Which top state and federal policy levers to advance #TelemedNow in 2020 and beyond?

#TelemedNow Twitter Chat Wednesday, June 24 – 8 PM ET Introduction & Welcome: Andrew Watson (@arwmd)-- Moderator Which top state and federal policy levers to advance #TelemedNow in 2020 and beyond? Q1 What #Covid #telemedicine changes have to be permanent? Is it reimbursement? State licensing? Platforms? What #Covid policies create the "new norm"? What state @US_FDA @CMSGov polices matter most?

A1 Notable Responses: Jamey Edwards (@jameyedwards) Ability to practice across state lines is a huge barrier overcome w/ #COVID19 temporary regulatory relief.Putting this #GenieBackinTheBottle would create #healthequity problems due to #healthcare supply demand imbalance & hurt underserved #patients Helen Burstin (@HelenBurstin) Payment parity will be critical to physician adoption, including payment for telephone calls. As @jkvedar said at HELP hearing: “Telephone visits are important to cross the digital divide. We should continue that level of reimbursement to address this underserved population” Matt Sakumoto (@MattSakumoto) I don't think video visit parity will be 1:1 in the future. What is the lower limit to make video worth the investment? I say at least 80%. (I don't think telephone reimbursement will go up any time soon...) #telemednow Matt Sakumoto (@MattSakumoto) Reimbursement: At least 80% parity to clinic visit, otherwise the infrastructure/effort not worth it. Continue across state-line access and rural exceptions. Video integration with EHR nice to have, but not a dealbreaker #Telemednow Sam Lippolis (@samiamlip) 100% MUST be all payers have NO geographic restrictions and any location (home, school, work, etc) where a patient is needs to be an acceptable place of service.Platforms need to be HIPAA complaint. Video visits MUST be 100% same pro fees as F2F as non facility rates Andrew Watson (@arwmd) Answering my own question…I am torn between #platform diversity we can use vs. payment parity as @HelenBurstin points out. Eventually it has to follow the money so IMO the increased in billing is the #1 area we have to preserve followed closely by platforms. #TelemedNow Ceci Connolly (@CeciConnolly) Before digging into policy specifics, a shout out to @SeemaCMS for ongoing support of #telehealth and flexibilities during #COVID19 pandemic that have enabled current flourishing Salim Saiyed (@SalimCMIO) At federal level need extensive policies. White heavy check marka good start bill introduced to allow #physicians to use #Telemednow to treat #patients in any location 180 days after the emergency, bypassing site and interstate licensing restriction Ritu Thamman (@iamritu) ˄remove Regulatory/policy barriers to allow doctors to practice across state lines ˄transparency of Social media data collection, 3rd party ads, web tracking, privacy & security ˄payment parity, eliminate restrictions forcing it. ˄Make apps in network too #TelemedNow Jagdish Patel (@jpkca) Reimbursement has to be priority to carry overhead. RVU needs to be equal to in office visit Jim St.Clair (@jstclair1) Professional services should be 100% parity. Salim Saiyed (@SalimCMIO) Agree with you start with #reimbursement parity. Our survey of few hundred docs showed the #1 uncertainty on payment clarity is the biggest road block. The rest can be sorted out by market forces #NoMoney #nomission no #TelemedNow Ceci Connolly (@CeciConnolly) Need to maintain flexibilities from @CMSgov eliminating obsolete location restrictions that were a hurdle for #teleheath. Lawmakers should also make sure @HHSgov retains authority ensuring appropriate providers/services covered under #telehealth rules. Helen Burstin (@HelenBurstin) It may be an interim solution until we get universal broadband, but we have to serve the patients who need us #TelemedNow R E Lewiss MD (@RELewiss) What is the relationship of #TelemedNow with major EHRs such as Epic and Cerner? Jamey Edwards (@jameyedwards) Epic and Cerner are integrating #telemedicine into their platforms, but they are not patient experience and engagement platforms so time will tell. Epic just launched a twilio integration and already has a Vidyo one and Cerner use Amwell for its home visits Nina Browner (@NinaBrowner) In addition to “location being anywhere” what about providing public spaces (libraries, health-internet-cafes) where internet and tech support is available to include in #telehealth pts with poor access to internet and technology #TelemedNow Humayum Chaudhry (@DrHankChaudhry) Interstate Medical Licensure Compact has been signed into law in 29 states, DC and Guam thus far. States and state medical boards see what’s happening with #telemedicine. TelemedNow Ceci Connolly (@CeciConnolly) As long as it is safe, secure, private for confidential patient-dr exchange this is wonderful; libraries, housing developments, large office buildings, could easily set up space. Connie Hwang (@hwangc01) Going against the grain a little here, but maybe blanket #telemednow payment parity isn't the goal? I'd welcome telehealth flourishing in more value-based & capitated arrangements, w/ payers having flexibility to design smart benefits for virtual services showing real impact. Andrew Watson (@arwmd) This is spot on. Telemedicine works best and a value-based or risk arrangement. #TelemedNow Although we have to #GSD @JuddHollander agree, How we position this down the road is also key. @draditijoshi Josh Gray (@JoshGray_hit) I like payment parity for throughout the epidemic. Risk of sick people saying home w/no help when they should have care is just too great. Docs should not be penalized for helping. I am fine w "overpaying" occasionally if that is what it take to keep people safe #TelemedNow Jonathan Marron MD MPH (@JonMarronMD) But what about the digital divide? We’re learning that #telehealth, while helpful, is ˅available to those most vulnerable: poor, elderly, less educated, minorities, those in rural communities, etc. How can we ensure that ˄use of telemed doesnt unintentionally WIDEN disparities? Q2 What can federal and state governments do to fundamentally enable #telemedicine from a regulatory standpoint? Licensing, medicaid expansion? A2 Notable Responses: Jamey Edwards (@jameyedwards) Government's role in making #telemedicine successful cannot be understated. Supporting a healthy environment for #telehealth means conducive regulations, smart policy & fair & equitable reimbursement. Mandating #interoperability would be a great step! Jim St.Clair (@jstclair1) Fundamentally? Restructure apporach to #medicaid to maximize efficiency of service delivery and value, with aim to stop using ED for care. #TelemedNow Sam Lippolis (@samiamlip) All states adopt FSMB telemed compact. Combine with nurse, psychology and PT compact - multi disc #telemednow team!! Ritu Thamman (@iamritu) Need action at federal level because health plans offered by large businesses can’t be regulated by the state offer stand alone unlimited #TeleMedNow for unlimited family members outside of employment Jagdish Patel (@jpkca) Brief points what Govt can do Protect the network Encrypt portable devices Secure wireless networks Write a mobile device policy Delete unnecessary data from HER Get rid off third parties' security Matt Sakumoto (@MattSakumoto) I like this idea - #TelemedForAll! Maybe we can get a Bernie/AOC endorsement #telemednow Matt Sakumoto (@MattSakumoto) Reciprocal state licensing. Pay parity for Medicare and Medicaid. Payment support for Remote Patient Monitoring. Support Broadband as a public utility. #TelemedNow Harriette Van Spall (@hvanspall) Data privacy/ownership, vendor monopoly, reimbursement remain issues. In Ontario, we are paid for #telemedicine services only if specific platforms are used; this restriction needs to be removed allowing for an open market to drive innovation, interoperability, cost efficiency. Andrew Watson (@arwmd) such a good point, and nice to get that perspective from Canada. Q3 What evidence can we provide policy makers to support permanent policy change for #telemedicine as mainstream care delivery? IE: Telehealth Framework to Support Measure Development 2016-2017 A3 Notable Responses: Jamey Edwards (@jameyedwards) Best evidence is rapid adoption of #Telemedicine by consumers. It isn't an edge #healthcare use case anymore. It's a mainstream tool that improves access to high quality care. Evidence includes: ˅costs, #waittimes, #carbonfootprint ˄satisfaction, outcomes June Ho-Kim (@junehokim) Interesting KEEP Telehealth Options Act from @RepBalderson directs @USGAO to study fraudulent activity related to expansion of #telehealth. May be important evidence to help sway policymakers. #TelemedNow Matt Sakumoto (@MattSakumoto) I guarantee there will be bad actors in the telehealth space. Just hope they don't ruin it for the rest of us! #TelemedNow Sam Lippolis (@samiamlip) I know CMS wants to see CMS data for decisions. BUT VA & DOD has YEARS of data, outcomes and BIG Ns. It's a govt payer - CMS should be willing to review VA & DOD #telemednow studies to validate. Jim St.Clair (@jstclair1) Right, hate to delay things with longitudinal studies, though I think there are some papers out there about health outcomes #TelemedNow

Matt Sakumoto (@MattSakumoto) Still too early to tell on outcomes...Telehealth biases toward young, health, tech savvy, and health engaged. I think we will show improvements in outcomes soon though! #telemednow Ceci Connolly (@CeciConnolly) Sadly yes, as there are bad actors all around us. Can't let that block significant progress for so many here, including most vulnerable w/few alternatives #TelemedNow Jamey Edwards (@jameyedwards) People will always try to take advantage of the situation. those bad actors are already here: Just need to highlight the good work and report the bad! Jagdish Patel (@jpkca) WE CAN COLLECT DATA FOR EVIDENCE Patient satisfaction - 67% of patients like it Outcome - many patients avoided ER visit because of virtual care Mortality data- Sure we can find it by state Readmission reduction Jim St.Clair (@jstclair1) I still hesitate to say "adoption" - how many pts had a choice? Why did my PCP immediately revert to in-person visits? #TelemedNow Jamey Edwards (@jameyedwards) Because that is how his business is structured and how he is used to practicing. He has rent to pay, etc...But the real question is, how many patients feel comfortable going back in when #Telemedicine doesn't require them to do so and is way more convenient? Jim St.Clair (@jstclair1) No sir, in this instance it's a PCP in a system, and a reflection of the system "backsliding". Very much an attitude of "we just need to do this anymore". Speaking as the pt. Not sure how many will decide to vote with their feet? #TelemedNow Jamey Edwards (@jameyedwards) that is an infrastructure fighting for survival instead of adapting to the new normal, hoping their market position can sway patients. I agree that patients will vote, but with their fingers instead of their feet :) Jim St.Clair (@jstclair1) I sure hope so, but I think my area exemplifies many areas where you take what you get or you're outa luck. Salim Saiyed (@SalimCMIO) The adoption has been phenomenal, & widely accepted by patients. #Telemednow is just another care deliver model, not a new way to practice medicine This is evident right here. Ritu Thamman (@iamritu) Patient satisfaction data is overwhelmingly positive. Hopefully outcomes data will also show improvement for Matt Sakumoto (@MattSakumoto) utilization/outcomes. At @UCSFHospitals COVID triage >1500 pts over video, <5% sent to ED. (Some convenience bias) #telemednow Ritu Thamman (@iamritu) There is a @CircOutcomes CHAT-DM Study using RPM :Text messaging intervention resulted in better glycemic control in patients with diabetes and coronary heart disease More Studies like this need to be done Helen Burstin (@HelenBurstin) YES! We more studies that demonstrate improved outcomes w/ RPM and #telehealth AND we need more funding @AHRQNews @PCORI @NIH. Telehealth should be woven into the fabric of outcomes research! #TelemedNow Andrew Watson (@arwmd) We need to remember the december issue of @Health_Affairs - so much substance in there. Connie Hwang (@hwangc01) believe @PCORI intends to remain very active in the #telemednow space. As of Jan 2020, PCORI has funded >91 CER studies focused on telehealth, and this work will be increasingly important in light of COVID-19.

Q4 What basic practice of medicine / data / HIPAA considerations should be surfaced for #telemedicine policymakers to consider? Est MD-patient relationship via Tmed? HIPAA ?

A4 Notable Responses: Sam Lippolis (@samiamlip) HIPAA compliance for sure. It's risk reduction YES established MD - PT relationship via tele. It's the art of medicine and providers KNOW what meets standard of care in their discipline. Policy makers should not decide how to DO medicine. Jamey Edwards (@jameyedwards) Need model where #patients "own" their health record supported by gov't platform & national identifier. Caregivers can be granted access by #patient when treating them w/ documentation being sent to central record. #Helps #telemedicine & solves larger problem. Ceci Connolly (@CeciConnolly) One big issue: outdated rules on privacy & data sharing. #HIPAA is woefully out of date for digital world; need to build new protections that give consumers control over their #healthdata while ensuring it’s protected… regardless of who is handling it. #TelemedNow Jagdish Patel (@jpkca) This can be divided by component like Hardware- medical carts, tablets, personal devices can be standardized to have universal mobile platform Jagdish Patel (@jpkca) Software- EHR integration should be available HIPPA for all software Encryption should be routine practice Analytics on platform to evaluate outcome E-script capacity Billing software at least available as option Jagdish Patel (@jpkca) Improvement in IT infrastructure and Broadband internet which is biggest barrier Jagdish Patel (@jpkca) Wearable and RPM could be future option for policymaker approval Ritu Thamman (@iamritu) ˄eliminate restrictions forcing telehealth technology to comply w federal privacy regulations in HIPAA:gives providers more flexibility to pick software,set up programs, less red tape of federal government ˄ Define #TelemedIcine to include video & phone Salim Saiyed (@SalimCMIO) We definitely need to allow for patients to establish MD-Patient relationship #HIPAA light for #telemednow, for e.g if a patient chooses to perform #telemednow outside, there is limits on we can enforce it ?

Q5 What #telemedicine infrastructure policy is required (broadband or endpoints), how can government programs ensure equal access? Do we certify bio-peripherals?

A5 Notable Responses: Jamey Edwards (@jameyedwards) Better #broadband infrastructure & proliferation of #5G will help ensure better coverage. Also include community centers / libraries /schools w/ #connectedhealth kiosks wired for #healthcare applications. Support whole continuum of care w/ clinician network too! Ceci Connolly (@CeciConnolly) Obviously, expansion of—and affordable access to—broadband is critical to continued success of #virtualcare Ceci Connolly (@CeciConnolly) But lawmakers & policymakers can do more: encouraging standardization between platforms and enabling better interoperability will protect health organization’s investment in expensive tools, making them more likely to launch #telehealth programs. #TelemedNow Ceci Connolly (@CeciConnolly) Finding ways to integrate those platforms into existing tools people already using would be big plus and make implementation easier for drs and consumers. #TelemedNow Ceci Connolly (@CeciConnolly) Finally, have to recognize that technology cost can be a barrier: greater latitude for audio-only care would be helpful. Jagdish Patel (@jpkca) Yes, Bio-peripherals should be FDA approved. FOr now, most of them come from Asia Salim Saiyed (@SalimCMIO) @US_FDA should have a separate, fast tracked approach to approve #bio-peripherals Can #Telemednow start its own list of "recommended" products for someone browsing ? Salim Saiyed (@SalimCMIO) as a country we need to focus on #rural #broadband Rapid launch of #5G (we are behind) Is access to #internet a #humanrights issue? As widely available to survive & perform basic function. If we manage to put a phone Telephonein every house, we can put #internet Helen Burstin (@HelenBurstin) We definitely need to push for broadband access and bridge the #digitaldivide. We also need to enlist patients to make the case for universal access to #telehealth for all Jagdish Patel (@jpkca) Having Broadband and good internet is plus point for success as many people at home don't have quality connectivity #telemedine Ritu Thamman (@iamritu) ˄ Broadband access is key @AjitPaiFCC on it ˄ Social media data collection, 3rd party ads, web tracking #Telemedicine privacy & security need to be transparent so don’t exploit rural women, lower income women ^ Make apps “In-Network” #telemedNow Jagdish Patel (@jpkca) Minimum Bandwidth of 384 KBPS or higher gives good results for conduction of telehealth services #telemedicine Jennifer Co-Vu (@DrJenniferCo_Vu) √ Broadband for all. √ FDA approval for Bioperipherals √ Insurance to pay for needed bioperipherals √ Broadband for all. Q6 Thoughts about which federal agencies must be engaged for #telemedicine policy? And why? @CMSGov @SeemaCMS and @FCC @AjitPaiFCC have been leaders.

? Transportation ? IRS ? HRSA rural health A6 Notable Responses: Matt Sakumoto (@MattSakumoto) All of the above plus probably ONC #telemednow Jamey Edwards (@jameyedwards) @USDA @US_FDA @CMSGov @FCC @VeteransHealth @WhiteHouse @MinorityHealth @NIH @CDCgov @CDC_eHealth @DeptofDefense @StateDept @ONC_HealthIT @USDS @congressdotgov @seemacms @ajitpaifcc

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