outsourcing and telemedicine: risks and rewards

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Sedgwick © 2013 Confidential Do not disclose or distribute. Outsourcing & Telemedicine Risks and Rewards

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Page 1: Outsourcing and Telemedicine: Risks and Rewards

Sedgwick © 2013 Confidential – Do not disclose or distribute.

Outsourcing & Telemedicine Risks

and Rewards

Page 2: Outsourcing and Telemedicine: Risks and Rewards

Sedgwick © 2012 Confidential – Do not disclose or distribute. 2

Ann GaffeySVP, Healthcare Risk Management

& Patient Safety

Kathy ShostekSr. Healthcare Risk Management Consultant

Jayme VaccaroDirector Professional Liability Claims

Page 3: Outsourcing and Telemedicine: Risks and Rewards

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Telemedicine

• American Telemedicine Association:

“use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and for the purpose of improving patient care, treatment or services”

• Transfers medical expertise instead of medical experts and patients

Page 4: Outsourcing and Telemedicine: Risks and Rewards

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Delivery of telemedicine

• Technology

Telephone service

High-speed dedicated line

Internet

• Information transmission

Voice

Data

Still images

Page 5: Outsourcing and Telemedicine: Risks and Rewards

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Telemedicine technology

• Store-and-Forward

Sharing information in a time-and-place independent way over the internet

Appropriate to specialties where diagnosis is based on images, such as dermatology and pathology

Because cheaper and doesn’t require sophisticated equipment or broadband, it is being used to simply introduce telemedicine at low cost to developing countries in specialties that traditionally used videoconferencing

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Telemedicine technology

• Interactive videoconferencing (teleconferencing)

Can consult in “real time” at a distance

Might require only a videophone and connection to the internet

Sophisticated systems include microphones, scanners, cameras, medical instruments and dedicated phone lines

Remote house calls

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Is the Doctor In?

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Where are we seeing telemedicine used?

• Teleradiology

• Telepathology

• Teledermatology

• Telecardiology

• Teleneurology

Telestroke

Epilepsy

Parkinson’s Disease

• Telepsychiatry

• Remote monitoring devices

• Telewound care

• Telehome care

• Telemedicine in prisons

• Telenursing

• Other applications

Baby CareLink

Smartphone, tablets

Page 11: Outsourcing and Telemedicine: Risks and Rewards

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Is it what patients and providers want?

• PricewaterhouseCoopers survey – 2010 31% consumers would use a smartphone app that tracked their personal

health information

40% consumers would buy a device and pay a subscription for an app that would send reminders

40% consumers would buy a device and pay for a service that sends data (heart rate, BP, weight)

56% like remote health care

88% of doctors would like their patients to monitor their health at home

57% doctors would like to monitor their patients via remote devices outside the hospital – but just want “exceptional” information – not all

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Rewards and promises

• Remote pharmacy services prevents medication errors

• Remote pediatric care reduces ED visits

• Clinical improvements in chronic condition management using Internet (hypertension)

Think Accountable Care Organizations

• Cost savings > 60% with mid-level providers treating common illnesses over Internet

Virtuwell

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Telemedicine trends

• Teleradiology eICU

• Remote monitoring Robotic eyes

• Telepsychiatry

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What are the top risks?

• Risks of outsourcing

• Telemedicine Contracting

Credentialing

Quality monitoring

• Risk management strategies

• Case studies

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Top risk management issues

• Contracting

• Credentialing and privileging

• Quality monitoring

Technology

Privacy and security issues

Information management and documentation

Page 16: Outsourcing and Telemedicine: Risks and Rewards

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The informed patient

• Self Magazine. November 2011

“When to Question Your Scan Results”

http://www.self.com/health/2011/11/outsourcing-radiology-dangers?printable=true

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Telemedicine regulations, standards, guidelines

• Centers for Medicare and Medicaid services

• State regulations and licensing Inconsistent in definition and application

• Joint Commission

• Professional Association standards and guidelines American Telemedicine Association

ATA with specialty organizations

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Credentialing and privileging

• CMS final rule published May 5, 2011

Final Rule (76 FR 25550) effective July 5, 2011

Hospital CoP: Telemedicine Credentialing and Privileging

• Credentialing by proxy in line with Joint Commission Standards

Rely on distant site hospital or telemedicine entity credentialing where an agreement exists and medical staff bylaws include such provisions

• Joint Commission standards

MS.13.01.01

LD.04.03.09

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Telemedicine contracting

• Agreements Duties, responsibilities and rights

Role in patient care

Provisions for credentialing, quality monitoring, insurance, record keeping, billing, and indemnification

Compliance with state/federal laws

• The Center for Telehealth and e-Health Law www.ctel.org

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Quality monitoring

• Monitoring telemedicine services

• Policies and procedures

• Providers and staff performance

• Integration with risk management and patient safety programs

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Technology

• Maintenance and user education

• Privacy and information security

• Information management and documentation

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Telemedicine is here to stay

• Standard of Care

• May mitigate liability risk

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Case studies

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Themes in Telemedicine claims

• The Use of Technology to Deliver Healthcare

• Financial Incentives

• Straight Forward Errors vs Judgment Calls

• “Guinea Pig” Syndrome

• Understanding the Depth of Your Technology

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Outsourcing: Typo or “Really Egregious”*Juno v Thomas Hospital (Mobile, AL)

• 59 year old diabetic female patient admitted to hospital #1 for clogged kidney dialysis access port

• The patient was discharged and admitted to hospital #2 when she experienced complications

• Hospital # 2 used hospital #1’s physician admitting orders and discharge summary and administered 80 units of Levemir insulin

• The amount was 10 times the dosage Rx by the patient’s doctor and the patient died

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Outsourcing: Typo

• The patient’s physician had certified on a form the medication and dosages the patient should have been prescribed

• He then dictated that information into a phone line

• Traditionally a hospital medical transcriptionist making $19.50 per hour would have written the information onto the discharge summary

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Outsourcing: Typo

• Company P, the second largest medical transcription outsourcing company in the US, subcontracted with two Indian Companies, contracted with Hospital #1 to conduct the transcribing for less

• Indian workers made $350 per month

• The information from the physician went via computer to India

• Indian workers prepared the discharge summary

• Sent it back to Hospital #1

• The hospital saved 2 cents per line by outsourcing

• The acceptable error rate for an Indian company is ½ to 1/12th

that of the US in terms of acceptable error rate

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Outsourcing: Typo

• The US officials testified the Indian subcontractors used American standards

• The Indian subcontractors testified that they used Indian standards

• There was testimony that the nurse should have used the original document prepared by the doctor

• The nurse testified it was not available so she used the discharge summary prepared in India and wrote the medication information onto the physician admission order containing the doctor’s signature

• This made it appear that the doctor had confirmed the information

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Outsourcing: Typo

• Nonetheless, the jury found that had the transcription been correct there would have been no death

• If the nurse was allowed to get the document from the records department, there would have been no death

• The jury awarded $140 million dollars to the patient’s family

• The bulk in punitives based on the financial incentives of Hospital #1

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Teleradiology: Adventures in the night

• The hospital contracts for radiological services during evening hours with Indian Company

• ED examines patient, orders x-ray of knee

• X-ray read as normal, patient released

• Next morning, x-ray over read by domestic provider, fracture seen

• No one follows-up with patient

• Patient sees his primary care physician 3 weeks later and correct diagnosis made

• Patient suffers permanent injury to knee due to delay in treatment and can no longer work in his physically demanding job

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Teleradiology: Adventures in the night

• Evidence shows the original x-ray was read by a foreign radiologist

• Evidence shows that the hospital chose the global teleradiology model vs a domestic or NightHawk model

• The NightHawk model would have involved a American licensed radiologist doing the first read, followed by a local radiologist doing the over read

• Instead, a foreign radiologist, non-licensed in the US did the initial read

• Evidence shows that the hospital saves a substantial amount of money using the global model

• What do think the a jury would do with this financial incentive evidence given the “Typo?” Case study?

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Telesurgery: A Work of Art

• Da Vinci surgery system Wide range of laparoscopic surgeries

Surgeon views a virtual reality representation of the patient’s internal organs

Surgery is performed via the manipulation of hand and foot controls that remotely maneuver the machines’ four metal arms

Technically the system allows a doctor in the US to perform telesurgery on a patient anywhere in the world

Hospitals can increase surgery market share

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Telesurgery: A Work of Art

• Advantages

Superior visualization

Enhanced dexterity

Greater precision and ergonomic comfort

Minimally invasive on complex dissection or reconstruction cases

Less pain, blood loss, shorter hospital stay, quicker recovery

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Telesurgery: A Work of Art

• Injuries include:

Burns

Tissue damage

Reproduction system damage

Blood vessel injuries

Bowel and intestinal injuries

Urinary tract damage

Nerve and muscle damage

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Telesurgery: A Work of Art

• Types of complications*

The arm jumped stabbing an artery

The bipolar instrument fired unintentionally during a procedure nicking the uterus

During a hysterectomy the robot hit the patient in the face prompting conversion to an open surgery

*FDA Database of Adverse Event Reports

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Resources

• American Telemedicine Association

http://www.americantelemed.org/

• HRSA Rural Health – Telehealth

http://www.hrsa.gov/ruralhealth/about/telehealth/

• ATA State Telemedicine Policy Center

http://www.americantelemed.org/get-involved/public-policy-advocacy/state-telemedicine-policy

• HRSA Telehealth Resource Centers

http://www.telehealthresourcecenter.org/

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Questions?