A Roadmap for Scalable Hospital Telehealth: ARMC’s Implementation

1. 1/26/2021
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
1/27/2021
Additional Supporting Document
Reza Sadeghian, MD, MBA, MSc, FAAP
Chief Medical Information Officer
Attending Physician- Pediatrics
Medical Director of Clinical Informatics
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
2
• Project Management Process
• How to bill, should we bill on complexity or by time?
• How to maximize the physical exam/visual exam during
evaluations.
• Improving work flows for use of telemedicine (use of ancillary
services – nurses, RTs, SW) to provide services or education.
• Ideal settings for use of telehealth under normal circumstances -
Best practice/standards – good resources and where to find
them.
• how to develop patient-physician relationship in telemedicine
encounter
1
2

2. 1/26/2021
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
3
Project Management Process
• Clinical Operation: (Registration, Scheduling, Rooming, Physician Visit, Order,
Referral and Follow up, Discharge Planning, etc )
• Clinical Workflow Assessment: Current and future state – Discussion with the
physician champion/ department chair of each specialty
• Information Technology Readiness Assessment/Vendor Selection
• Revenue Cycle Assessment
• HIM
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
4
Few examples
• Telephone visit:
– Outpatient
– Registration
– Orderset
– Documentation ( Telephonic template )
• Bi-directional video visit ( Zoom, WebEx, VSee, Doxy, Vidyo, Polycom, Amazon Chime, etc )
– Outpatient specialties/subspecialties
– Registration
– Orderset
– Documentation ( Telephonic vs Regular progress note )
• Portable Telemedicine cart
– Both inpatient and outpatient:
– Psychiatry: For inpatient rounding and ER
– Internal Medicine: ICU during the night shift – Inpatient rounding
– Family Medicine: Outpatient clinic visit, inpatient rounding, subspecialty consult
– Surgery: Burn unit
3
4

3. 1/26/2021
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
5
Look at your State Telecommunication Service
Handbook
• How to bill, should we bill on
complexity or by time?
– If we are talking originating site being the
home and distant site being a clinic then
we would need to bill the time code.
– Once we go to originating site being PCP
and distant the Hospital specialist then
we bill originating site a flat rate and timed
code for the distant site.
– The professional component does not
change for now for any payor. They
would still bill E/M based on
complexity. Once the emergency is over
then Medicare would not qualify for
reimbursement.
• Texas Medicaid Provider Procedure
Manual
• New HHS guidelines
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
6
• How to maximize the physical
exam/visual exam during evaluations?
• Ideal settings for use of telehealth
under normal circumstances -Best
practice/standards – good resources
and where to find them.
• iPad
• Robots
• Phone camera
• Zoom/WebEx/VSee
• Etc.
5
6

4. 1/26/2021
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
7
Physical Exam
• TM Visit Physical Exam (DELETE what is not pertinent)
• VITALS: Pt reports temp of _ degrees F orally. Home BP today _. (if measured)
• Weight measured at home: _. Blood sugar measured at home: _. (if measured)
• GENERAL: Stable appearing, in no distress. Alert and oriented.
• SKIN: no visible facial rash or concerning facial lesions noted. No skin redness or discoloration seen.
Patient denies new skin findings on brief self-exam of arms, legs, chest, abdomen.
• EYES: conjunctiva clear, sclera non-icteric, no eye drainage, grossly normal EOM.
• EARS: hearing grossly intact, no pain elicited with ear tugging bilaterally
• MOUTH: no visible perioral lesions, no perioral cyanosis, no lip swelling.
• NECK: Grossly normal ROM, no visible thyroid enlargement. Patient did not palpate any cervical LAD
under physician-guided exam.
• HEART: Patient self-reported heart rate of _ beats per minute (measured by pt with physician
instruction, or by fitness tracker HR monitor).
• LUNGS: Does not appear dyspneic. No audible wheezes or rales. No nasal flaring.
• ABDOMEN: no tenderness with patient self-palpation diffusely around abdomen under physician
guidance, no pain elicited with jumping or leg lifts
• MUSCULOSKELETAL: No significant cervical kyphosis, grossly normal active ROM in upper
extremities.
• NEURO: Intact recent memory. No facial or eyelid drooping. No speech impairment, answers
questions appropriately.
• PSYCH: Judgment and insight good; normal mood and affect.
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
8
• Improving work flows for use of
telemedicine (use of ancillary services –
nurses, RTs, SW) to provide services or
education.
• Multidisciplinary care, interspecialty
rounds, scheduled case conferences,
and case discussions. This approach,
involving primary care physicians,
nonphysician clinicians, and even
patients and families (community
training).
• Eg. Zoom
7
8

5. 1/26/2021
www.arrowheadmedcenter.org
The Heart of a
Healthy Community
9
• How to develop patient-physician relationship in Telemedicine
encounter
– Continuity of care ( Avoid consumer-directed telemedicine )
– Convenience of care
– Patient acceptance
– Preserving humanism in medicine and using new technologies to improve
medical care.
– Inform patients of any service limitations.
– Ensure the patients understand how the technology works.
9