ASHA PowerPoint 1

1
Developing Telepractice Proposals for Health
Care Schools
Janet Brown, Michael Campbell, Vickie Pullins
November 22, 2008 Session 2540 ASHA
Convention
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ASHA and Telepractice

• Janet Brown, MA CCC-SLP
• Director, Health Care Services in SLP

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Preview

• Overview of ASHA, telepractice, and current
  issues
• Information for developing telepractice programs
• Information for ensuring clinical quality

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ASHAs Policy Documents (2004) for SLP

• Speech-Language Pathologists Providing Clinical
  Services via Telepractice
• Position Statement
• Technical Report
• Knowledge and Skills
• www.asha.org/telepractice

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Telepractice(aka Telehealth, Telemedicine,
TeleSLP)

• Telepractice is the application of
  telecommunications technology at a distance by
  linking clinician to client, or clinician to
  clinician for assessment, intervention, and/or
  consultation.

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Quality of Service

• Telepractice (telehealth) is an appropriate model
  of service delivery for the profession of
  speech-language pathology and audiologyThe
  quality of the services delivered via
  telepractice must be consistent with the quality
  of services delivered face-to-face.
• --Position Statement

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Challenges in Definition

• Is it a direct service or ancillary to the
  service (e.g. electronic worksheets)
• If it is a direct service, is it the same as what
  would be provided face-to-face?

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What About Distance Supervision?

• Not called telepractice
• Council for Clinical Certification (CFCC) has
  approved distance supervision as an acceptable
  means of supervision
• Doesnt meet Medicare requirement for student
  supervision (in the room)

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ASHAs Activities in Telepractice

• Since 1998
• Medicare application
• Telepractice brochure, DVD, web pages
• www.asha.org/telepractice
• American Telemedicine Association
• Center for Telehealth and E-Health Law

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State Licensure

• Most state licensure laws dont address
  telepractice
• Growing trend for state boards to become aware
• Different definitions being used by each state
• Requirements affirm that SLP must be licensed in
  their state

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Current Initiatives

• Developing model language for state licensure
• Forming a committee to develop guidance on
  professional issues surrounding telepractice
• Discussing terminology

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For More Information

• www.asha.org/telepractice
• jbrown_at_asha.org
• 301-296-5679

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Developing Telepractice Proposals for Health Care
and Schools

• Michael Campbell
• The University of North Carolina at Greensboro

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Getting Started

• Support from organization/stakeholders
• Become educated
• Check with state licensing board
• Must consider
• Client users
• Clinician users
• Service delivery environment
• Training necessary
• Develop a business plan (template at Business and
  Finance SIG _at_ ATA website)

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Business Models
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Telepractice Settings

• University
• Healthcare
• Hospital
• Skilled Nursing Facilities
• Outpatient
• Home Health
• Public Schools

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Sustainability

• Fixed Expenses
• Equipment lease or purchase
• Space lease or purchase
• Salaries
• Variable Expenses
• Training expenses
• Marketing costs
• Supplies
• Travel
• Revenue

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Break-Even

• Relationship between initial investment outlays
  and required volumes to reach profitability
• Intersection of total income and total costs

How many consultations do I need to perform to
cover my costs?
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Break-Even Analysis

• Revenues equal expenses
• ATA Business and Finance SIG tool _at_
  http//www.atmeda.org/ICOT/BF.Sig.Presentations/Bu
  siness2020Finance20SIG20Breakeven20Analysis
  20Tool.xls

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Funding Sources and Reimbursement
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Possible Funding for Telepractice

• Contracts
• Private Pay
• Insurance
• Medicare/Medicaid
• Conrad Bill introduced 4/3/08
• Medicaid Reimbursement
• Is now available in 27 states
• Gives states flexibility in determining what may
  be reimbursed

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Grant Possibilities

• Office for the Advancement of Telehealth (OAT)
• Universal Service Administration Company (USAC),
  Rural Health Care Division
• Appalachian Regional Commission, Telemedicine
  Program
• Congressional Earmark Funding, US Department of
  Education
• Corporate Grant Writers working with vendors

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Technology
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Telepractice Types

• Store and Forward
• Tele-Monitoring
• Video Conferencing

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Store and Forward Equipment

• Capture Device
• Audio
• Video
• Still Image
• Text
• Storage Device
• Computer
• Network Storage (Server)

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Connection Types

• Local Area Network (LAN)
• Internal network
• Network that you own and control
• Uses Ethernet based technology
• Covers small geographic area
• High speech connections between network devices
  and buildings

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...Connection Types

• Wide Area Network (WAN)
• External network
• Leased not owned
• More expensive to operate generally
• May not be available between rural and urban
  areas
• Connection can be made between LANs

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WAN

• Wide Area Networks are the set of connecting
  links between Local Area Networks.

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WAN Types

• Common Wide Area Network technologies
• Plain Old Telephone Service (POTS)
• Digital Subscriber Line (DSL)
• Cable
• Integrated Services Digital Network (ISDN is
  HIPAA Compliant)
• T1 (HIPAA Compliant)

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Bandwidth

• Bandwidth bits/second
• Greater the bandwidth more information higher
  image and audio quality
• Measured in (bps) Bits Per Second
• K kilo 1,000
• M mega 1,000,000 million
• G giga 1,000,000,000 billion

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POTS

• Plain Old telephone Service
• Most common network in use today
• Sometimes the only source of communication in
  underserved areas
• Maximum bandwidth of 56 kilobits per second

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ISDN

• Integrated Services Digital Network
• An international communications standard for
  sending voice, video, and data over digital
  telephone lines
• ISDN is a digital phone line
• ISDN number looks just like a telephone number
  (111-222-3333)

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...ISDN

• Two types of ISDN
• Basic Rate Interface (BRI) _at_ 128 kbps max.
• Site to site
• 384 kbps min. for video conferencing (3xBRI)
• Primary Rate Interface (PRI) _at_ 1.5 mbps max.
• 1 PRI 12 x BRI
• Multisite
• Supports high definition video

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Internet Protocol (IP)

• Method of addressing network devices
• IP is a higher level protocol that can be
  transmitted over different connection types, T-1,
  DSL, Cable and ISDN can be used to transmit IP
  information
• IP is more flexible than ISDN
• IP address (192. 168.999.222)

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Advantages of IP

• Improved reliability
• Decreased cost of ownership
• Predictable usage fees
• Call speed flexibility
• Tighter security

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T-1

• Dedicated leased line
• T-1 is a point to point connection
• Flat rate service
• 1.5 mbps maximum

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Virtual Private Network (VPN)

• A cost effective and secure way for remote
  networks to communicate with each other across
  the Internet
• VPN offers less reliability, performance and
  security than traditional WAN connections, such
  as T-1 and ISDN

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Internet2

• Furnishes a 100Gbps network backbone to more than
  210 U.S. educational institutions, 70
  corporations and 45 non-profit and government
  agencies.
• Provides the U.S. research and education
  community with a network that satisfies their
  bandwidth-intensive requirements.

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comply or.

• Security

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Privacy and Security under HIPAA

• Privacy is what you have already promised to do
• Security is about how you fulfill that promise
• Networks are how the authorized (and
  unauthorized) get PHI
• Improper network activity can specifically be
  identified as a security incident
• Network security is of paramount importance

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Sources of Security Threats

• Insiders/Outsiders 70 / 30
• Malicious, dishonest, corrupt, distracted,
  disgruntled, negligent
• Naturally curious, poorly trained, terminated
• Hackers and crackers
• Computer criminals

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Security Tools for HIPAA Compliance

• Firewalls
• Boarder controller
• IDS/IPS
• Secure switches
• Anti-virus
• Two-factor authentication
• Secure VPN
• IEEE 802.11i/Robust Security Network (RSN) is
  coming for wireless

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Speech and Hearing
Program
Site Program
Firewall
INTERNET
Firewall
Server
Rural Public School
Site Program
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Telepractice Security

• Security is more than just a Login
• You must be ready to
• Protect
• Detect
• Respond .to any type of adverse event

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Regulatory and Legal Issues
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Professional Liability Insurance

• Is telepractice covered?
• Are there any limitations to location?
• Who is responsible?
• Watch out for exclusions and limitations for
  damages.
• Carrier should be notified when a clinician is
  planning to provide services via telepractice
• ATA endorses TelMed through Campania Group
  (800-831-9506)

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Informed Consent

• ASHA recommends and some states require that the
  clinician who has ultimate authority over the
  care of the patient receive the patients
  informed consent before delivering care through
  telepractice

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The Joint Commission

• The Joint Commission developed telemedicine
  standards, effective 1/01/01 and revised 1/01/04
• Applies to hospitals and ambulatory care
  facilities
• Practitioners who treat patients via telemedicine
  must be credentialed with the organization that
  receives the telemedicine service.
• Medical staff of the receiving facility
  determines which telemedicine services are
  appropriate.

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HIPAA and Issues Unique to Telepractice

• Covered entities must enter into business
  associate agreements with technical providers
  (non-covered entities) who assist with the
  delivery of healthcare by telemedicine.
• Programs will need to do a reasonable risk
  assessment with respect to data transmission
  consistent with HIPAA security policies.

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Stark Law

• Clinician refers a patient to a facility in which
  (s)he has a financial interest (i.e. conflict of
  interest).

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Anti-Kickback Laws

• Prohibit anyone from receiving or paying anything
  of value to influence a clinical decision.
• Referrals
• Placing telepractice equipment at a site with the
  anticipation of receiving referrals
• Use of space / lease arrangements
• Always check with legal counsel.

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Research Needs

• Development of assessment and treatment protocols
• Compare procedures with traditional interventions
• Assessment of technology and various settings
• Cost benefit analysis
• Client, caregiver and clinician satisfaction
• Education of clients, community, clinicians,
  healthcare professionals and students

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Helpful Links

• ASHA Telepractice Documents http//www.asha.org/
  members/telepractice
• American Telemedicine Association (ATA)
  http//www.atmeda.org
• ATA Telerehabilitation Special Interest Group
  http//www.atmeda.org/ICOT/sigtelerehab.htm
• The Center for Telehealth E-Health Law (CTeL)
  http//www.ctel.org
• Office for the Advancement of Telehealth (OAT)
  http//www.hrsa.gov/telehealth
• Health Resources and Services Administration
  (HRSA) http//www.hrsa.gov

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...Helpful Links

• Telehealth Resource Center http//www.cteconline.
  org/TRC.html
• Universal Service Administration Company (USAC)
  http//www.usac.org
• Appalachian Regional Commission (ARC)
  http//www.arc.gov
• Agency for Health Care Research and Quality
  http//www.ahrq.gov
• Office of Rural Health Policy
  http//www.ruralhealth.hrsa.gov

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Clinical Challenges of Tele

• Vickie Pullins
• LinguaCare Associates, Inc.

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Eliciting Target Phonemes

• Adequate visual/auditory cue
• Difficult without manual manipulation

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Groups of More Than 2

• Difficult to keep on task
• Increased distraction with equipment
• Difficult to elicit the target number of
• productions

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Carry-over in the Classroom

• Lack of weekly contact with teachers
• Facilitator not communicating with teachers

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Utilizing Paraprofessionals

• Technical training
• Familiar with therapy materials
• Behavior management
• Liaison with school staff

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Caseload Selection

• Middle School Students
• Fluency Language
• Articulation Autism
• Learning Disabilities
• Behavior Disorders
• Down Syndrome

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Outcomes

• 163 scheduled sessions
• 126 completed sessions
• 18 students treated
• 9 students completed goals and were dismissed
  from speech/language therapy

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Quality Control

• Satisfaction Surveys Completed
• Parents
• Students
• Administrators
• Teachers
• Results
• Parents 95 Very Satisfied
• Students 99 Very Satisfied
• Administrators 100 Very Satisfied
• Teachers 64.5 Satisfied
• 35.5 Very Satisfied

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Documentation

• Daily log with accuracy counts
• Daily documentation of use of Poly-Com HDX 4000
  via T-1, ISDN Lines
• Daily documentation of number of sessions
  scheduled and number of sessions completed
• Daily documentation of downtime recorded in
  minutes
• Daily documentation of on-site sessions and care
  coordination for Medicaid Reimbursement

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Conclusion

• Telespeech is a valid venue of service for areas
  with no access to on-site services
• Greater teacher involvement is needed
• Additional technology is needed to enhance
  therapy materials utilized

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Telespeech has been amazing just to watch the
students be more alert, not only in seeing
another person talk to them on t.v. but also
enable them to learn and enhance their skills in
speech and language.