SD4 - Telemedicine Pilot Program (SB369, Chapter 763, 2016)

Executive Summary:
Background. In Virginia, a nurse practitioner (NP) licensed in a category other than certified registered nurse anesthetist shall be authorized to render care in collaboration and consultation with a licensed patient care team physician as part of a patient care team. Pursuant to 18 VAC 90-30-120, all licensed NPs must practice in accordance with a written or electronic practice agreement. The collaboration requirement has been raised as a barrier to care, particularly for NPs who desire to work in rural areas and with underserved populations where there are shortages of physicians who could serve as collaborators. During the 2016 Session, the Virginia General Assembly passed SB 369 authorizing the Center for Telehealth of the University of Virginia (UVA), together with the Virginia Telehealth Network (VTN), to establish a telehealth pilot program. This pilot program is intended to assess whether the use of telehealth technology-enabled patient care teams could help to mitigate these barriers and ultimately expand access and improve coordination and quality of health care services among these underserved areas and populations. The pilot program is to include the following six core components:

1. The Center for Telehealth shall consult all appropriate stakeholders in establishing the pilot program, including but not limited to the Medical Society of Virginia, the Virginia Council of Nurse Practitioners, the Virginia Academy of Family Physicians, the Virginia Chapter of the American Academy of Pediatrics, the Virginia Hospital and Healthcare Association, the Virginia Community Healthcare Association, and public and private institutions of higher education located in the Commonwealth that award medical degrees.

2. The pilot shall include one or more patient care team physicians and one or more licensed nurse practitioners who presently practice in or who relocate to rural or medically underserved areas of the Commonwealth

3. The pilot shall provide technology, training and protocols to participating patient care teams to assist such teams in the delivery of telemedicine services in accordance with the goals of the pilot program

4. The pilot shall include a process for assisting nurse practitioners who seek to participate in the pilot program with identifying and developing a written or electronic practice agreement with a patient care team physician who will provide the required leadership of the patient care team through the use of telemedicine

5. The pilot shall develop and maintain a list of physicians who are ready to serve as patient care team physicians and making such a list available to nurse practitioners seeking physicians to serve as a patient care team physician in order to participate in the pilot program and makes such a list available on the UVA Center for Telehealth, Virginia Telehealth Network and Department of Health Professions websites

6. The pilot shall evaluate the success of patient care teams in improving access to care and coordination of care through evaluation of established clinical evidence.

Progress Report. General Fund dollars were appropriated to support the pilot program for a two-year period in the amount of $200,000 for FY2017 and $190,000 for FY2018. During the first year of the two-year pilot:

• A Steering Committee and Advisory Committee (with a Data Subcommittee) was established to provide guidance and direction for the development of this pilot program.

• Seven sites were selected to participate in Phase 1 of the pilot. These sites included Federally Qualified Health Centers (FQHCs), free clinics, nurse managed clinics and hospital based clinics. Of the initial seven sites, five are currently active. Active sites have all been provided with technology, training and protocols. For some sites, having the technology, training and protocols did not immediately drive utilization as there were other barriers that had to be resolved. However, once these barriers were identified and addressed, creative use cases and success stories have emerged as a result of this pilot:

• In collaboration with the Medical Society of Virginia (MSV) and the Virginia Council of Nurse Practitioners (VCNP), a Practice Agreement Template has been developed. Additionally, a survey was developed and sent out to the membership of the MSV and VCNP to identify barriers and opportunities.

o Barriers identified include:

o Just under 19% of all NP respondents experienced a period of time in their career where they were limited in their ability to work with patients and just over 9% of all NP respondents experienced a period of time during the past 12 months where they were limited in their ability to work with patients because they were unable to find a collaborating physician.

o Should they need to find a new collaborating physician in the upcoming year, close to half (46%) of all NP respondents expressed a lack of confidence in their ability to do so within 30 days. NPs who were required to find their own collaborating physician relied largely on existing relationships and personal contacts as their primary mechanism.

o Physician attitudes and misunderstandings about liability, scope of practice and responsibilities of NPs is a barrier to establishing collaborative agreements with NPs.

o Although the majority (83.3%) of physicians do not charge NPs to be a collaborating physician (corresponds to the percent of physicians who have NPs within their own practices or who work in hospitals and health systems that that have this responsibility a part of their employment contract), cost did emerge as a barrier for NPs who must pay for the time of a collaborating physician.

o Opportunities identified include:

o Among physicians currently serving as a collaborating physician, a significant proportion would be willing to collaborate with more NPs. In fact, many of them are quite vocal about how much they value the work of NPs. An opportunity exists to identify physicians who have had positive collaborative relationships with NPs and reach out to them to serve as champions for engaging their peers.

o Just over 10% of physician respondents who are currently not serving as a collaborating physician with an NP indicated an interest in doing so. An opportunity exists to contact the physicians who have expressed an interest in establishing an Agreement with an NP as a collaborating physician and facilitate connections between them and the NPs looking for collaborating physicians.

o Just over 20% of physician respondents indicated that the ability to use telehealth as a tool for collaboration would increase their willingness to become a collaborating physician. An opportunity exists to contact the physicians who would be more motivated to collaborate if they had the ability to use telehealth as a tool and to engage them in this pilot project and to view telehealth as a potential incentive for collaboration for a subset of physicians.

• An evaluation plan has been developed for this pilot and data collection efforts are currently being integrated into the telehealth platform with data collection to begin in November 2017.

Preliminary Findings and Results. After completing the first year of a two-year pilot program, the following are preliminary findings and results:

• Barriers to establishing and maintaining collaborative agreements between NPs and physicians are very real, and have a limiting impact on NP’s ability to provide patient care in Virginia. These barriers include things like liability, cost, attitudes and misperceptions, and technology.

• There are physicians willing to serve as collaborators for NPs.

• A clear mechanism for identifying NPs in need of collaborators and physicians who are willing to serve as collaborators is needed.

• This pilot and the use of telehealth technologies can help to mitigate some of the barriers, but will likely not mitigate all of them.

• In addition to the need for collaborative agreements with a collaborating physician, there exists an even greater challenge of finding specialty and subspecialty care physicians to work with NP practices.

• Access to technology and training are important, but not always sufficient to drive utilization of telehealth. A more intensive personal investment of time must be factored in to help end users to map their vision and overcome internal and external barriers.

• Once barriers to utilization of telehealth are identified and adequately addressed, success stories related to improving access to care coordination and quality of care in rural and underserved populations are quick to emerge.