The document summarizes Howard Chapman's presentation on telehealth in Federally Qualified Health Centers (FQHCs). Motivating factors for Southwest Virginia Community Health Systems (SVCHS) to enter telemedicine included lack of specialty care access in rural areas. SVCHS partnered with UVA to provide telemedicine services through six sites. Successes included high utilization and access to 33 specialties. Reimbursement and licensure posed ongoing challenges.

1. Virginia Telehealth
Summit
March 18, 2010
Institute Conference
Center
Danville Virginia
Telehealth in FQHCs
Howard Chapman, Jr., Executive Director
Southwest Virginia
Community Health Systems, Inc.

2. SVCHS Site Map

3. SVCHS Patient Origin Map

4. UVA Telemedicine Program

5. Telemedicine: History
 Alexander Graham Bell
 Hugo Gernsback (vision)
 Massachusetts General
 University of Nebraska
 NASA
 Dept of Defense
 University of Virginia

6. Motivating Factors that prompted
entry into Telemedicine
 Access to Specialty Care
- HRSA Grant provides access for primary
care and prevention
- There is a shortage of area Specialty
Providers in the rural areas we serve
- These area Specialists have heavy
schedules of paying and insured patients
- They have no requirement or provision to
provide care to indigent or uninsured
patients

7. Motivating Factors that prompted
entry into Telemedicine (continued)
- When specialty services are not available to
patients they usually go without or the primary
care physician tries to offer what level of care
they can
- Too often this results in their completing
procedures over their head or that the practice is
not equipped to provide
- This becomes a “Risk” issue, especially with
FTCA coverage and practicing within the
approved Scope of Services

8. UVA Telemedicine

9. Cancer outreach:
Mobile digital mammography

10. UVA Teleradiology
 SVCHS installed two Digital X-Ray Units from our
CIP Grant from the Economic Stimulus Funding
 We now use the UVA Department of Radiology for
our X-Ray interpretations
 SVCHS is charged a flat fee per X-Ray procedure
 SVCHS then bills for both the professional and
technical component
 UVA Radiologist is available to consult with SVCHS
providers for STAT readings
 STAT readings during evening and Saturday hours
is through the link with the ER at UVA

11. Other Motivating Factors
 Rural Isolation
 Telemedicine Removes much of the “Rural
Isolation” and makes it easier to recruit and
retain physicians and providers
 Providers and staff can receive CME Training
and credits through Telemedicine
 It puts the resources of a major university at the
fingertips of a rural physician
 Grand Rounds schedules are available through
UVA for our providers who want to participate
 Poison Control is available through
the UVA Telemedicine Link 24/7

12. Other Motivating Factors
 Patient Education
 Shortage of other Health Care Resources and Ancillary
Care Providers (i.e., Health Educators, nutritionist, etc.)
 Patient Education Programs
- Established Format
- Customized Programs for our Patients
 Important for the participation in the Health Disparities
Collaborative and Patient Self-Management Goals
 CDC First Responders Training was provided
through the UVA Telemedicine Link at our
Saltville site for the Anthrax terror alert

13. Planning Steps
 The University of Virginia (UVA) was working to establish
the Southwest Virginia Telemedicine Health Alliance and
had grant money to support the program
 There was no investment on our part except for the
space and staff time devoted to training and using the
equipment
 SVCHS had to agree to make the telemedicine equipment
and services available to the entire community and other
area providers as part of our commitment
 After two years we had to pick up the cost of the
communication lines (same lines we use for our EMR
and practice management System)
 Universal Services Administration assistance with the
communications and connectivity cost
 UVA’s first connection in rural southwest Virginia was
over $4,000 per month for a T-1 line in 1994

14. Planning Steps (continued)
 SVCHS was added in 2001 and the cost was
about $1,000 - $1,200 for a rural T-1 connection
(Universal Service Administration assistance
moved that to about $450 / month)
 Now a broadband fiber connection is about $400
/ month without the Universal Services
Administration Assistance
 Communication lines are now required for EMR
and data exchange anyway
 The cost of Telemedicine Equipment is down as
well. In 2001 the equipment was around $60,000
and now the cost around $22,000

15. Implementation Schedule
 SVCHS has been operational since
2001 with the UVA Telemedicine
Program
 Expansion to other sites include initial
UVA training and orientation
 We have our Telemedicine Manager
conduct training and orientation with the
provider (NP) that will be using the
equipment and the providers and staff
that will be making the referrals

16. Facilitators/Impediments in the
Process
 Karen Rheuban, M.D., Medical Director for the UVA
Telemedicine Program is a great Champion and Facilitator
for the use of telemedicine
 UVA has been doing this for years and is one of the most
advanced and recognized programs in the nation
 Impediments include:
 Reimbursement Issues (must be at least a mid-level provider
operating the equipment)
 Reliable Connectivity for the system
 Laws and regulations around licensure
 JCAHO and other credentialing issues

17. Challenges
 Funding of telehealth (Stark, Anti-kickback Laws)
 Reimbursement
 Outcomes
 Confidentiality
 JCAHO
 Licensure
 Malpractice
 Telecommunications venue/costs
 Integration with EMRS/RHIOS
 Interagency alignment related to policies
Federal (definition of rural, rural vs urban)
State (eligible plans, coverage of store and forward)

18. Reimbursement varies by state
 Reimbursement
- Virginia Medicaid (urban and rural)
- TennCare MCOs
- Medicare (rural)
- Private payers
- Anthem grant for Virginia
- Contracts
- Peds cardiology
- Psychiatry
- Dept of Corrections
 Formal request of Virginia Medicaid 1995,
expanded 2003

19. Licensure
 No portability
 Primarily serve Virginians
 Primarily provide consultations
 International patients easier than
other states
 Discussion surrounding model of
nurse compact
 Tennessee BOM references a
“telemedicine license” for out of state
providers

20. JCAHO
 2000 JCAHO standards required credentialing and
privileging at all the remote sites
 2004 JCAHO standards revisions (more coming)
 Credentialing and privileging at a JCAHO
accredited consult origination site
 Remote hospital medical staff to agree to
telehealth relationship
 Link to quality data for feedback
 Agreements between institutions

21. Successes and
Accomplishments
 SVCHS is one of the most highly utilized UVA Telemedicine Sites
 SVCHS has a great working relationship with the UVA
Telemedicine Program
 We now have telemedicine equipment in 6 of our 7 sites (plans to
add 2 additional telemedicine sites by December 2008)
 UVA offers access to 33 separate specialties and services
through telemedicine
 They accept the SVCHS Sliding Fee Payment as Payment in Full
for our indigent patients
 They have private grant funding to support payment for patients
whose insurance carrier does not cover telemedicine services
 They have provided a digital retina camera for eye
exams for our diabetic patients that can be
emailed to the UVA Ophthalmology Department and
the results emailed back

22. Southwest Virginia Community Health Systems, Inc
UVA Specialty/Subspecialty Participants
 Cardiology  Obesity
 Dermatology  Oncology/Tumor boards
 Diabetes  Pain management
 Emergency Medicine  Pediatric cardiology
 Endocrine
 Pediatric nephrology
 ENT
 Pediatric oncology
 Gastroenterology
 Genetics  Plastic surgery
 Geriatrics  Psychiatry
 Gynecology  Pulmonary medicine
 Hematology  Radiology
 Infectious Disease  Rheumatology
 Nephrology  Surgery
 Neurology  TCV
 Neurosurgery  Toxicology/Poison control
 Ophthalmology  Urology
 Orthopedic
 Wound care

23. Lessons Learned
 To receive Credit for the telemedicine encounters they must be
provided by a mid-level (NP/PA) or physician.
 This allows for the user and encounter data for BPHC and the
UDS Report to count
 Reimbursement as a consult visit (incident to visit) to be
reimbursed to the specialist and the provider using the equipment
and conducting the exam at the site
 This is not the most ideal care for the insured patients, but they
have transportation and the resources to seek care elsewhere
 For our indigent and uninsured patients it is often the only option
for access to specialty care
 Video Conferencing is often a great way to conduct meetings and
business among remote sites
 UVA allows a bridge for that to happen, but connections are
limited
 For a fee more links can be accommodated for these meetings

24. Health Center Controlled
Networks – IT Funding
 Community Care Network of Virginia (CCNV)
 Owned by Virginia FQHCs
 Statewide EHR Network (eClinical Works)
 Quality Improvement Grant working with HRSA required data
 Tracking Healthy People 2020 Guideline data as a quality
measure
 Patient Kiosk to enter patient data (PHQ-9 and other data)
 IT Committee looking at “Enhancements” to current system (i.e.,
case mgt., patient call reminders, dental, mental health, etc.)
 CCNV is included in the Regional Health Center Grants to
connect to HIEs
 CCNV is also part of the QI Grants that went to VHD
 Collaborative partner on several Beacon Community Grants

25. Health Information Exchanges
 CareSpark and MedVirginia operational in Virginia
 Collaboration of Patient Care by sharing data
among community/regional providers
 More informed and better decisions in managing
patient care
 New insurance Products (Active Health)
 Reduction of Costly Procedures – MRIs, Cat Scans,
etc.
 Reduction of Medication Errors through e-
prescribing
 Pay-for-performance

26. Thank You!
Contact Information:
Howard Chapman, Jr., Executive Director
Southwest Virginia
Community Health Systems, Inc.
P. O. Box 729 /319 Fifth Avenue T. K. McKee Hospital Building
Saltville, Virginia 24370
Telephone: (276) 496-4492 Ext. 108
Fax: (276) 496-4839
Email: hchapman@svchs.com
Web Site: www.svchs.com