. “Follow-ups are a major issue in healthcare; the non-compliance for follow-up can be as high as 40 percent. And now we have a simple way to do a high-quality follow-up, but due to regulatory challenges, it forces us into using a technology that’s not as high-quality,” he says.

Fleischut does make clear that he supports regulation that requires a doctor-patient relationship to be established before a virtual visit takes place. But in the example he gives, that relationship has already been established, and still, if the patient crosses state lines, problems arise. “Now we have the means and a technology to ensure higher compliance and higher-quality care, and what I think is the right care for the patient, but it’s a challenge—even though it’s your own patient,” he says.

Nonetheless, NYP is continuing to surge ahead in its telehealth and other virtual care initiatives. Fleischut points to a recent collaboration between NewYork-Presbyterian and Walgreens in which kiosks, located in private rooms inside some Walgreens and Duane Reade drugstores in New York, offer instant examination, diagnosis and treatment of non-life threatening illnesses and injuries though NYP OnDemand services. Here, patients can reach board-certified Weill Cornell Medicine emergency medicine physicians, who provide exams through an HD video-conference connection. At the end of the examination, if the physician writes a prescription, it can be instantly sent to the patient’s preferred pharmacy.

Fleischut opines that the next step is to ramp up remote patient monitoring (RPM) services, an innovation which he feels the industry is ready for. He also mentions the 2016 launch of NYP Ventures, a strategic investment fund that supports innovative digital healthcare companies. The venture arm of the organization just recently opened its second office in Silicon Valley. “We really don’t think about this as just telehealth,” Fleischut says. “We hone in on virtualization—and that’s everything from AI [artificial intelligence] to machine learning to robotic process automation. We feel that these are fundamental core tools that are needed in the future delivery of care.”


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Senate Passes Opioid Response Bill with Substantial Health IT Elements

September 18, 2018
by Rajiv Leventhal, Managing Editor
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The U.S. Senate yesterday passed The Opioid Crisis Response Act of 2018, which includes numerous important health IT provisions, by a vote of 99-1.

The bill was originally sponsored by Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.), and includes proposals from five Senate committees and over 70 senators. The House passed its version of the legislation in June and now it’s expected that a committee will be convened to reconcile the differences between the two.

The legislation’s core purpose is to improve the ability of various health departments and agencies—such as the Department of Health and Human Services (HHS), including the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the Departments of Education and Labor—to address the opioid crisis, including the ripple effects of the crisis on children, families, and communities, help states implement updates to their plans of safe care, and improve data sharing between states.

There are several key health IT provisions in the legislation, including: enabling the Centers for Medicare & Medicaid Services (CMS) to test various models that provide incentive payments to behavioral health providers for the adoption and use of certified electronic health record (EHR) technology to improve the quality and coordination of care through the electronic documentation and exchange of health information; requiring the use of electronic prescribing for controlled substances within Medicare Part D; facilitating the use of electronic prior authorization within Medicare Part D; and expanding access to telehealth services for substance use disorders.

Regarding telehealth specifically, the Senate version of the bill will allow for payment for substance use disorder treatment services, via telehealth, to Medicare beneficiaries at originating sites, including a beneficiary’s home, regardless of geographic location. It also requires guidance to cover state options for federal reimbursement for substance use disorder services and treatment using telehealth including, services addressing high-risk individuals, provider education through a hub-and-spoke model, and options for providing telehealth services to students in school-based health centers.

Health IT Now's Opioid Safety Alliance—a working group of prescribers, health systems, technology companies, pharmacies and pharmacists, professional societies, and patients advocating for the use of technology to fight illegitimate opioid use—supported the Senate’s passing of the bill. Said Joel White, HITN Opioid Safety Alliance executive director, “We are especially encouraged by the inclusion of commonsense Opioid Safety Alliance-endorsed language in this bill that will remove bureaucratic barriers to vital telehealth services for those suffering from addiction, modernize prescribing practices for controlled substances, and streamline prior authorization claims to improve efficiency while bolstering patient safety. These solutions can make a world of difference both in dollars saved and, more importantly, lives spared."

White did add, however, as Congress convenes a committee to reconcile the differences in the House and Senate-passed bills, lawmakers ought to include the House-passed OPPS Act (H.R. 6082) as part of any final conference agreement, “thereby ensuring that addiction treatment records are no longer needlessly isolated from the rest of a patient's medical history—a practice that has hindered informed decision making and threatened patient safety for too long.”

Indeed, the Senate version of the bill requires HHS “to develop best practices for prominently displaying substance use treatment information in electronic health records, when requested by the patient.”

White also noted, “Additionally, OSA remains concerned about the lack of real-time, actionable data provided to clinicians by states' prescription drug monitoring programs (PDMPs). With lawmakers poised to devote additional resources toward these programs, we should know if taxpayers are getting a return on their investment. We support the inclusion of language that would require an objective study and report on states' use of PDMP technology." 

As stated in the bill, states and localities would be provided with support to improve their PDMPs and "implement other evidence-based prevention strategies.” The bill also “encourages data sharing between states, and supports other prevention and research activities related to controlled substances."

What’s more, another section of the bill reauthorizes an HHS grant program “to allow states to develop, maintain, or improve PDMPs and improve the interoperability of PDMPs with other states and with other health information technology.”

Sen. Alexander, meanwhile, said yesterday he is “already working to combine the Senate and House-passed bills into an even stronger law to fight the nation’s worst public health crisis, and there is a bipartisan sense of urgency to send the bill to the President quickly.”

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Survey: Healthcare Organizations Report Gaps in Disaster Preparedness Plans

September 12, 2018
by Heather Landi, Associate Editor
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As Hurricane Florence churns toward the East Coast this week, disaster preparedness is a timely topic, yet a new survey finds that only 72 percent of healthcare providers believe their organization’s disaster plan is comprehensive enough to cover a variety of disaster scenarios both inside the organization and across the community.

The findings are even more troubling among specialty care providers, such as cardiologists and endocrinologists, who provide critical treatment to individuals with chronic diseases, with just 29 percent reporting that they have a comprehensive disaster plan in place. More than two-thirds (68 percent) of survey respondents were affected by two or more disasters in last five years, according to the survey, yet most respondents doubt their organization’s disaster plans are up to the task.

DrFirst, a provider of e-prescribing and medication management solutions, surveyed 109 healthcare professionals across acute, ambulatory, hospice and home care about disaster preparedness. According to the DrFirst, the results are critical for addressing potential safety issues that affect the health and lives of millions of Americans who are increasingly subject to hurricanes, wildfires, and floods as well as other man-made disasters like digital and criminal attacks.

“The fact that almost 70 percent of the surveyed healthcare providers have been affected by more than two disasters in the last 5 years should be a major wake-up call for the healthcare industry,” G. Cameron Deemer, president of DrFirst, said in a statement. “As we learned in the aftermath of major disasters such as hurricanes Maria and Harvey, natural disasters lead to surging demands for acute and emergency care, especially from the most vulnerable patients who may have been displaced from their homes without medications or critical medical supplies, like oxygen or diabetic testing equipment. We must take measures now to address the critical gaps impacting patient care and safety, such as communication challenges and ready-access to medical records and specialty care providers.”

The survey revealed another key vulnerability—the widespread dependence on disaster communications methods that fail to meet legal requirements for secure communications between medical teams, pharmacies, and patients, according to the survey. Under the federal law known as the Health Insurance Portability and Accountability Act (HIPAA), a patient’s private health information can only be shared with the patient or other providers via secure methods such as password-protected portals and secure messaging.

One-third or more of clinicians surveyed across acute, ambulatory and hospice/home health state that calling by phone is their top method for communicating with pharmacies, EMS units, patients and families, local authorities, and community health providers in times of disaster. Secure messaging and email complete the top three modes of communication.

A striking number of clinicians use regular unsecured text messaging to reach hospitals: more than one-quarter of respondents use this mode to communicate with hospitals during and immediately after a disaster strikes, and 22 percent report using unsecured texting to communicate with patients or their family members. According to the Centers for Medicare and Medicaid Services (CMS), the use of phones for texting of patient health information is only permissible through a secure messaging platform that provides message encryption. Encryption is also required when emailing patient health information.

Healthcare professionals working in hospitals were more aware of the need for secure messaging tools than individuals working in other settings, including specialty care providers. Forty-four percent of hospital-based respondents said that secure, HIPAA-compliant medical messaging is a key requirement of a disaster preparedness plan.

In fact, hospital-based respondents indicated that the only requirements more important than secure messaging were the installation of backup generators in case of power outages (56 percent) and the ordering and maintaining of extra inventory of supplies and medications (52 percent). Yet, specialty providers place the need for including secure messaging at the very bottom of their disaster planning requirements.

Survey respondents also see telehealth is a viable disaster solution, as 45 percent cited telehealth as an effective option to provide care to patients across the community during or immediately after disasters or emergencies. However, more than half expressed concerns that connectivity and other technical issues could impact the reliability of telehealth, and only 27 percent believe their organization has deployed adequate telehealth capabilities.

Another key finding from the survey is that many organizations preparing for an impending disaster still rely heavily on paper, with most advising patients to keep copies of their medical records. Just 40 percent of respondents believe their electronic health record (EHR) has sufficient information available to take care of all patients during a disaster.


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CPT Codes Updated to Reflect HIT Advancements

September 6, 2018
by Rajiv Leventhal, Managing Editor
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The American Medical Association (AMA) announced the release of the 2019 Current Procedural Terminology (CPT) code set, with changes reflecting new technological shifts in the industry.

According to the AMA, there are 335 code changes in the new CPT edition reflecting the CPT Editorial Panel and the healthcare community’s “combined annual effort to capture and describe the latest scientific and technological advances in medical, surgical and diagnostic services.”

Among this year’s changes to CPT include three new remote patient monitoring codes that reflect how healthcare professionals can more effectively and efficiently use technology to connect with their patients at home and gather data for care management and coordination. Also, two new interprofessional internet consultation codes have been added to reflect the increasing importance of using non-verbal communication technology to coordinate patient care between a consulting physician and a treating physician, according to AMA.

“The CPT code set is the foundation upon which every element of the medical community—doctors, hospitals, allied health professionals, laboratories and payers—can efficiently share accurate information about medical services,” AMA President Barbara L. McAneny, M.D., said in a statement. “The latest annual changes to the CPT code set reflect new technological and scientific advancements available to mainstream clinical practice, and ensure the code set can fulfill its trusted role as the health system’s common language for reporting contemporary medical procedures. That’s why we believe CPT serves both as the language of medicine today and the code to its future.”

McAneny added that the AMA has urged the Centers for Medicare and Medicaid Services (CMS) to adopt the new codes for remote patient monitoring and internet consulting and designate the related services for payment under federal health programs in 2019. “Medicare’s acceptance of the new codes would signal a landmark shift to better support physicians participating in patient population health and care coordination services that can be a significant part of a digital solution for improving the overall quality of medical care,” she said.

In July, as part of CMS’ proposed Physician Fee Schedule and Quality Payment Program rule, the agency recommended various provisions that would aim to support access to care using telecommunications technology, such as: paying clinicians for virtual check-ins, paying clinicians for evaluation of patient-submitted photos; and expanding Medicare-covered telehealth services to include prolonged preventive services.

New CPT category I codes are effective for reporting as of Jan. 1, 2019. Additional CPT changes for 2019 include new and revised codes for skin biopsy, fine needle aspiration biopsy, adaptive behavior analysis, and central nervous system assessments including psychological and neuropsychological testing.

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