February 2, 2023

November 2022 - Teledisaster: Asynchronous Texts to Education (Jarone Lee, MD, MPH, FCCM)

This webinar discussion focuses on the lessons learned from Dr. Lee’s tele-disaster medicine work in Ukraine and in other countries—utilizing provider-to-provider SMS or text-based messaging. He highlights the scalability of tele-medicine and various opportunities within the telehealth space.

Jarone Lee, MD, MPH, FCCM, co-founder of Health Tech Without Borders, a Non-Governmental Organization (NGO) focused on providing telehealth for disasters.

Dr. Lee is an associate professor at Harvard Medical School in Emergency Medicine, and Vice Chief of Critical Care and Trauma, Emergency Surgery and Surgical Critical Care at Mass General Hospital, where he oversees one of their ICU floors.

Read the Transcript

- So, welcome everybody. Good afternoon, good morning, depending on where you are. Emily Hayden again, chair for the telehealth section. We have several of our members, actually, all of our executive committee here are coming in, so welcome. And so, this is our monthly speaker series and monthly meeting. And so, today, we have the luck of having two speakers for us. We're gonna have our first one, Dr. Jarone Lee, and then we're gonna have Jeff Davis later in the hour, speaking about regulatory updates on telehealth and payment reimbursement. But first, I wanted to introduce our first speaker here, Dr. Jarone Lee. He's a friend and colleague here with me at Mass General. He is an associate professor, Harvard Medical School, in emergency medicine, he's the Vice Chief of Critical Care and Trauma, emergency surgery and surgical critical care at our hospital, so he oversees one of our ICU floors. And so he, we have the luck of, when he's down in the ED doing shifts, to be able to give such great pearls from the critical care world. He also co-founded Health Tech Without Borders, which is an NGO focused on providing telehealth for disasters, with a focus with, what I said in the email is that, a modality that we don't do as much of, and probably because we're not reimbursed for it as much of, but the sort of the SMS or text-based messaging, provider to provider. And so, he's gonna be presenting about this. And so Jarone, thank you for coming, and I'm gonna hand the floor over to you now.

- Thank you, Emily. Thank you for that kind introduction. Thank you guys for having me on this. And, you know, listening to what I have to say, I wanted to just spend the next, like, 15, 20 minutes, and I was trying to figure out how to put this together. So Emily, please, if I go over time, give me a signal and I'll stop. But I wanted, I put it in a way where, I figured I'll go through some lessons learned from our tele-disaster medicine work in Ukraine, but also across the world, where, not only in Ukraine, a lot of our work is primarily in Ukraine, I would say probably 90% of our volume is, but we are supporting many other humanitarian efforts, including in Pakistan with the floods, to Northern Iraq and all these other places that I can definitely talk about at another point. And so, before I start, I wanted to show some pictures from one of our NGO partners that has boots on the ground. You know, we are not a boots on the ground NGO, where we're pure digital health response tele-med. And so, we actually don't send anyone in-country, but we work with a many different, you know, agencies, governmental agencies, as well as NGOs to do the work. And so these are some nice pictures that came out of their work there. And so, again, you know, I have different affiliations linked to this versus I am, a lot of this is under the Center for Global Health at our hospital, at Mass General Hospital, as well as I am a founder for Health Tech Without Borders as a pure disclosure of course. And as all these things happen in global health and everything we do, right, it's really takes a lot of different groups to get this work done. And so I'm gonna be talking a lot about the work, but behind the scenes and sometimes not even behind the scenes, there's a lot of different partners that we work with regularly and a lot of silent partners as well. So in the next, you know, few minutes, I am gonna talk a lot about technology. I think that's sort of the goal of this in some ways. But I do wanna say that, you know, technology really is here to connect us and connect people and connect for us people in crises, right? Technology these days is at the point where it should not be the limiting factor for what we do for access to care. And so five less, sorry, four lessons that I wanted to quickly go through. First is, I think you guys will understand that, you know, tele-med digital health is rapidly scalable. Second one is, I think what Emily was talking a little bit about. I'm gonna do a slightly deeper dive into our work and how maybe high tech is not always better and then this need for sort of virtual safe spaces for discussion. And lastly a little bit about our digital health capacity building for humanitarian disasters. So lesson zero is really telehealth works, you know, years ago I got deployed for hurricane relief with Hurricane Irma, huge hurricane that destroyed the Keys. And we were down there for three weeks. I was one of the few doctors for about 140 mile stretch of area. And, you know, we got a lot of interesting consults and patients who came into our field hospital, including ones that required high-end dermatology. We had folks come in with rashes for two to five years, which was interesting, right? And you know, in a disaster setting, we probably could have done less, but I had the opportunity to have really a reachback to our hospital and call some of our friends for a lot of these specialty consults, not just derm. And we were able to diagnose these guys with essentially tele-med in that point. I sent some rashes over and we figured this out, a five year rash that they went to multiple doctors and hospitals for, over the course of the last few years. So first lesson is that, you know, tele-med is, and digital health is scalable, right? So let's start in the US. So this is a map of the United States of where there are hospitals and ICU beds. So the blues are hospitals with ICU beds, orange are areas with hospitals without ICU beds and gray areas are places without hospital at all. And so you can imagine most places with the orange or gray usually have critical access hospitals or clinics that usually will transfer to a blue area. The problem is that at the very beginning with Covid starting to surge, I think everyone sort of realized that that's gonna be a big problem, especially for areas with critical access hospitals without ICU care. And so, you know, a group of folks caught together with governmental funding through the DOD to create something called the National Emergency Tele Critical Care Network that has staffed over and helped over 40 hospitals across 16 different territories and such. And you know, they've covered about over 5,000 patient care days. I think at one point I was covering the entire state of Vermont and parts of Minnesota. And we were also in Guam and other places, but like I said, about 13 different states and territories, 40 hospitals with really no cost to the hospitals themselves. So going to Ukraine when the conflict happened, we were asked to put out a call to action to see how we can support their healthcare system knowing that it'll probably be difficult to access healthcare for the general public, right? For all the reasons that we know. And so we were able to put out a call to action across not just social media but different networks, internal networks, external networks, as well as through hymns. And it's amazing what we got. It sort of showed how many folks wanted to help. We had over 800 physicians, over 20 countries volunteer within three to four weeks at the start of this. And I'm happy to report actually, this is a little old, the slide is old, but I think we've completed about 65,000 consults to Ukrainian patients, families and, you know, children since the start of the conflict. The other part is, you know, we also put a call to action for tele-med companies, digital health companies to see if they can use their, you know, solution to help Ukraine as well. And we got over 40 plus different health tech companies that came forward. Most of them of course were built for very specific use cases that did not work for what we needed. And so we ended up going active with four. We're down to one now over the last like two to three months, that's still active. Just to sort of show a little bit about the data is of our 65,000 visits, this is missing data though, because of safety and security reasons and a few other reasons, we decided not to collect demographics, right? And so it's not a required field when you enter the tele-med platform. So we have probably about 19,000 cases with age of the patient themselves. But you can sort of see majority of our patients are between 18 and 44 years old. Some on the older and some on the younger side. And then majority of the consults, same thing. We, I think we have about 25,000 of the 65,000 that we have gender and majority were female that were reported. That number doesn't correlate fully with what we see on the final diagnoses though. So this is a complete data set because you cannot close out a visit, or the clinician cannot, the physician cannot without putting the final diagnoses. And as you guys can see, we're doing primary care, right? The people we're helping are not at the hospitals and we have other systems set up to support the doctors and clinicians at the hospital. But this was really to take care of the public. A lot of 'em were accessing us through bunkers and other ways where it was just too dangerous, to access healthcare for other reasons. I actually believe that majority of our cases are pediatric related. It's number three here. But a lot of the infectious disease and general care just doesn't capture the age appropriately. So I think majority and a lot of our care is really around pediatrics. And so the second lesson is high tech is not always better. So staying in Ukraine of our, you know, I think this is through July 1st, where we looked at the data, it was about 54,000 visits at that point. And the data's similar right now when we repolled it recently. But essentially 99% of our, you know, care is all text-based. It's all texting between the physician and the patient back and forth. A lot of reasons for that, right? And you can also say it's an austere environment, poor connection. But I think that even normally, I think folks have moved towards more of a text-based modality and they like it. We do have a few who are audio and video of course of the visits. But as you can see, majority were all text-based. The other interesting part is the average time for a text-based consult is probably what we heard around 20 to 40 minutes versus a audio video, which is synchronous and it takes somewhere between 5 to 10 probably. And people still enjoy the text-based modality more so than even a shorter stay with a doctor in front of you who you have their full attention. Going to the US back to the NETCCN data. Similarly, this is interesting in that for the NETCCN cases, it was all peer-to-peer, right? It was physician to physician, not really direct to patient. And as you can see, majority of the consults, including the ones I did, were all text back and forth, maybe sent some pictures, maybe sent some lab values at most, but we didn't really need to do video synchronous, or audio synchronous calls. So about 60% of the consults were all text-based as well. Lastly is we do have a pilot at the US Mexican border working on the Mexican side in two to three refugee camps supporting their clinicians as well in different ways. And as you can imagine, depending on who has deployed with that NGO there, we get different questions. So when, in July we had, I think, I believe there were internal medicine physicians down there taking care of majority of the patients. So most of our consults were all OB related, high-risk OB and pediatrics. And I'll say that all of those consults, all hundred percent of those consults were all purely text-based and we didn't even do any audio video synchronous calls for this. So the next one is really about virtual spaces and the other ask we got asked from Ukraine was really to build ways for clinicians to support each other and do webinars and teaching based on whatever the topic was. And for each of these, we built in live translation from American to Ukrainian, usually with one of our Ukrainian physicians from the US. And the lectures took longer because of the translation, but even after the lectures with the QA sessions, it lasted two and a half hours each with everyone staying on board. And we had probably about 80 or 100 Ukrainian clinicians on each of the sessions. And there was a lot of peer-to-peer discussion, you know, afterwards, after the lectures themselves. And so the first one we really started was around burn care, austere conflict burn care that was asked us to do once after the live missile attacks. And so a lot of these topics that we get sort of track with the news. And so more recently we're working more on the seaburn education with like chemical radiation and sort of nuclear events. And so we have a lot of lectures and sort of things getting translated in that space. We're also working with the WHO and the Minister of Health on a rehab series, because we heard that essentially they're great at, you know, stabilization of care of patients of trauma patients and they have high volumes of that and in many ways have been at war for a long time now. But they don't really have a developed rehab system. And, you know, the European system has taken a lot of these patients. We've taken some here, at Mass General within our Spalding network as well and many other places across the US, but the volume's massive. So we've been working with them not only on the educational component, but also on sort of capacity building and trying to build out some rehab hospitals across Ukraine. And lastly of course it's mental health, right? And so we have a webinar series that we first started on mental health where on different topics around this, but we also started something we call the Helping Healers Heal group, which is 3H is what we call it. But essentially we have US-based Russian, or Ukrainian speaking mental health specialists working directly with mental health specialists within Ukraine, taking care of patients. I think we've reached about 75 different patients through a network of 12 different mental health specialists. We just started piloting this about two months ago and we're hoping to scale it soon. And lastly, you know, ecosystem development is key, right? And like I said, I think technology should not be the bottleneck for what we can do to help folks, not just in Ukraine but across the world, or even in the US, right? Rural health and areas that we can't reach. And with Ukraine, the healthcare system was pretty, is continues to be pretty devastated, right? This is one of the hospitals out there as you can see. And so we've been doing whatever we can, both on the digital health side and not, but, you know, there's a lot of off-the-shelf technology that works well in this environment that needs to be sourced, put together, organized for Ukraine and other places. And so one of 'em is the butterfly that we've been working on and since it's drop rate and everything else and we've been able to push a bunch of them in and they've been showing us some great cases and pictures of how they've been using it and they've been very thankful for it since a lot of places just don't have access to ultrasound. And this is one case where it was a explosion, I think it was a mine explosion where they diagnosed hemo pericardium with the butterfly. So I just wanna talk about Pakistan really quickly. As you know, unfortunately Pakistan's also devastated with the recent floods. It's sort of left the news, but we're starting to support them as well through different technologies and whatever we can. First is, you know, we're working on educational programs for both the flood victims as well as a peer-to-peer consult system for their clinicians in the area. The other thing we've been working on is with this NGO called Untapped Shores, where they've been working in Africa to teach kids. they have a device, which is pretty cool, right here in the right upper corner that all you need is a 12 volt battery plus some sea water and you can essentially create chlorine or bleach and with the right amounts can have pure clean water, well not pure, but clean enough, clean portable water to drink. And so they've been using this technology across Africa for years and we just sent a bunch to help with Pakistan and probably will expand that program as we move forward. So we were asked by, I think we were building sort of the first in class tele disaster medicine course and we were asked by a few different medical schools across the world to sort of teach this. So you'll sort of see this hopefully soon where we're starting to build a curriculum now and Dr. Hayden will be one of our speakers, which will be amazing. While also working with, you know, different tech companies, like if you guys don't know and haven't seen this, this is the hollow lens, it's a Microsoft product, but there's a lot of different similar products where it's augmented reality, right? So you put these glasses on and you can sort of see what the other person's doing remotely. And surgeons have used this a lot for different surgeries and they can sort of see each other and support each other in the OR remotely, whatever they need. We've been working with different nursing groups within Ukraine to see how we can use this to start teaching 'em, you know, high risk, lower volume procedures that they do, knowing that the curriculum's slightly different. The other one we've been thinking about for this is really around the rehab side, because there's just not enough rehab specialists to send over there, but we have to build up their capacity and it's a high touch field, right? And I think that once we get some initial education going, we could probably use this to help augment their care and their learning. The other thing we're working on is something called the chatbots. And so we have worked with the US military and other folks to get the trauma combat casualty care, the TCCC as well as Stop The Bleed protocolized care where you don't really need a live person on the other side into a chatbot for more educational purposes. Of course you can't use this in live, you know, in a live environment. But we also heard that there's a lot of need for education for the frontline medics. So actually we are the in the final stages of that and are testing it now and it should get hopefully sent out and deployed in the next one or two weeks. And lastly, we're building out our virtual hospital, probably less so for Ukraine but for other sites where you can get access to entire list of specialties, including ICU rounds and everything else through our partner with VC. And just to show you guys, you know, the technology's there, right? And like this is one of the VC hubs that they send in to different disaster areas, including, right now there's a lot of these also across Africa as well, but it's not that expensive from what I understand. Each of these dongles is, to make 'em is only, you know, a few dollars at most and it has everything from auto scopes to even an ultrasound in it, built-in. And I think that's it. Thank you and happy to answer any questions.

- Wow Jarone, I think every time I speak to you there's at least two or three more things that you're doing. So just seeing this. Wow. And of course this is also your side hustle, right? You lead an ICU, you oversee many other things in our department and otherwise, so super impressive. So I know looks like Dr. Bern, you have a question? So do you wanna go ahead and speak up with your question?

- Yes, if you can hear me well. I have two questions actually. The first question is, it's been reported frequently during the Ukraine conflict that the way that the Ukrainians were monitoring telecommunication, the Russian generals were not using secured channels and they were using that as a way of targeting them and that's why the rate of kill for Russian generals was so high. Was there a concern that your location for people in country would be compromised or could lead to more injuries because of that tracing technology? And then the second question was, you said most people using text, did you have access to the Starlink for audiovisual, I've been told that they're using that quite a lot.

- No, that's a great question. So for the first question, yeah, I agree. Operational security is key, especially in a war conflict zone, not just in Ukraine but in other places, right? To the point where we had a lot of thoughtful discussions and trying to figure out the best way to not only protect the patients, but to protect also our volunteers. Just because if, if you can imagine that people can sort of trace back to our volunteer group as well and cause some chaos that we don't want, even though we're small potatoes and probably not involved. But you never know. I also say that, you know, the cybersecurity there and the warfare is very active and I know it's less reported on to the point where our austere burn series, even though we kept it quiet, never recorded, no one really knew about it, was shut down by bad actors within a week that we had to reorganize and be sure we were safer and we completed at all nine lectures. But we did have to pivot a little bit. But it shows how active it is, right? I know this is being recorded so I'll say that we are very cognizant of all the problems and we are thinking about it actively with our partners, and we have a lot of great partners in this space, if that's helpful. The second part is yes, Starlink is very helpful to not just us, right? And I think this was reported by the New York Times with the recent Elon Musk wanted to turn off Starlink and so the DOD and the Pentagon got involved. But essentially Starlink is key to a lot of operations within Ukraine, including ours. And people have had access to it. What I've heard is that as areas get liberated or get taken, things get turned on and off of course and internet access gets tough. The other thing I've heard is Starlink is of course not secure. So we have to be sure our end is very secure and the tele-med platforms and the communications we use is secure. Does that answer your question?

- Yes it does. Thank you.

- Oh, there's those questions here. I know there's people here that do global maritime, lots of other stuff. So any other questions or thoughts or comments for Dr. Lee? We have about six more minutes before we're gonna switch to our next presenter, so. I think actually Jarone I'll ask you too, you mentioned about the tech side, how about the people side? 'Cause I think that's one of the things that with telehealth, I think sometimes we get very into, okay, well what's the tech we're gonna use? What's the video? What's gonna be this? How about the people side? What are some lessons learned in terms of providers that are providing this? It sounds like, I know I think these are Ukrainian physicians that are providing the actual, on the physician side of the text based. Can you give a little bit more of some of those lessons learned?

- Yeah, and so I'll say it's not only the Ukrainian physicians, right? And there are some that are donating their time as well, but we have a lot of non Ukrainian foreign physicians, outside of Ukraine that are donating their time to make this all happen. That's how we were able to scale it, at least initially. And it's I think that tele med, both synchronous video, audio as well as tech space is a unique skill that we don't learn in med school, even in our normal day practice in the EM, right? To the point where internally at Health Tech without Borders, we're starting to think about how we can build a onboarding packet, or some way of giving lessons, best lessons learned and what to do, right? Or best practices for how to do these consults. And you know, the stories we get are, as you can imagine, we've had one of our Indian volunteers who was based out of India who was volunteering run a cardiac arrest and sort of, you know, teach the family CPR for a cardiac arrest in front of 'em that actually turned out better. But there's stories like that all the time that, you know, of all the consults we get, but there's a lot of, I think, need for better education around it. We did partner with the Finnish emergency medicine group, which does a lot of telemedicine because of how cold, from what I understand, they're just used to it, because of the environment they live in. And so they had a lot of pre-made material that we were able to also cannibalize and use as well.

- Other questions, I see someone saying, Kathy's saying amazing work, reimbursement compensation model around the text-based care, not necessarily international work but domestically.

- I don't know if that's for me, but.

- Yes, I'm gonna give it right to you unless someone else wants to answer that one.

- Yeah, we're not gonna touch the US for all the tele-med rules here.

- Yeah, it's a great question Kathy. If there's someone else that can speak to it if there is any type of text base, I don't think there is and if it is, it'd be so small that it hasn't, we haven't proliferated this in the country yet, but someone else speaks up if they know.

- [Alex] This is Alex Chiu, if you look at a company 98.6, they do a lot of text-based care within the United States. There's a lot of other companies that are worldwide as well. They do a lot of text-based care as well. Right now I think we're seeing a lot of pay out of pocket for most of all of them, or subscription where they just have access and then the, I think they do more on record and forward. So it's less on the real time side, but seeing a lot of it and a lot of the health systems have some of text-based care as well. A lot of the EMRs also have it already built-in and then it just uploads directly to the EMRs. So you see all the texting back and forth. So most common platforms are around that not only us, UK I think I've seen a couple of other companies that are that are there that have used it there too. But that's my take.

- Awesome, thanks Alex.

- Thanks Emily.

- I'm sorry go ahead.

- [John] Oh sorry, John Hinds here. So I agree about the text-based care and the self-pay model. A lot of companies are utilizing it. Even a lot of the large employer groups are using companies such as 98.6 to be able to offer another company's CRSMD, where they have some partnerships with some private insurances to offer text-based options for patients. But also I believe last year Medicare for doctors who have already established a patient doctor relationship to use text-based care as a way to do follow-up. So let's just say you're a primary care physician and you kind of wanted to send someone a routine kind of follow up because you started an initiative. There is some reimbursement for text-based care if you already established a patient doctor relationship. So in the ER world, probably not, but it is being utilized as a way for physicians to be reimbursed for more touchpoints. So things such like diabetes or like heart failure where the traditional model is you come back in the office, if you can send a text for people to answer some questionnaires, the touchpoints are higher, you're able to engage them a little bit more without having to come into the office. So it is kinda going in the direction where texting and also like these forms are kind of pre completed templates are being used for patients to engage the providers.

- Awesome, thanks. And I do have someone set up emergency medicine physician Liz Burner's gonna be coming to us sometime at the end of wintertime to talk about some of the work that she knows of and that she's been doing Emergency medicine based texts, SMS based much more on the social determinants of health, not as much of something that's being reimbursed. So I am looking at time. Jarone, did you wanna have any parting words before you have to go on a flight down to DC and try to drum up more support for all your work?

- So I just wanted to answer your question again on the text-based care. I just wanted say interestingly talking to some of our volunteers, they actually enjoyed it on the physician side, because they were able to see multiple patients at once with text-based care, right? And so instead of only one-to-one, you're stuck for 10 to 15 minutes, sometimes 30, 40 minutes, you're actually seeing maybe 10 to 20 patients, which I think is a different finance model as well that we can think about in the US. No, thank you for having me on. I'm gonna put our link to our website for any folks that wanna see it and we have all of our lecturers recorded, except for the burn series, if you wanna watch 'em as well. So, thank you again.

- Thanks so much Jarone, I really appreciate it. And we are now gonna transition over, speaking of reimbursement and text-based, we're gonna switch over now to Jeff Davis. I don't think Jeff Davis needs much of introduction 'cause many of you know him. But just in case if you didn't read my email before, he's our ACEP Director of Regulatory and External Affairs. He's gonna be talking to us about ACEP's advocacy specific for telehealth reimbursement in parity and just to sort of how best we can help inform him in ACEP's work on this and the stance that ACEP has been taking. So let's see here. Jeff, yes, you're here. The floor is yours, sir.

- Okay, can you see my screen?

- Yeah, perfect.

- Great. So thanks, thanks so much Dr. Hayden for that introduction. And again, I'm gonna give an update like she said, on what's going on in the regulatory congressional world and telehealth and what we can do going forward together to kind of really push CMS in the direction and congress in the direction we wanna go into telehealth. So I'll get going here. So again, that's a picture of me. I'm the Director of Regulatory and External Affairs. I wanted to start with this, some of the major takeaways from what's going on in the Medicare space. Medicare as you know, is the foundation of setting payment policy, not only for, you know, obviously Medicare, but also for Medicaid for private payers. And really we look at Medicare as a way of figuring out what the landscape of telehealth policy is gonna be across the board. So that's why even though Medicare may not represent a lot of your patients, you know, a small proportionate of your patients, depending on where you work, the policy set in Medicare are really, really important. So that's why we take a really great look, important look at Medicare. Ryan McBride, who's also on the call gave a little update on this during scientific assembly. But I wanted to reiterate some of the key points, 'cause I think they're very important to kind of looking at where we go from here. So just to give you a sense, so telehealth as services under Medicare, as you know, are restricted in terms of what they call it geographic and originating side requirements. So they can only be provided in normal times, not during a pandemic, but in normal times in rural areas. And they can only be provided when the patient is actually in what they call originating site, which could be a facility, critical access hospital, but they cannot be at home. But during the pandemic, all that's been waived and congress has already taken action. And we're talking about this a little bit at the end, about future progression actually to extend those waivers for 151 days past the end of the public health emergency. This 151 days is around five months. And this happened as Ryan explained to you during scientific assembly, because of when we thought last year the pandemic would end. It keeps on getting extended, 90 days being extended numerous times. So that's where the 151 days came from. The next thing I wanna point out is that right now you can use FaceTime and Skype for telehealth and Medicare and some prior payers in Medicaid is also allowing you to use FaceTime and Skype, which are non-HIPAA compliant. That ends as soon as the PHE ends. So right now the public health emergency is set to end in January. It could be extended again, 90 days, we just don't know. It's been extended again about 11 times already. So we don't know exact 90 day increments. We don't know when it will end officially. Audio only, Telehealth only codes can be billed 151 days after public health emergency. Another big thing that I wanna point out is that EMTALA, the medical screening exam component of EMTALA can be conducted via telehealth. We got guidance from CMS. This is something we worked on at the beginning of 2020 in March when the pandemic first hit, we got CMS to clarify that telehealth can be used to do the medical screening exam and that's gonna last even past the public health emergency. So that's permanent policy, which we got from CMS. And this is what we're gonna talk about a little bit more later. But the codes that you typically bill, the ED E/M codes, the critical care codes and some observation codes are all being billed via Medicare for telehealth at equal ways at parity through at least the end of 2023. And that's the big advocacy push we're gonna do. I'll be talking about to Dr. Hayden's point, but what you can do, I'll get to that in a minute, but this is where we, this is the critical area. So keep mindful of the fact that these codes are gonna be removed at the end of 2023. Again, telehealth services are paid the same rate as in-person services. Now there is some discussion about parity in terms of the facility rate, versus a non facility rate. Right now all codes in telehealth in the Medicare, even if you don't work in a facility, are paid at the rate at which they would've been paid if the service were being delivered in person. So in that facility. So that means that a lot of times that the non-facility rate is provided. So let's say this affects primary care for example. So if you are a primary care physician and you provide telehealth service from another setting, you can bill as if you were provide the service in person from that office-based setting. So you can bill a non-facility rate, which is usually higher than the facility rate. But starting at the end of the year in which the public health emergency ends, you would go back to using the facility rate only. So that's something that affects not really you, but primary care, but you might hear about that as well in the parity discussion. But again, this didn't really impact you that much. So the place of service code is again, like I was just mentioning, considered as if the service were conducted in person. So let's say you're billing from the emergency department, you were used place of service code 23, which is the ED place of service code. You would add a 95 modifier to that. So that policy lasts again until 151 days after the end of the public health emergency. So it's important to understand that once this period ends and you go back to how you billed previously for telehealth services. Another waiver that expires to the end of the public health emergency is allowing physicians who are licensed in one state, to provide services to patients in another state. So that being able to provide services across state lines that also expires. And then again another policy is the direct supervision requirement for teaching hospitals that can be get telehealth and that expires within the public health emergency, except for rural areas. It expires for urban areas. And then before I get into like future, what we can do in terms of advocacy, it is really important to remember that no matter that the office and outpatient codes are always available on telehealth lists for Medicare. And you can always bill those services even from the ED setting. And that's something that is very important to recognize. So I know we really want to keep our ED E/M codes, critical care codes and observation codes on that list of Medicare food services, but you still have the option of billing the office and outpatient codes as well. So the final rule, a big fee schedule and program final rule just came out, which you may have may have seen this, the big, what I call the big tamale of rules for Medicare. And they finalize a lot of policies. The biggest one is outside the telehealth space, but the conversion factor, which puts codes into dollars actually goes down 4.5%. And we're working with congress to travel an offset for that reduction of 4.5%. 'Cause obviously that's a huge reduction to payments and something that we, one of our top legislative priorities is to get that, to get it fixed for that. But what also in the telehealth space, CMS really just kind of finalized what they proposed in terms of solidifying some of the proposals that were in the policies that were in the Consolidated Appropriations Act, which again temporarily extended the waivers for 151 days. It allowed certain services first via audio only. So for 151 days past the end of the pandemic. It also, one thing that's very important for mental health services is that there's an in-person visit requirement for mental health services. It delayed that requirement for 151 days after public health emergency. So that requirement would start 152 days after the public health emergency ends. So those were the big policies in the rule. Again, not much in our space, the ED E/M codes, observation codes and critical care codes, they remained on the list of approved telehealth services through the end of 2023. So what's really the next step here, and this is where again, we want you to kind of weigh in here. So we really need congressional action to extend geographic and original site waivers for longer than 151 days. So the 151 days is where we are now. We are asking for two years, a two year extension. Ryan can chime in at the end. There's some talk about extending it for a six month period, so that's a little longer than 151 days, but at least a little longer than 151 days. But we're supporting legislation that were due for two years and then we get to the ED E/M codes. These again, are the typical bread and butter codes that you typically bill that we are considering whether some or all of them should remain on the list of approved telehealth services past the end of 2023. CMS in their rulemaking has said very explicitly that they're gonna remove those codes from that list. So we will no longer be able to bill those codes via telehealth as you were able to do during the pandemic after 2023 unless they receive clinical evidence saying that there's clinical benefit in terms of providing these services. So what does that mean exactly and how can you help with that? So this is actually something that is a pretty high bar and I'll get to it in a minute. So they have different categories. CMS has different categories in terms of how they add codes to the list of approved telehealth services. Again, right now, the ED E/M codes, observation codes and critical care codes are temporarily added through the pandemic and through 2023. But in order to get them permanently added, they have to meet something called category 2 criteria. This is something that was laid out in regulation a few years ago, but it's a very, very high bar in terms of adding new codes to the list. Once these codes get on the list and meet this criteria, they're permanently added, they're paid at parity with in-person services. So it's a big step. It's a big kind of bar that they put here. And I highlighted it's a long kind of description of what category 2 means and what the evidence you need. But I just wanna read one second really what you need to provide. So the evidence that you need to submit to meet category 2 should include both the descriptive of relevant clinical studies. So clinical studies demonstrate the service furnished by telehealth to the Medicare beneficiary improves the diagnosis of treatment of an illness, improves the function of a malformed body part, including dates and findings and a list and copies of published peer reviewed articles. And that's key there. Published peer articles relevant to the service when furnished via telehealth. So pretty much what it's saying here, I know that that's a lot of words on a page, but you have to provide clinical studies, peer reviewed studies showing why the ED E/M codes, observation codes and critical care codes added clinical value. And examples of that clinical value are listed below. I'll provide these slides to you, but I think it's a really kind of telling kind of... It's gonna be tough to be able to prove that these codes are even more effective. It's almost like they have to be more effective than providing them in-person. So that's something that I've actually ran to CMS multiple times saying that this bar is too high and they should revise it, but they haven't done so yet and that's still the bar. So what do we need to do? Just to give you a sense of what we need to do. We need to write a letter to CMS by February 10th, 2023 in order for them to consider for the next year's rulemaking. So they do rulemaking for the next year to plan out in advance for 2024. 'Cause remember I told you the ED E/M codes, observation codes and the critical care codes are removed at the end of 2023. So we need them to put in the rule for 2024. Then they meet category 2 criteria and can be continued on permanently. So we have to write them a letter by February 10th, 2023. So they need a lot of lead time before 2024, almost a whole year 'cause of the rulemaking process, explaining and trying to meet this category 2 criteria. And it needs to include again, what codes we're trying to promote, so it will be the ED E/M codes, observation codes, critical care codes, a detailed discussion of why they should be added and look at the last point, evidence that supports adding these services meets the category 2. Category 1 is off the table. I don't wanna get into what that is, but we need a category 2 basis. So we have to write a letter to CMS by, again, February 10th, 2023 in order to get these codes permanently added. So there's not much time and we need clinical evidence again, published reviewed studies and again, so what are we trying to get? So we, again, we have the ED E/M codes, all five codes, some observation codes and critical care codes. Can we get all of them? Should we push for some of them? All of them? I think there's still some discussion at our ACEP board level of whether it's appropriate to push for the levels ED E/M levels 4 and 5, because those are really high intensity services and maybe and only should be done in-person. And if they are done via telehealth, would that undermine our work to really increase the value of those codes in the ruck for the last few years. So that's a consideration we're thinking about right now. But we do, you know, our discussions, you know, with Dr. Hayden and others about the observation codes, really pushing for the observation codes to be added permanently. And that's what we can include in our letter. But ACEP will write a letter by February 10th, 2023 pushing for all or some of those codes that are right now temporarily added to be permanently added. But we need your help, we need that clinical evidence. So again, we can't get any of those codes on the list. All those codes will be removed if we don't have that clinical evidence. So I hope I've hammered home that point, Dr. Hayden, if you want, if I'm not clear enough, let me know. But I'm trying to be very explicitly clear that we need clinical evidence in order to get those codes added.

- Jeff, do you have a pipeline with annals to sort of fast track some of this type of data to be peer reviewed and published before February 9th, 2023?

- I mean, yeah, we could write the letter on the last day February 10th. Yeah, we could, I mean we could also tell CMS, I mean, like the studies are coming, or maybe share with them some, I know it says peer reviewed, but if we can... I think that we're looking for anything at this point, like any kind of concrete data, even if it's not peer reviewed. I know it says peer reviewed there, but I think we'll take what we can get at this point. So I know that a lot of you, and I know Dr. Hayden, you're a researcher so a lot of you are in the process of doing reports and we just experienced, we were experiencing a pandemic so you didn't have enough, you don't have enough time to collect the data and actually do some analysis on it and get a peer reviewed before that February 10th date. So that's something to consider. And another thing I just wanna, again, emphasize is that even if those codes are removed, you can still bill the office and outpatient codes after that. You can always bill the office and outpatient codes and I've talked to some emergencies, were only billing outpatient codes for telehealth and not billing the ED E/M codes. And that's always an option as well. So I just wanted throw it out there as well. So any questions and then I'll get into some congressional action. Dr. Curtis.

- I was just noticing that when you were putting up the criteria for the category 2, even though it was described as in comparison to, you know, in-person the first two bullets say in a patient population without access to clinically appropriate in-person diagnostic services, and the same for the second. So really in those bullets it's the comparison group is no care.

- Yeah.

- Which is a little lower bar. So just to point that out there's things that happen in medicine that are not based on evidence inside and outside of emergency medicine, but I think it's a little easier to compare it to no care particularly rural populations.

- Yeah, no that's a good point, that's a good point I think. Yeah, no, that's a very good point.

- Jeff, it's Emily here. Another question too, just specific with our virtual observation unit and also our hope to be able to have all five emergency medicine E and M codes is that in the home-based care space, and I'm not assured, but in the home-based care space, I don't know if patients can be admitted from telehealth visits or community paramedicine visits under office based billing and go directly to in-patient home hospital. That was one of our pieces of why we're probably transitioning very soon to emergency medicine E and M codes as sort of part of a compliance piece and with all of the capacity issues. And we just saw what was sent by ACEP to the president and about our capacity issues to close doors on the ability to be expanding our healthcare space to patients homes by going back to just office based billing. I think that's going to be really nearsighted right now.

- Yeah, that's a really good point. Yeah, that's a great point.

- I'll put it with the data that we finally have to compile and get to you by February 8th, 2023.

- So before we go forward, I just wanna talk about the end of the year package. And I don't know if Ryan wants to chime in on anything, but we've heard that, you know, once the election is a bit, is election today, as you know, once that gets hammered out and we go into what they call the lame duck session when we know what's gonna happen next, congress and people are, you know, leaving Congress or it's the end of the term and it's called the lame duck session. What's gonna happen? There's, according to Ryan and Ryan can come in discussion again about extending that 151 days to six months, 'cause it's interesting and I think he talked about this during scientific assembly meeting, but the congressional budget office assumes that the public health emergency will end in May, 2023. So actually extending it for one more month, which is like 151 days to run five months to six months, actually won't cost that much money. So they're thinking about doing that, and again we've supported the legislation that would extend the waivers for a full two years. So before I go on, Ryan, did you wanna mention anything?

- Yeah, so I would just say, you know, I think, and as I mentioned during scientific assembly, but for those who weren't there to hear it, you know, if Congress loves nothing more than a deadline, so if they don't have to act on something, they typically won't, especially if it costs money. So there, you know, there was sort of a prevailing thought beforehand that given that the telehealth flexibilities were already extended 151 days beyond the public health emergency, assuming that it was going to end sometime in 2023, there was no urgency to formalize some sort of telehealth extension in this year end package, this sort of Christmas tree that's coming together. However, given the way and sort of, you know, the fun ways that the Congressional budget office makes their assumptions and does their scoring of legislation, as Jeff said, if you assume that the public health... The way they're assuming right now is that the public health emergency will end at May, then you've got five months after that you have basically just to extend it throughout fully to the end of 2023 only comes down to about a month or a month and a half really of actual cost to the federal government to extend it for that full flat year. So there may actually be something in that package. We're still trying to get a good sense on that, but again, we're not gonna have a clear sense until the dust settles a little bit. And that may be, you know, several weeks here in DC. But, you know, I think the way Congress is only scheduled to be in until December 16th, which is also when they have the government funding deadline. So assuming that they're gonna try to wrap up all of their year end business before then, it's gonna be a real race to the finish line. But we'll keep you posted.

- So I'm gonna copy another slide that Ryan did during the scientific assembly. But just kind of looking at what's next out there. Again, there's been, you know, some reports that telehealth, you know, services again were done by only urban providers during the pandemic and more than rural. And that kind of, I think kind of scared Congress a little bit in terms of what the direction would be in telehealth. The GAO recommended that the CMS strengthen oversight of telehealth services. But one new thing that came on after Ryan gave you that update was that the alliance for Connected Healthcare connected the study which really show that telehealth did not add to volume and it also did not lead to more revisits. So that's a talking point that hopefully will sway the Congressional budget office in terms of the cost element, if it does not add the total volume, meaning again, if you weren't gonna get service anyway and you got a telehealth service that would add to volume. This would be simply a replacement of in-person care and also not leading to more revisits, which is a really good talking point for the Congressional Budget office. So that Alliance for Connected care data are very important as well. And then I'll just end before I get to questions in the last five minutes. Other questions. I just wanna put in some resources. So we did do a summary of that final rule that I referred to and we have a new regulatory page where we provide updates including on telehealth policies. And then I write a Regs & Eggs Blog every Thursday morning and I'll put the link in the chat, but I've written many blogs on telehealth policies so you can go back and look, but it might be due for a new blog in telehealth policies, 'cause it's always changing. So, , but you can check that out and I'll put the link... I'll send this slide deck around, but I'll put the link in the chat as well. Dr. Bern.

- Thank you very much. I know that we're about ready to close down. My question is this, as it relates to the February deadline, there are some places, this first question is, do they require that the peer review data only be within the US or can it be from other locations? And I'm familiar with quite a few studies in Israel where they using both telemedicine and follow up as well as primary activity. The second is where is telehealth being used currently within the federal government in terms of the NDMS units, in terms of military, in terms of VA, in terms of Indian Health and identifying those groups that are using it and getting that information. And then lastly, the first lecturer speaker had some very wonderful maps that showed where there were gaps in the country for hospitals and where telemedicine might be useful. So I can see a collaborative effort between the research section, the rural health section, EMS section and, you know, the public health section that could collaborate on this to give you the manpower to put this together quickly.

- Yeah, no, those are really good points. It does say that the evidence has to be connected to a Medicare beneficiary, but I have been talking to the VA and the VA's gonna put out some studies about the effectiveness of telehealth services during the pandemic in the VA population. So that's data that I don't mind using. At this point Dr. Bern, I'm willing to put together whatever data you can get for me, whether it's Medicare beneficiary or someone else. Anything we can provide CMS that would help them kinda understand how effective emergency telehealth services are, I think would be great. So even though it says Medicare beneficiary, we can do the international studies. I think we should try to stay domestic for now. But I think definitely looking at the VA population, IHS, others are a really good ideas. And I do know that data's coming. We already are talking the VA about this already. So that's one thing we're doing.

- Looks like Jeff.

- Dr. Palmer.

- Yeah, Dr. Palmer, and then we gotta close out. So Dr. Palmer, any question?

- Yeah, Jeff, thanks for your comments here. I was just saying that, you know, as both an emergency medicine physician and a critical care physician, as I sit here today in my tele ICU suite, you know, I'm actively managing patients with septic shock, ARDS, I am resuscitating patients, you know, and so it's this ongoing process where from a critical care codes perspective, we are now starting to be denied our billing codes for some more private insurers. But I know that the CMS is still going on, but, you know, there is really good evidence in my opinion, for critical care codes out there that we should, I feel easily be able to, you know, convince them about, you know, the value of critical care. I think the emergency medicine side, I don't think there's as much literature there, but you know, for those higher acuity patients, you know, those are just like critically ill patients. So I feel like there's a lot of carry over there. So I'd be happy to help participate. You know, I.

- No, that'd be great. I think I had sent a letter to you maybe like even like a year or two ago about my passion for the critical care. Billing codes and so I can dig that back up, but I'm just interested in continuing the critical care billing for sure as it impacts our bottom line here dramatically.

- No, that's great. Yeah, I'd love to engage with you and I think this is gonna be a conversation that we're gonna have to have, you know, over the next couple, you know, I don't have much time, but really thinking about where's the best clinical evidence, and what code should we ask for? 'Cause if we ask for every single code they may not have clinical evidence for it. They maybe say, okay, we're just gonna deny everything. But if we very strategic in terms of what codes we push for, if we had the best clinical evidence for it, I think that gets us our best shot.

- Awesome, thanks Jeff. And I know Sata, you had something, I know you wanna talk about the newsletter. I know some people are jumping off, but please put your plug in now and maybe we'll send it on the Engage platform too.

- Alright, perfect. I actually put it in the chat and it ties into everything that just happened. Jeff Davis has actually graciously agreed to do our health policy corner in our upcoming newsletter and it'll capture some of the things we just went over, but also just in terms of voices in the field, you know, the people doing the work. I think as Rishi had mentioned previously, and, you know, what we heard earlier from Jarone, like if you know of people or you're all doing things that you think the general readership should hear about, please send me 500 words about that. I put my email address and the deadline would be December 4th for the January newsletter. But if, you know, there's subsequent newsletters, so you guys can just keep it coming. That's it.

- Awesome. Great. We're pushing the needle forward, you guys, go telehealth, telehealth Tuesdays. We'll see you in the speaking about facilities fees in Telehealth in December. So look forward to seeing you then and on the Engage platform. And thanks everybody for being engaged today. So, all right, take care everyone.

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