Transforming EMS: 6 considerations for implementing an EMS telehealth program
Engaging payers, the medical director, administrators and field providers was key to MedStar's successful telehealth implementation
This article originally appeared in the Paramedic Chief Digital Edition, "Care delivery in real-time: Implementing telehealth in EMS." Download a copy here.
It is very difficult to find anything positive about the nearly yearlong pandemic our world has endured. However, a small bright spot from the challenges of the pandemic is how it has helped accelerate the EMS transformation into more than merely a method of conveyance.
In an effort to preserve healthcare system capacity, many EMS agencies have implemented innovative alternative destination and treatment-in-place programs. Waivers implemented by CMS in response to the public health emergency have created an economic environment that supports these types of programs.
One example is a series of waivers implemented by CMS related to telehealth. It wasn't very long ago that agencies looking for telehealth providers for the CMS ET3 program had difficulty finding willing partners. However, waivers include relaxation of origins for telehealth reimbursement that now include locations like the patient's home, waiver of some HIPAA requirements for telehealth and the ability for telehealth reimbursement for some interventions that are comparable to the allowable reimbursement for an emergency department visit.
This has led to a significant increase in the number of telehealth providers looking to potentially partner with EMS agencies to enhance patient navigation. Here are six considerations to factor in if you are thinking about implementing a telehealth offering as part of your transformation strategy in your EMS agency.
There may be state or local regulations that prohibit EMS personnel from suggesting to the patient that there may be a more appropriate outcome from their EMS response than an ambulance trip to an emergency department.
Be sure you research the regulations, and, if it is not currently allowed, determine if there is a way to conduct a program within the existing rules.
In some cases, you may be able to obtain a waiver from state or local regulatory authorities. In others, you may actually need to change statutes to permit this service enhancement. In the latter case, do the research, engage stakeholders and seek out committed legislators who might be willing to change state laws to allow EMS service enhancement to include the use of telehealth for patient navigation.
2. Medical director
First, ensure that your medical director is comfortable using telehealth for the purposes of patient navigation. This is a significant change from traditional EMS, and some medical directors may be apprehensive of this intervention, or at least require additional training or other system enhancements, such as expanded quality assurance programs.
If your medical director is on board, they need to be integral to every step of the program development and implementation, including program goals, selecting a telehealth provider, the technology platform used, clinical profiles of patients eligible for telehealth intervention, records retention and the quality assurance process.
Traditional EMS is generally reimbursed for patient transport, therefore, programs that reduce patient transport can have a negative effect on system revenue. CMS's Hospital Without Walls waiver authorizes Medicare payment for ambulance transport to alternative destinations, but it stopped short of allowing payment for treatment-in-place services. Though CMS does not currently reimburse for treatment in place, other payers may, and are. It's a good idea to have conversations with your large payers to see if they would be willing to reimburse for treatment-in-place services facilitated through telehealth. Large payers like Anthem, as well as several state Medicaid agencies, reimburse EMS agencies for treat-and-refer programs.
Reimbursement for the telehealth provider is available from most payers, including Medicare, so EMS agencies should not have to pay a telehealth provider. In fact, another CMS-issued waiver allows the telehealth provider to pay ambulance agencies for facilitating telehealth services. This means that even though EMS can't receive direct reimbursement from CMS for telehealth services, the telehealth provider could reimburse the EMS response agency.
Your revenue cycle team should be included in program development as well. As there are opportunities for reimbursement, your billing systems need to be able to generate claims for your role in the telehealth process. You may be billing third-party payers, or perhaps the telehealth provider. Knowing what's possible with your billing system is a crucial consideration.
4. Field provider
How nimble is your field workforce? Do your providers embrace, or even thrive on change? Or, are they perhaps resistant to change? The best transformation plans will likely fail if the field providers are not supportive. They should also be an integral part of planning and implementing a telehealth program with significant boots on the ground, reality check input on issues like the technology platform, documentation processes and types of patients (or even scene types) included in the eligibility.
5. Medical records
Medical records are the backbone of agency clinical operations. Accurately documenting the use of telehealth is critical for quality assurance. It is likely that you will need to transmit ePCR information to the telehealth provider – both clinical and demographic information for their quality assurance and billing purposes. This is a key component of successful telehealth implementation.
6. Communications center
Don't forget about how a telehealth implementation will impact your communications center. New dispatch dispositions may need to be configured in your computer aided dispatch system, such as "Treated on scene via telehealth" or others if alternate destinations are part of the program. You may also need to build some reports to monitor scene times for responses in which telelhealth is utilized to assess impact on operations.
The MedStar telehealth experience
MedStart launched a short-cycle test of a telehealth program on Oct. 26, 2020, in preparation for ET3 implementation. The short-cycle test included patients who initially indicated the desire to not be transported to a hospital ED. In these scenarios, if the patient met clinical guidelines identified by our medical director, the patient was offered a telehealth intervention to determine alternate resources for medical care. Here's how we used each of the telehealth implementation considerations as we developed and executed the currently operating telehealth program.
- Regulatory. Texas is unique. It is a delegated practice state, meaning that the scope of services provided by our EMS agency is determined by our medical director, who actually led the development and implementation of our telehealth program.
- Medical director. Dr. Vithalani is fully engaged in the telehealth program; creating and implementing the medical directive for the clinical and scene-type eligibility, helping select the telehealth provider and platform, designing the QA process and outcome measures, and training the field providers.
- Financial. We've been actively engaged with most of our largest payers, many of whom are willing to pay for treatment-in-place telehealth services, both to MedStar, as well as the telehealth provider. We've collaboratively designed billing codes and even sent test claims to the payers.
- Field provider. A hallmark of MedStar's service delivery is innovation. Our field practitioners embrace change. Many field providers actively participated in the design of the telehealth program, including testing the platforms being considered. We also created a dedicated email distribution list for the field providers to easily send ideas and recommendations for consideration.
- Medical records. Our medical records manager has been key to our success. He made numerous changes to our ePCR software interface for crew documentation, transmission to the telehealth provider and potential alternate destination sites.
- Communications center. Our communications center manager made several changes to our CAD that facilitates the telehealth project. We use the Logis Solutions CAD, and most response status changes are generated by the field staff through a mobile smart device. The smart devices are now configured for the crew to select any potential outcome, no only for treatment in place via telehealth, but also a myriad of alternate destination sites. The system will even route the crew to the alternate destination site using real-time traffic patterns.