Hello, everyone and welcome to Telemedicine Institutional Structure. In this module, we're going to look at how an office of telemedicine should be situated within a health system. All the different options that are available and the different models that are out there nationally. We're also going to look at how you should staff that office, what ancillary teams you're going to need to make that office effective, and then how do you resource helping both your internal providers and your external customers, your patients. Let's get started. The first model that we're going to look at for telemedicine structure is a centralized model. This is where you have a central office of telemedicine that services the whole health system. In our model here at Hopkins, we have one office for the whole health system. It not only services all the entities within the health system, but it is funded by all the entities within the health system, so that it's services are free to the users. While our office is centralized, when a project comes through the office or a new service line, we depend on our entities to give resources to that particular project. If we're looking at doing telemedicine within skilled nursing facilities, then those divisions come with folks to actually do the services. The Office does not house any clinical resources to provide services, the divisions provide their own clinical resources. They also provide some operational support and an administrative support that follow these projects along. Once the Office of Telemedicine has partnered with them to stand them up, it is handed back over to the division to not only staff them and continue providing services, but also to administrate them. You can look at different examples like behavioral health or pediatrics. They're going to come with their own resources, but the Office of Telemedicine is going to get them started, and keep them going. This way, we are free to our users, but we are also funded by our stakeholders. Let's look at another model. This is a centralized non funded model. In this model, the Office Telemedicine is central. It's strategy is central, but all of the funding comes from the regional telemedicine offices. If we were to use this model in Hopkins, we would say hospital A had its own regional telemedicine office and so does Hospital B. This one you have a central office for strategy, but you have regional offices that are self-funded for your actual operational teams. Another model is a centralized, self-funded office. This is where your office have telemedicine and strategy is central across your health system, and your service lines are used to fund that office. Let's say you were going to start a new E-counsell service line. That E-counsell service line would have a financial plan and they would take the revenues from the E-counsell and they would fund staff to operationalize that. In that way, the centralized office would have a staff member on site or central, and it would be funded by the funds generated by the E-counsell line. There are some models that have a integrated telemedicine structure. This is where your Office of Telemedicine and your in-person are two separate groups, but they make decisions in concert. Whatever you're going to do in your in-person, you would make decisions for your Office of Telemedicine, you would have resources on both sides and they would both be institutionally funded. This is a rather lovely model. I think this is the future of where things are going to go. Very few systems have integrated to this level. Once you've decided where your office is going to sit and how it's going to be funded, it is paramount that you get your support teams in place. This is a model of Serotonin, because telemedicine makes our health system happy and makes it run. You can see here all the different components that you're going to need to have a successful Office of Telemedicine. Without these folks, your office can be set up and it can be funded, but it is not going to be effective. Let's talk about your most important first, and this is your leadership component. Having C-Suite level leadership support is crucial. They're going to set the mission, they're going to make sure you have the funding, they're going to prioritize initially and re-prioritize as the whole health system landscape changes. They're also going to be pivotal into busting any barriers that you come across. You're going to need that C-suite clout to help you through those, and they are also going to decide whether to expand political capital when you're looking at telemedicine, where to expand that capital, are you going to use it at your local level with your local state offices to get legislation passed for medicaid in your state, for instance, or with your Maryland Board of Physicians? That's going to take local clout and then you're going to have to decide what political capital you're going to expand at the national legislative level. What change you want to make there and you're going to need your C-Suite for that. Now, your clinical champions are paramount in importance. You're to going to need clinical champions, not only in your clinical director at the Office of telemedicine level, but at your divisional level. When you start talking about behavioral health, you're going to need a clinical champion. They are to really give you guidance as to what's going to be effective, where can you use telemedicine most, how can you get your faculty and your physicians on board, and they're going to help you engage them. The next group you're going to need and will not be able to function without is your IT. Telemedicine is uniquely reliant on IT because we need that technology to reach the patient. You're going to need them to help you create your platforms, to integrate your platforms, to maintain those platforms. Your infrastructure is going to be critical once you start rolling into inpatient telemedicine. If you don't have your wireless team on board to make sure that all your devices connect and maintain those connections, then really your program is dead in the water. You need those internal folks as well. You're going to need to support these programs on the IT site and you're going to have to have IT support for your programs, for your patient support, and for your provider support. We're going to talk a little bit about that at the end of this module when we really start looking at help desks, for all of these and how you're going to link all your help desk together. Then you need your IT partners here to decide when something is stable, to maintain that, and then how to expand it, how to grow it, how to scale it. Without your IT partners, this becomes next to impossible. Your legal teams are, this is not optional with telemedicine, essential and so you're going to need guidance. What is legal to do? What's the best way to do that? What are some things you're going to need to put in place? What is your state laws for consent? Now when you're operating outside of state laws, what are their laws and how do you integrate those into programs? You're also going to need them for defense. There are many different audits that are happening in the telemedicine space and you're going to need your legal teams there to help you. Your providers bear personal risk when it comes to licensure and providing telemedicine to outpatient in out of country patients, so you're going to need your legal teams to tell you what's defensible, what's not, how can we help our providers stay within those boundaries? You're going to need your internal contracts, you're going to need legal to help you between entity to entity, you're going to need your external contracts when you're providing telemedicine services to external groups in external health systems. When you looked at external partnerships, you're really looking at growth and sustainability and making sure that those contracts are written in a way that, not only protects our providers, but make sure that we're providing services at their market value rate. You really need your legal team to help you with this and then as we move into the legislative space, your legal team is really going to help you, not only defend where you are, but to get into new spaces. One example for this would be, is it our case for national opposition licensure? Can we use constitutional law to help move us away from state licensure into national licensure and without your legal advice, it becomes very hard even if you've got the political clout to pass a bill through. You're going to need the legal stability and the legal backup in case precedent to move something forward and actually promote change. Your legal team becomes one of your most important groups. You're going to have some specialists on your team. You're not just going to have one lawyer on your team. You're going to have a lawyer that's looking at your professional side. A lawyer that's looking at your facility in hospital side, a lawyer that's looking at risk, a lawyer that's looking at HIPAA and privacy, a lawyer that's looking at licensure and credentialing. You're going to need a broad spectrum of legal support. As you build your legal team, make sure that you have contracts and contacts for this. Some groups don't have internal legal support. They contract with external legal support. Totally a viable path to go on. Here at Hopkins we have both, and we have tertiary. We have internal legal teams for things that we feel we can handle internally. We have external, and then we not only have external, but we also partner with international legal groups. Sometimes in some use cases we use all three of those legal teams and sometimes we just use our internal. But you're going to want to have paths for all three as you build your program. Your next group that becomes critical is your billing and compliance teams. We have set meetings with our billing and compliance teams twice a week, is that important. You need these folks to look at payer contracts in negotiations. You need these groups to build out within your system billing logic so that when a provider drops a bill, each of your payer's need that bill in a different way and they need it different in all telemedicine instances. You need that billing team to build that for you and test it for you to make sure it's flowing through your systems. You need them to do audits to make sure we're getting billed and make sure that logic is correct. You need them to look at the different roles that are dropping that bill and make sure that they are able to do that. It's within their scope of practice, that they're dropping it in the right way, that the bill is moving on the hospital side and on the appropriate side in the right way. Billing for telemedicine is very complex. You need the right people on your team that can assess and adjust those things as necessary. You also want to really look at, on going back to our legislative arm and things that we're moving forward. You need billing and compliance to be able to look at the data and tell you where you are and then take that data, put it into bite-size chunks and readability so that when you put it in front of your local representative, your congressperson, the data tells the story. They're able to see, oh, look at this, that if we don't change things at the state level, the state is going to end up liable for these charges because payers won't cover it or patients are unable to cover it. Really show the impact of billing in your area. A really important group. When we talk about auditing, this brings us into quality reporting. There's auditing on so many different sides. If your institution is part of an ACA an accountable care group or if they are reporting for a primary care specialty program that they're working with, with their state, Medicaid, any one of these or HEDIS measures. You're going to want to make sure that your telemedicine scores are going up to the right people and that they are showing them in the right manner as they're reporting at a national, and a state, and a payer level. Really having your quality reporting team together is so important. There are also going to be identifying quality improvement QI programs. They're going to be putting together some of this data for your lobbying for your new legislation. You can start to see how all these groups tie in together, and they're going to feed in the office of telemedicine to improve acts as that central body to pull in all of this data and get it into a digestible format and then hand it off to your government affairs folks to do this. But you're going to need your billing and compliance folks, you're going to need your legal folks, you're going to need your quality of reporting folks in order to get that data and to look at it properly. That brings us really to our government affairs folks where all of this stuff is going in. They're going to be the ones where the C-suite says, "Yes, we want to extend political capital in this area." Then your QI people and your billing people have said, here's the data you need. The government affairs folks are going to take that altogether, put it together in a package and advocate for you and really push for that new legislation and get those lobbying efforts underway. Those are your teams that you're going to need to be effective. Let's take a look at now at the actual staffing of your telemedicine office. Here at Hopkins, we staff in three silos. We are one office, but we have three verticals within that office. We have our clinical, we have our operations, and we have our IT arms within our office. These are staffed with a variety of folks. The staffing; we have a medical director, we have an assistant medical director, we have an administrative director. That's me here at Hopkins. We have assistant administrative directors. We have IT directors. Then we have program coordinators that go across all three verticals to link everyone together. We have project managers at the top of each of these verticals. Then we have project leads within each one of these verticals. We have support analysts in IT and in operations, which are very important. We have strategy analysts. They're mainly over on the clinical side. We have quality reporting analysts, business intelligence analysts. Lots of different analytics to look at within these arms. But it's important to know that they all report up differently, but all within one office. It'll be interesting to see nationally how folks staff their offices. But this is how we staff ours here and they all work together. Now, another model. Let's look. Once you look at your project leads, you have project leads within those verticals. You can divide up their responsibilities a few different ways. We divide ours by relationship. We have a project lead that's assigned to a specific group. In this example, we have a project lead assigned to pediatrics and pediatric endocrine. We have another project lead with GYOB and all of our smaller groups. We have another wall with General Internal Medicine and Neurology. They are actually taking all different types of projects. They will be doing e-visits, e-consults, direct-to-patient video visits. They would handle all the different modalities of telemedicine for each of these groups. No matter what these groups want to do, they have a single point of contact that reaches out. That contact is then aware of how their divisions work, what resources they have in their divisions, who the players are, they're working with the same physicians over and over. They're just introducing new modalities to the same group of people. This is not necessarily how other groups do it. Some folks do it by specialists. You have your medical director and your administrator, and then you have a specialist. This specialist would be a specialist in e-visits or video visits or ICU or urgent care. A new division would come along, in this example, hematology, and they say, I want to do an e-visit. They would work with one specific person for e-visits. They say, we want to do video visits, they would work with a different specialists for video visits. You can really see how you can use your project leads and your project managers differently depending on how you set them up. This brings us to our last piece that we want to talk about. This is, how do you connect resources to your providers and patients. Different groups have different help desk. There are some that are common to health systems across the nation. Most folks have a video help desk. Most folks have a patient portal help desk. Most folks have an EMR help desk. Then how do you link these help desks to help your patients and your providers? What we don't want is patients on hold with an EMR help desk when really what they needed was the video help desk. Then we don't want patients working with the video help desk if they have a problem with their patient portal. You're going to have to build some work decision trees, some rubrics, some matrices, that no matter where a patient or a provider calls they get to the right help desk quickly and that we're able to help them. Another thing to make sure that you have is timeliness. It's different if a patient needs help with an appointment, if their appointment is in two months versus if their appointment is in two minutes. Who should they be calling and who should they be contacting? If they have an appointment in two minutes, they should be really talking to the clinic where that appointment is going to occur. If they have an appointment in the next hour and they need help getting their video set up, they should be pointed to the video help desk. It's things like this that you really want to consider when you're building your program is, how do you want to escalate things? How do you want to present things? A help desk catalog will look very different for your video help desk than it will for your patient portal, than it will for your actual patient. What does the patient need to know in the moment? Would a quick YouTube video showing them how to set up their patient portal be more helpful than waiting online and having someone walk them through it using phone? Really looking at what tools you want to use, when do you want to connect, how do you want to connect, is going to be paramount to making your office of telemedicine effective. I hope this quick module helped you start to think about the important questions. How do you want to set up your office? How do you want to staff that office? What different teams are you going to need outside of your office to help your office be effective? How do you want to utilize your team for effectiveness? Then how do you want to link your patient and provider resources to make that most effective? Thank you so much for watching, and good luck. Bye-bye.
