everyone. I think we'll go ahead and get started in the interest of time. We have a lot of ground to cover. Thanks for everyone who's here. The topic today is about dialing into telemedicine. Telehealth is, of course, kind of our new reality. It was something more in the future for a long time. And thanks to COVID, it really accelerated the process of getting it here and now. And so in that sense, this is exciting to be talking about it. We have a great panel of experts who will be delving into very different aspects of telehealth and kind of peeling it apart in terms of outcomes data, reimbursement, and then switching gears and moving into the ICU with a broad overview of tele-ICU. Again, 15 minutes is probably not a whole lot of time to uncover or unpack. Each of these topics could almost be a day-long symposium, but we'll try to do our best to just present a brief overview. And we'll leave questions for later. So I'll start with one, which is optimizing communications in telehealth. I have no disclosures that are relevant for this. So the two words, information and communication, they may be used interchangeably, but they convey different things. Information is what is given out, and communication is when you're actually getting through. And that is really relevant in a relatively sterile environment like telemedicine, where you don't have that touch and feel of talking directly to the patient. So patients often may feel that they're getting a reduced level of service, that this is something where they just dialed in, they saw the physician on the screen, and sometimes in a matter of minutes the session is done. And so they just don't get the sense that this was something that added a whole lot of value to their day. Technology itself reduces the presence of body language, and we'll talk a little bit more about nonverbal communication and how to perhaps incorporate that into a tele-visit. But certainly that is something heavily absent, just the act of auscultating a patient and touching their shoulders while talking to them, or holding their hands when conveying a diagnosis of cancer. I mean, those are the types of things that really are missing, so it makes it particularly challenging, and hence makes it more important to enhance your communication skills while using that kind of a platform. And comprehension may be less obvious, increasing the need for explicit communication, depending on the patient, demographic, their age, how comfortable they are with digital media, and so forth. Communication is no doubt important, and there is plenty of studies and data that shows not only that does it build better rapport with the patient, but it directly impacts health outcomes. And we'll be seeing a lot more of that in Supriya's talk coming up shortly. But certainly improves compliance, improves patient satisfaction scores, improves clinician satisfaction, self management and reduction in malpractice claims. One study showed a 19% higher risk of non-adherence amongst patients who communicated poorly. And on the other hand, by training physicians on optimizing their communications, you could actually improve the odds of compliance by 1.62 times. So really impactful, certainly as an organization, if your organization is employing a lot of physicians, that this is well worth investing resources to make sure that the physician workforce is well trained, and particularly in communications and telehealth. So this is sort of one paradigm that is used. There are many, but this is a popular paradigm that looks, that kind of unpeels it based on privacy, environment, and performance. Sort of a PEP paradigm or framework to better understand telehealth and telehealth etiquette. So privacy and security, of course, making sure that you use a secure HIPAA compliant platform. For many of us who are in an employed setting, this would be already inbuilt into the nature of your own system. They would have these guardrails in place and these safeguards in place to make sure that all the physicians are compliant with it. But for those who are perhaps new to this or are in their own standalone practices, it's important to recognize that this shouldn't be just a FaceTime phone call. I mean, there needs to be secure platforms that are HIPAA compliant. Visits have to be conducted from a private space. Be mindful of the fact that if you are in a setting where there are other providers, that you use headphones so that you maintain that patient privacy. Inform the patient if there are others who are present. Reconfirm that you're talking to the right patient. Certainly very important. And then in terms of patient location, certain states mandate that these televisits can only be reimbursed if the patient, not necessarily the provider, but certainly the patient has to be in the geographic area of the state itself. So for example, in California, we have Reno, Nevada right next door. Lots of patients may be going there for a week or so. So if they happen to be outside of the state, then you cannot actually do the televisit. So very important to confirm that at the time of the visit that the patient is physically located. And just make sure that that is meeting those jurisdictions for medical practice in that particular state. And then of course, confirming consent and permission and documenting it in your note. So moving on from privacy into the environment. So certainly dressing professionally, maybe even wearing a lab coat. So avoiding doing these visits with you in your pajamas as tempting as that might be. And avoiding anything very, very distracting. And then in terms of setting, making sure that the light's appropriate. Many of these patients may have some levels of visual impairment. So really making sure that they are able to be seeing you. And again, because of the body language having to be through a virtual medium, this is really important. Making sure the webcam is at an eye level. And then making sure you have an appropriate background through which the patient can conduct this. Avoidance of visual distractions, any kind of clutter, distracting backgrounds, auditory distractions, not being in a noisy place and so forth. And then of course ensuring technology is appropriate and testing those connections prior to the visit. And then you finally come on to the performance after privacy and environment. And so performance is where the effective or enhancing effective communication comes in. And these are sort of the four pillars of that. Making sure you're present and visibly so to the patient. Identifying the patient needs for the visit. What is the purpose of this visit? Are you here? Is the purpose to discuss a particular lab result? So don't assume that just because you have a particular agenda for that visit maybe you're seeing the patient for an asthma follow-up. But the patient may be really wanting to talk about maybe a CT scan report that was done prior to the, you know, from the time that they last saw you. So really try to engage with the patient early on in terms of what really is their agenda. Many of these tele-visits take place in a time sensitive, you know, limited time engagement. And so that is very important. Active listening and empathetic listening. We'll talk a little bit more about that. And then responding with empathy. So again, we talked about, you know, the professional look, having the empathy-driven mindset, being present, and then being organized. So before the tele-visit starts, make sure you've already glanced at the patient chart and really gotten a sense of, you know, don't start off the visit and then start scurrying through their chart to figure out what exactly is the patient all about. For new patients, make sure you get to introduce yourself, identify your role within the organization, set the agenda for the visit, chat informally. Again, tele-visits, you don't have the benefit of the in-person type of communication cues. So setting up that rapport may need an extra bit of effort. And then again, just double-checking, making sure all the technology is in place. In terms of verbal communication, important to obviously reduce medical jargon as you would in an in-person visit, but even more so because you're speaking through a medium, making sure that you're clear, not mumbling your words, keeping things as simple as possible, speaking very clearly, not speaking too many long sentences, and then repeat yourself periodically to make sure that the patient is still engaged and is actually understanding the critical points that you want the patient to take away. Longer pauses, this is something I practically have found useful, is in an in-person visit, I rarely make use of too much of pauses. But in a tele-visit, particularly there is lag time, and sometimes patients start to ask a question as you are still talking, and then they get a little disturbed because they feel they are interrupting you, and then they kind of hold off, and then they may lose their train of thought by the time you're done. So making sure that you're a little more deliberate about the use of pauses and keeping those pauses slightly longer, maybe even five seconds or ten seconds long in between. You don't necessarily have to say anything, just pause at the end if you've made a particular explanation about a physiology or a CT scan report, just pause and see is the patient coming back to you right away with any kinds of questions. And usually if you keep that pause pregnant enough, you know, for five or ten seconds, there will be some kind of information seeking that you elicit from the individual. The 73855 rule is applicable to many settings. Some of you may be familiar with it, but this is particularly useful in a telemedicine visit, which is only 7% of communication happens with the spoken word. And the vast majority of it happens with, to some extent, voice tone, a lot more with body language. And we may forget this during a tele-visit because we think, well, we are only speaking to a screen, so normally if there were certain hand movements, certain eye gestures, head nodding, things like that that you may engage in, you may feel it's not relevant anymore. After all, I'm looking at a screen and the patient's looking at a screen. But recognize that if you do that, you almost may lose 90% of the communication value of the messaging, whether that's smoking cessation, adherence to an inhaler, compliance with their CPAP, so many things that you really are relying on the strength of your messaging in order to be impactful to the patient. So non-verbal communication is really key. So head nodding, forward leaning when appropriate, just really trying to tell the patient that you have my undivided attention, that I am actually paying attention to you. As tempting as it may be during a tele-visit in particular to be looking at a different screen or looking at the labs while the patient is talking to you, and that can very quickly degenerate into a perception that you're not engaged, that you're not really interested. Maintaining that eye contact can be particularly challenging because you really are trying to look at the camera in order for the patient to feel that you're looking at them, but then you're also trying to look at the patient to pick up on their body cues. So it really takes a little bit of experience and practice to start learning how to alternate between that. And then limiting negative body language, trying to keep more of an open stance, avoiding arms crossed, fidgeting movements that can be very distracting, and maybe conveying certain negative cues in terms of non-verbal communication. Empathetics is sort of the new buzzword for patient-centered care. I think a lot of us, particularly in institutions, are being increasingly mindful of the role that empathy plays or empathetics-focused care. And so telehealth is particularly an area where this is even more useful. So asking, first of all, about their familiarity with virtual care. We talked about displaying non-verbal empathy. Acknowledgement type of statements, you know, I'm sorry you feel this way, or validating type of statements where, yeah, that really is painful, or that must be really scary that you have a history where your mom and one more family member passed away early on with lung cancer. And so I can understand why this lung nodule would be particularly distressing to you. And then naming those emotions. You must be feeling afraid. And so really articulating that. Those are all ways of developing that relationship during the course of what is really a very limited and often challenging encounter in a telehealth setting. So empathetic listening, I mean, we used to sort of focus on what is the concept called active listening. And now that is evolving into this empathetic listening, which is, you know, providing brief, acknowledging responses, giving non-verbal acknowledgments. We already talked a lot about the body expression and eye contact and so forth. And then really inviting them to be more expressive. You know, tell me more about how you feel about that, or why are you, you know, why is it that you feel that this, you may not be able to do this, or so forth. So sort of putting it all together is, you know, making sure that you introduce the technology, convey respect, set the agenda ahead of time, really try to say, you know, in today's visit, you know, we have a lot of ground to cover. You have asthma, sleep apnea, heart failure, we are trying to get you to quit smoking, lose weight. So really have in your own mind, this is a 15-minute visit or a 20-minute visit. How are you going to unpack that visit? What are the things that you are going to focus on? And really lay that agenda ahead of time, so that the patient is also prepared, if sometimes they have a list of questions, and they may tell you, you know, I have a list of questions, and then you could sort of say, okay, we'll leave this much of time for that, or perhaps if you're running over and you're going to be behind for your next appointment, you can say, well, let's table a few of those questions for our next visit. Or something, conveying empathy, eliciting the patient narrative, you know, we talked about, you know, reflective listening, and then collaboratively developing a plan with shared decision making. Confirm the patient's understanding, ask them, you know, can you repeat what we just said, or did you understand, or in your own words, what do you think were the key messages that you got, and then have an appreciative closure. So with that, I'll stop, and I'll invite Supriya Singh to get to the next topic, which is outcomes data and telehealth. Good afternoon, everyone. I'm Supriya Singh. I work out of Houston in the VA with Baylor College of Medicine. Our goal today is to talk briefly about the outcomes data in telehealth. I have no disclosures. Our learning objective today is to touch briefly on different types of telemedicine, talk about the telehealth performance measures, and how to gauge if a telehealth program is successful, and then briefly touch on physician and patient-related outcomes. So as you know, there are different types of digital health technologies out there. It could be electronic health record, provision of electronic scripts, telehealth, telemedicine, and certainly wearable devices like a Holter monitor or an active watch in the case of sleep disorders. So telemedicine is the provision of clinical services to patients by physicians as well as other practitioners from a distance via the electronic communication with the goal to decrease barriers as well as to increase access to healthcare. Telehealth, on the other hand, includes telemedicine, which is once again the clinical services, but telehealth also incorporates the non-clinical remote services. It could be a CME given via the Zoom or Teams. It could be other training provided to the physicians remotely, and certainly communication of results or electronic health records between providers. So there are different types of telehealth services. Some that you have, of course, come across is the synchronous or the live video, where there's a real-time interaction between the physician as well as the patient, and it can actually substitute the face-to-face interactions. Asynchronous, on the other hand, is the transmission of recorded health records from the patient to the provider that is used by the provider to render healthcare outside the realm of real-time. Remote patient monitoring are various medical data points that are once again provided by the patient to the provider, and the goal of the provider is to make sure to go over this medical data with the end goal to decrease hospital admissions. So in our speciality, certainly COPD, narcolepsy are some areas where we tend to use the remote patient monitoring. The mobile health is the new kid on the block, and this is something that came into vogue during the pandemic. This is one of the ways where a patient can be educated via their cell phones. They can be promoted to do healthy behavior. They can be provided alerts about disease outbreaks. So those are some of the ways the mobile health can be utilized. There are various ways for which the telemedicine can be used, but the end goal of all of these applications is certainly to improve patient coordination, enhance the overall health performance. It should be cost-effective, and once again, decrease any kind of barrier that will decrease the access to care. Certainly in the rural communities where we have a lot of older patient population who tend to have chronic conditions, telehealth can be utilized to provide long-term care to these patients, and this is one of the reasons that telemedicine is very well accepted in certain remote areas like Alaska as well as South Dakota. So telemedicine certainly has taken off. These digital health companies, in order to maintain that trajectory, have to certainly show us good outcome data, especially patient-centric, which should be equivalent as well as non-inferior to face-to-face visits. So keep in mind that telehealth is not only providing clinical care. It also involves policies, the workflow, the scheduling, the billing, as well as the payment of its providers. Over the last two years, or three years rather, it's grown significantly from 11% in 2019 to almost 76% currently. It initially peaked during the pandemic in the month of April, and then since then, it's kind of stabilized. In our, of course, speciality pulmonary medicine, we all tend to use telehealth, but psychiatry is out there, which uses a lot of telehealth. So the way we decide if a telehealth program is successful, certainly in the past, was based on the financial return of that facility. Patient satisfaction was not aggregated and measured in the past. But over the last couple of years, there is this quadruple aim, which is going towards improving patient experience, enhancing the overall health of the population, reducing the costs, as well as focusing on the physician experience. So how do you measure telehealth success? So measuring success can be very tricky. Not all metrics that one measures are meaningful, and then there are several aspects of telehealth which are actually very difficult to measure. As Yogi Berra says, if you don't know where you're going, you'll end up someplace else. We have millennials who don't want to come and sit in the clinic for two hours or one hour or half hour Getting been seen they want to be seen Whenever they have the time they can log in they can see or they can do with that So I'll try to cover a couple of the things we will try to understand the new documentation and billing rules as determined by CMS We'll try to address the changes in the rule post COVID-19 public health emergency being over We can try to touch into what can expect in the future and I can share some thoughts but again, only time can tell how the Congress and CMS and the insurance company decide how you're going to get paid and we'll try to talk about some physiological telemonitoring reimbursement It can be you know, we have a lot of way in the past it was Computerized based technology where the patient will come mainly it was designed for the rural areas and Patient will be going to a places where there is no psychiatry facility or a specialty facility and they will go to a place where they will be sitting in a Clinic and then the physician is dialing from the remote area But during the core time a lot of the things were added the phone calls the visit virtual consoles and things like that History of telemedicine goes a long time ago. It was envisioned in 1920 as a virtual alternative physician house call I Started developing in mid-centuries when NASA tried to provide a way to the medical care for the astronauts in 60s it was linked to airport in 70s delivering health care to the Indian Reservation in 80s It was utilized in Armenian earthquake in 90s. It was getting it delivered to the rural population and You're almost 1999 I try to set up an asynchronous model in Tanzania and Africa where I try to get a capacity building for both Telepathology where we link them and they will upload the slide and it will take about two hours to four hour to upload few slides Going over there. So I think a lot of the advantages in being there But let's see what the telehealth before my 16 2020 waiver when the covert came in Only 0.3 percent of the traditional Medicare beneficiary in part two. They were using telehealth service in 2016 Medicare cover telehealth service says only when the patient was in rural area Patient had to leave home to go to a different site that has a audio visual equipment Physician must conduct telehealth from place of practice So in other words the patient has to go to the clinic. They cannot be from home They have to be in rural area the physician and the patient have to be in the same state They cannot cross the street is a you know state line and the telehealth was limited the patient who had a pre-existing Relationship. So in other word you have seen the patient in the office and it was kind of a follow-up you're doing They were not really allowing that Medicare co-insurance and detectables were applied and they wanted to make sure that it was an audio video on approved technology Platforms. So in other word, it has to be HIPAA compliant and all that. So there were very very strict regulation Just before March 26 2020 So what happened the corona virus came in social distancing happened and the emergency waiver came in so house resolution bill 6074 the corner virus preparedness and response appropriation act came in and 1135 waivers, so they had a 8.3 billion emergency funding So the telehealth services were provided during the emergency period They waive a lot of the Medicare Medicare restriction and requirement during public health emergency So the patient can be at home. The physicians can be at home their own home the patient Doesn't have to be like a stab list patient. There can be a new patient and in other word also, they went into it that rather than having a HIPAA compliant you can still use a lot of the other Platform and people were using doc symmetry people using some of the other Platform which would not completely HIPAA compliant They provided full reimbursement for the telehealth services whether it was audio or audio video combined Or if it is audio only with a little bit less reimbursement, and I'm going to go all the dollar and cents They rapidly adopted during the shelter-in-place the video visit and telephone options and we all have done it because the patient couldn't come in whether the patients were afraid or Staff were afraid or our stuff was sick and we couldn't do that. So a lot of changes and leeway that happened even during the pandemic I think if you look at the Seema Verma and she testified before the Senate Finance Committee and she say I can't imagine Going back people recognize the value of this so it seems like it would not be a good thing to force our beneficiary to go back to in-person visit and People you know, sometimes you're tired. You're working your job you can Come in in 15 minutes or 20 minutes. You can Connect with your physician but trying to take a half day off the job sometime can be very challenging So what happened? Then the telehealth care after the waiver stopped We know on May 31st, the emergency was stopped the waiver went away So the question was like what's going to happen the Medicaid telehealth utilization during the time if you look During the time between 1990 and 20 or 63 for There were five thousand five percent claim at the end of 2021 were tele Versus 0.3 before the covert so during the core time it really picked up You actually really didn't require any physician relationship Like you have to be having a previously established patient physician may conduct telehealth from home. I think I Totally agree with dr. Subramanian that we need to be very professionally dressed but I can tell you I did about 2,000 television segment for the ABC News and Top wise it's always good. The bottom was always PJ's and They would not even believe it. But that was a very fact and a couple of times. I've taken the calls While in the restroom you blurred you put this green thing So try to avoid that because I we have seen a lot of mishaps The hardwires are on and so and so forth. So don't do that. You know, your reputation is too important Tell you I'll can provide it be to the patient in the end of this state. That was all the Advantages we have we can do it from home patient can be at home You can cross the state line and the coinsurance and deductible were waived So the patients were happy and audio video or audio only So all those things, you know, which were happening and you know, the traditional what we were doing was in Health physician shortage area or rural area and as you mentioned the psychiatry Was high in the list the mental health challenge is going up and up and up and I can guarantee that the mental health is Going up. There is a shortage of psychiatrists And the psychologists that tele services are never going to go away Because we cannot have enough resources to reach in the remote part in the rural area So I think that thing is going to be going in so a couple of the guidelines I think you know Which was there? Before that, you know, you have to you have the EM codes, for example Nine nine two one four two one three or nine nine two zero two whatever codes you're billing for your regular E&M for the initial patient or the established patient the covert codes were basically the same The time may include you can actually use the decision-making or the time Review of system was not really too much important exam was kind of not very very mandatory You can do a focal examination and I think we are going away and away from the examination. I think the biggest distancing between the patient and the Physician happened when this set of school was discovered and if you can look at the history of how this Was discovered that was the first barrier between the physician and patient and now I think you know It's going to go more and more CBD technology. I think we have in our office. We have the technology where They can put the stethoscope on the patient. We can listen to the heart lung we can Examine the patient and somebody from the remote can have all the information But most of the time when we are doing in the covert We didn't require any of those things and it's still after the covert. I think we may not require it One of the thing is we were billing with the modifier 95, but after the covert When the waiver went away in May 31st, we are going to bill Either zero to or 10 modifier depending on if the patient is at home or patient is at some other location at home I've seen some patient who are taking The calls video calls when they're in the car and I have to request that Video calls when they're in the car and I have to request very politely Do you mind pulling off the road because there is still driving and they just have the camera attached So, you know yours you have to emphasize safety first You should not communicate you just want to make sure that the safe location and it is required that you have to put the patient location and if you're Doing it. One of the other requirement is that If the patient is in safe location, especially for mental health if they run into anything or suicidal what they are What are the nearest emergency? facilities You have to build the most important code you put the modifier. So and I'll go over all the course, too Now during the covert time besides the audio video synchronous They also allow the phone calls the phone calls were not built as your normal 9 9 2 0 3 or 9 and 2 1 3 or 2 1 4 They have to use a different court and those were paid at a much lower rate And a lot of the folks were making a mistake They were doing the telephone visit and they were billing as a tele visit So those were not same for the phone calls you you can use 9 9 4 1 4 For 5 to 10 minutes for 4 2 2 11 to 20 4 3 4 21 minute or greater So that can be built and I think you know We'll go into what changes and what extensions they have allowed so as the emergency when it ends on May 31st the CMS will Really realize that We have gone so much and abruptly if we end everything it can become challenging So they wanted the Congress to pass some bill to extend some of the services till the figure it out What services they are going to cover on a permanent basis and what services they are not going to cover on a non-permanent basis? So I think we go over to the phone visit and I 9 4 4 1 4 2 4 3 and if they are MD Or and be allied health practitioner you do that, but if you're a physical therapist Occupational therapist or a clinical psychologist, then you have a different code 9 8 9 6 6 6 7 and 6 8 that would be your code So what happened so when May 31st everything? Changed and you had three month extension Then what happened the Congress were given some of the mandated tasks that they need to make sure that they can actually Go in and see if they can modify So they pass a house resolution bill 4040 advancing technology beyond covert 19 2022 and they passed on July 22 2022 by a vote of 416 to 12 That's very rare to see in the Congress with that high level of bipartisan bill so they continued flexibility till December 31st to 2024 but not for everything some of the thing will expire in the December 2023 some of them will be there and we'll go over all of those. So basically I think These are the services if you are doing a virtual direct supervision that expires on December 31st 2023 so in other word if you are doing a pulmonary rehab supervisions physician has to be on-site During the covert time they can do a virtual supervision. That thing is going to go away on December 31 2023 Audio only that has been extended to December 31 2024 evisit For both new and established patient because if you recall before the covert time, it was only allowed for the established so that one is also extended till December 31st 2023 Virtual check-in again, you know, there is something Which has some specific rules that you know You got something you call the patient if you are calling within seven days of your previous visit That you don't get anything or if you call in and then within 24 hour you set up the another visit or a full visit You don't get reimbursed. So in other word, it can be a very short it pays like seven ten bucks, but That is a virtual check-in code is still there, but that's expiring on December 31 23 Question is it would it be extended further? We don't know that place of service again, you know in before the covert they have to be in the facility They cannot be at home. But now, you know, this is extended till December 31st 2023 It can be if the patient home is 10. Otherwise, it's 0 2 and we used to use 95 modifier originating site again It can be in anywhere before that it was in a rural area Now December till December 2024. It can be patient can be at their home Payment parity. I think the patient it is extended till December 31 2024, but they are going to reduce at the facility rate So if you recall that, you know, if the patient is in the office It's reimbursed at a higher rate because the physician is incurring the cost of the office But if you're seeing in a hospital facility They're paying physician at a lower rate because they don't have any overhead hospital bills a facility charge separately Provider types again physical therapist OD and a speech pathologist. They will be able to continue till December 24 COVID-19 vaccine. We know that it's gone and They've extended till December only on patient who doesn't have insurance Enrollment and opt-out enrollment again before that they can drop in or they can get expedite the new application Now it's not it's just going to go through the regular process and again telehealth platform the physician after August 9 2023, they must use a HIPAA compliant and a lot of the Doximetry and other folks they are now HIPAA compliant a schedule 31, you know schedules substance or November 2023 if they have got it in the program before that they can still continue till November 11 2024 but the DA is looking into it and see how the thing goes I think I've discussed some of that thing in the interest of time. I'm going to pass that thing modifier. We also talked about it so the Reimbursement again, we have the code for 99202 203 204 205 again before that it was just on how many system exam how many review system? That is all gone. It is all based on complexities and I don't need to leave it there This is where the money is so in 2022 the payment was If you look at the payment office visit for 202 most of the time as a consultant We are looking at offices at 99204 203 or 205 So it it has gone down by minus 1.2 or 0.7 percent On the follow-up again, it is very little change But if you are doing a tele visit, so you got to realize that now they are going to pay on the facility Charges not the non-facility. So in other word if you're looking at 99204, which is your console level for you are supposed to get one sixty eight dollar forty two cents and And you're going to end up in getting paid if you're doing tele at 134 19. So there is like about Significant cut so they are still going to continue to pay till December 31st 2024 but the reimbursement would be less because they're realizing that you're not consuming That much of your office time and the follow-up visit again You know, it is Interesting 99214 if you're doing a follow-up if you're getting paid 128 bucks And now you're going to do a telly you're going to get paid 9760 Telephone visit essentially not much change because they were paying in pennies Most of the time if you're doing 11 to 20 minutes, you're getting paid 3668 now you're going to get paid 3592 so but it's still I have a feeling that that thing is going to Go into it. I think I'm going to go through this very fast physiological Physiological monitoring. So if you're setting up some of the physiological monitoring device like remote pulse out peak flow blood pressure You can bill as nine nine four five three they don't allow for your work are you but they pay four point five five office expense and again, you can build every 30 days and They will pay up to 1.6 time RUV so that's about around fifty five sixty dollars for that This is another code like, you know, if you are more physiological monitoring work by clinical staff So a lot of the time, you know, we have of the RTs Doing the CPAP clinic. They are Actually going through the CPAP download data and they're communicating with the patient So you can actually bill first 20 minutes point six one and then subsequent 20 minutes you can add another point six one RUV So I think this is a code we use a lot the other code I think a lot of the physician uses because a lot of the time we are looking at some of the data as they are Sending it to us. We can look at it And if we spend once a month, we can build nine nine zero nine one, which is a 30 minute It's pays. I think around 1.2 RUV Virtual check-in as I also mentioned it pays very little you use a G modifier for that But again, there are still rules that if it before seven days if you have seen it or you will see it in 24 hours That would not work This is I think we already said that nine nine zero nine one. It's 30 minute work for you can build once a month You can look at the patient data and you have to communicate with the patient again Ideally it should be physician making one phone call But most of the time I've seen the allied health care practitioner doing it so it can pay about $60 Therapeutic monitoring I think medication adherence and all that you can actually have a point five four RUV and again You can do that is for setup and follow-up. You can have a nine eight nine seven six So I I think I went through a lot of different Monitoring system, I think I'm over my time so in the interest of the time I'll stop over here, but I can tell you that a lot of the things have been extended For a year or two. It's not going to go away. I think the Congress is very clear CMS is very clear. It's not going to go away. It's going to stay with some modification HIPAA compliant device and also it will be remaining where you'll be reimbursed at a little lower rate So I'll stop over here Thank You dr. Sarani switching gears now to the inpatient side and talking about tele ICU Emily Hurst Thank you All right So I have ten minutes to talk about the inpatient side, but we'll get there. I'm gonna see if my presentation will load here so dialing into The EICU I am I do have some disclosures. I've worked in telehealth since 2014 So the last ten years and I work in all sized health systems across the United States I provide programs potential partners actively mold and develop their programs and I had to read that disclosure officially to you guys today. So You'll see two different spaces that I've worked in Many lectures that I've heard today. They've talked about South Dakota in the rural hair rural care That is where the original program I started when about with a vel e care Ten years ago and I've been the EICU medical director there the electronic ICU medical director and then for Henry Ford Health System I have started a virtual ICU program and I'm the medical director in that space, too So just talking a little bit about the virtual needs of an ICU and how it continues to change the complexities of using Using international colleagues and then the platform changes and some development ideas So the only thing that's constant in telemedicine is change I know it's cliche because that's medicine in general, but telemedicine is on crack. It's even more and changing even more rapidly The gold standard just a kind of level set where everything came from was 24-7 monitoring That would be with typically nursing staff and a physician But some programs did have a support specialist or kind of like a unit secretary pharmacy respiratory therapists and a PPS just depending on the program and how extensive and how many different health systems or Within its own system the different size hospitals It was serving that then 24-7 program worked through a platform that had real-time vital signs and alerts You'll hear AI everywhere, but it is not AI yet It is definitely up and coming but it was really what was called real-time vital signs Which were then input into the program and then alerts were given to the physician so if they can't see them with the naked eye or standing at the bedside they could get that information and alerts that they Knew they needed to look into the patient That platform also has a video integration so that you can see the patients directly over the video monitor And two-way is is ideal now. It has not been two-way for a long time VICU has been around for 30 years now Which is kind of hard to believe but it is actually one of the oldest types of Telemedicine and there are two programs in the United States that have been doing it that long The video integration can be one way, but it is much more effective and now I would suggest that in the 2020s Everything is two-way Documentation is actually directly into the electronic medical record Which is excellent because then not only do you have a repository of documents that you can look at in your your platform? So your colleague coming on can see what you did But then also the providers on the other side that are at the bedside can look to see what you did from a telehealth standpoint So again, this is the gold standard. This has been what's largely been around for the last probably 25 years So what's happened as you've heard my colleagues say is kovats kind of turned everything up on its head The good part about kovat is that it expanded the functionality of the current programs we had dramatically So programs that already were in existence Found all sorts of other ways that they could expand their programs visualize their patients interact and manage things through kovat There are also within telemedicine what we'll call late adopters people that just are really nervous about it They aren't very invested in it Not really sure where they want to go and they have hesitancy about the benefits Kovat increased their connection and support and belief and what telehealth could do which was a really positive for it on The flip side even though we know telehealth is here and coming and that lots and lots of hospitals are Adopting whether they want to or not The financial constraints are driving new models The cost of telehealth is very expensive and particularly in the EICU so the first thing that a program is going to cut if they're struggling financially in a system a hospital system is the BIC or the EICU program because it's an added layer of support on top of it already is happening at the bedside So we've been seeing that but it's driving new care models, which is great The EMR is also because of security threats have been incredibly restricting. I have worked with International partners for my entire career, which I adore because I didn't have to do nights anymore So my international colleagues were u.s. Trained fabulous physicians and they were up during their daytime I was up during my daytime and nobody had to work nights, which worked really well in the EICU space However with the security threats now There are lots of issues with states and even EMR saying that they will not credential certain providers that are in certain areas that are either destabilized Or that have connection issues and security threats It's also causing an issue with state and site so just hospital as well as state credentialing concerns They are saying they will not credential certain providers Based on their location and the way they connect to their EMR for security threats So this has really been a relatively new problem That's evolved in the last year and we're really trying to work through it particularly with our partners that we've worked with for so long internationally The new platforms are rapidly evolving That's been really interesting. The gold standard is becoming obsolete Not because things are moving so fast, but because they've recognized other people are up-and-coming they've had their platform for 30 years They're like hey, let's let them put into it. We've got money we can get elsewhere So there the gold standard platform is no longer choosing to evolve and so all these other ones are coming up They haven't quite caught up to the gold standard yet But they will be and it's going to be really interesting to see how that continues to evolve The other thing that's really key and important to talk about when you have a virtual or an electronic ICU program is Within your hospital system you'd be remiss if you don't take into account the differences between the hospital sizes you have if You just have one form of way you interact with all of your different hospital sizes. You're going to find yourself short of Actually giving them the care they needed Critical access hospitals require full management a lot of them once they're on event or a BiPAP They're shipping them out So that support is actually really intense for them because they don't have access and they just want to stabilize and send out the community sized hospitals Oftentimes have really complex and sick patients And they don't have access to all the hospital all the specialists as well as you know And then through kovat they had to keep patients that they were not used to managing So you had to really elevate the support of the providers that were being forced to manage patients They've never taken care of before and then your tertiary and quaternary hospitals Which really want to standardize and level set their care that is the best way that they're utilizing telehealth and the ICU standards And then they want to share their expertise not only within their system But then beyond and so that's the next level of vision for EICU expansion So some of the solutions that programs have been working through our on-demand programs So that means you're just asking for the care when you need it So that's been really great because it eliminates the cost of 24 7 monitoring and you only call when you want them the only problem is when you've got like leapfrog Compliance and some of those other programs your hospital may want it does not comply with those things So that's a balance that the hospital has to decide financially which way they would want to go for internal program development Absolutely wonderful for your program because you build something that's specific to the needs of your system But it's incredibly slower Sometimes they used to say it took about 10 years to fully Integrate and develop a program of your own. However, I think it's quite a bit shorter than that, but it's still long I mean, I would say at least a minimum of five years for you to really get a program going It can also be cost prohibitive and more or more efficient depending on how many critical care beds you have There is a higher number of patients that a critical care ICU EICU patient can see And so if you are only maintaining 24 patients, then you're not sustaining your program You're paying somebody to only get a couple calls a night, which isn't effective And then with the platform transitions that I already mentioned the platform robustness is evolving So you can as a program partner with a lesser-known platform and then evolve your program with it And that's a really financially solid way to kind of grow your program and then also evaluate your current program if you already have one and see if what you're Using you pay you're you're paying what you you are paying you're using what you pay for goodness gracious. I'm backwards Because some of the programs you can actually turn off components of because you are you're not utilizing them effectively and you're paying for them So you might as well see if that's effective for you So determining what your hospital needs Do you already have a program in place if you do what works with that program at what doesn't if it's not working effectively? I certainly encourage you to change it and then also looking can you afford what you currently have? That's really important and there are lots of changes that can be made so you can continue to sustain your program And if you don't have a critical care the ICU program What are the expectations for electronic or virtual ICU you need to know going into it what you want it to do for you? And how it's going to function for your program because if you just go in blindly You'll have a really hard time defining what you're looking for And then what resources financial personal electronic can you contribute to offset the costs do you already have a program that was previously into? Implemented what are your financial resources that you can like critical care billing now that has changed dramatically and a lot of hospitals are using It now because of that and what personnel do you have that are interested in it? So telemedicine as we know I have said by one of my colleagues up here is going to continue to explode I would encourage you to be on the forefront of that change until it's kind of interjected into your world So checkout programs look into it see what the right fits might be because it is going to continue to come As it's been having lots of benefits Build a program that suits your needs again from the patient not just the patient standpoint But also from a staff and a financial standpoint And then if you think that there's not anything out there Then I would encourage you to keep looking because there are so many different options there's really multitudes of different programs, and you can find something that specifically fits your needs and then the last key part is Instilling the vision and the opportunity within your program if you don't have a champion within your hospital That's willing to talk communicate and encourage the others to come along you're gonna Have a really hard time implementing a program getting that vision out there and the opportunities are critical to developing a really great program and And going from there, so I did that really fast because I only had about 10 minutes, but I think we can all Take questions if you guys have any of them

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