Zoom Bombing – how to prevent

Researchers at Boston University and Binghamton University recently published a paper A First Look at Zoombombing describing the phenomenon of malefactors joining online meetings with the goal of disrupting them and harassing the participants. This prompted Zoom and other suppliers to require additional security measures, such as requiring passwords for meetings. The researchers found that these measures were ineffective, since anyone who has access to the URI for the meeting most likely has the password as well. Instead, the authors recommend that meeting products create a unique URL for each participant. Zoom offers a way to do this but requires the meeting owner to distribute the links and for each user to log in first.

Fortunately, SBR Health recognized this problem at the inception of the company and provides three very simple but effective mechanisms for controlling access to meetings. The video meeting takes place over Zoom or Vidyo but all invitations and access control are handled by SBR. Health care systems can choose any one of these mechanisms or combine them as they see fit:

  • Email Link. Each patient, or guest can automatically be sent an email when a visit is scheduled whether that visit was create in the SBR system or within the electronic health record (EHR) system, e.g. Epic. The email contains a URL that is unique to each participant. When the patient clicks on the link to join the meeting, the system knows the identity of that participant and displays the name and other identifying information (DoB, MRN, etc) to the provider.
  • Patient Portal. if the health system has a patient portal or other web site, the SBR system can display a button to bring the patient into the visit. This way the patient portal performs the authentication without the patient needing to supply any additional credentials.
  • Username and Password. An account can be created for each patient on the SBR system. This can be done by the office staff, using SBR’s Admin site, or it can be created automatically upon receiving the information from the EHR. The office staff can give the information to the patient or the SBR system can automatically generate an email.

In this way, SBR provides a secure and convenient way to satisfy the HIPAA requirements for identifying the patient and prevent intruders from entering the visit.

 

Telemedicine parity enacted in Massachusetts

On January 1, 2021 Governor Charlie Baker signed An Act promoting a resilient health care system that puts patients first (S.2984) which previously passed the Massachusetts Senate 157 – 0.

The new law contains a number of provisions including several important changes to the use of telemedicine:

  • Expands the definition of telemedicine to include video, telephone, remote patient monitoring, and asynchronous tools
  • Insurance coverage is mandated with no restrictions on the site where care is delivered, e.g. patient at home is now included
  • Payment for primary care and chronic disease management is at parity with in-person services

The requirement for coverage expires two years. The requirement for payment parity expires 90 days after the end of the Covid emergency.

The new provisions have yet to be incorporated in the codification of the General Laws but the text of the Act is available here.

The Act modifies the following chapters of the general laws

  • 118E – DIVISION OF MEDICAL ASSISTANCE (Medicaid)
  • 175 – Insurance
  • 176A – REGULATION OF RATES FOR CERTAIN CASUALTY INSURANCE, INCLUDING FIDELITY, SURETY AND GUARANTY BONDS, AND FOR ALL OTHER FORMS OF MOTOR VEHICLE INSURANCE, AND REGULATION OF RATING ORGANIZATIONS
  • 176B – MEDICAL SERVICE CORPORATIONS
  • 176G – HEALTH MAINTENANCE ORGANIZATIONS
  • 176I – PREFERRED PROVIDER ARRANGEMENTS

For each of them, it inserts essentially the same language. The exact text for Chapter 175 [Insurance] is below:

Section 47MM
(a) For the purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings: “Behavioral health services”, care and services for the evaluation, diagnosis, treatment or management of patients with mental health, developmental or substance use disorders. “Telehealth”, the use of synchronous or asynchronous audio, video, electronic media or other telecommunications technology, including, but not limited to: (i) interactive audio-video technology; (ii) remote patient monitoring devices; (iii) audio-only telephone; and (iv) online adaptive interviews, for the purpose of evaluating, diagnosing, consulting, prescribing, treating or monitoring of a patient’s physical health, oral health, mental health or substance use disorder condition.

(b) An individual policy of accident and sickness insurance issued under section 108 that provides hospital expense and surgical expense insurance and any group blanket or general policy of accident and sickness insurance issued under section 110 that provides hospital expense and surgical expense insurance that is issued or renewed within or without the commonwealth shall provide coverage for health care services delivered via telehealth by a contracted health care provider if: (i) the health care services are covered by way of in-person consultation or delivery; and (ii) the health care services may be appropriately provided through the use of telehealth; provided, however, that an insurer shall not meet network adequacy through significant reliance on telehealth providers and shall not be considered to have an adequate network if patients are not able to access appropriate in-person services in a timely manner upon request. Coverage shall not be limited to services delivered by third-party providers.

(c) Coverage for telehealth services may include utilization review, including preauthorization, to determine the appropriateness of telehealth as a means of delivering a health care service; provided, however, that the determination shall be made in the same manner as if the service was delivered in-person. A policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within or without the commonwealth shall not be required to reimburse a health care provider for a health care service that is not a covered benefit under the plan or reimburse a health care provider not contracted under the plan except as provided for under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O.

(d) A health care provider shall not be required to document a barrier to an in-person visit nor shall the type of setting where telehealth services are provided be limited for health care services provided via telehealth; provided, however, that a patient may decline receiving services via telehealth in order to receive in-person services.

(e) A policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth that provides coverage for telehealth services may include a deductible, copayment or coinsurance requirement for a health care service provided via telehealth as long as the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person consultation or in-person delivery of services. The rate of payment for telehealth services provided via interactive audio-video technology may be greater than the rate of payment for the same service delivered by other telehealth modalities.

(f) Coverage that reimburses a provider with a global payment, as defined in section 1 of chapter 6D, shall account for the provision of telehealth services to set the global payment amount.

(g) Insurance companies organized under this chapter shall ensure that the rate of payment for in-network providers of behavioral health services delivered via interactive audio-video technology and audio-only telephone shall be no less than the rate of payment for the same behavioral health service delivered via in-person methods; provided, that this subsection shall apply to providers of behavioral health services covered as required under subclause (i) of clause (4) of the second sentence of subsection (a) of section 6 of chapter 176O.

(h) Health care services provided via telehealth shall conform to the standards of care applicable to the telehealth provider’s profession and specialty. Such services shall also conform to applicable federal and state health information privacy and security standards as well as standards for informed consent.

Congratulations, Viewcare

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Congratulations to our Danish partner, Viewcare, and their customer Holbæk Hospital, for winning the prestigious Digitaliseringsprisen (Digitization Prize) for 2019 for their Virtual consultations project built on the SBR Health platform.

Google does a pretty good job translating the prize site:

With virtual consultations, Holbæk Hospital has made their interdisciplinary health efforts available at the individual citizen. The solution is thought from the outside, with the patient as the starting point. It connects citizens, relatives and healthcare professionals across specialties and geographical location. Citizens save transportation time and can have the consultation where they like, the region saves transportation costs and the consultations become more targeted and efficient.

Push Notifications


Starting with version 3.3.40, the SBR Health mobile applications support Push Notifications. This is a feature of the iOS and Android platforms that allows the SBR server to send messages to the mobile client even when the device is asleep or the SBR app is not running. Because the messages are sent via servers at Apple and Google, the battery consumption is very minimal.

Sone of the ways push notification can be used:

  • A patient checks in for a scheduled appointment or submits a request for an on-demand visit. If the provider has the application open, the device makes a ringing sound and displays the patient information as usual. If the application is in the background or the phone is asleep, the phone beeps and displays a notification. If the app is not running at all, but the provider has previously logged in from that device, a notification appears in the device’s notification area. In any case, with one click, the provider can answer the call.
  • A provider makes a virtual Rounding call to a patient. If the patient has the application open, a dialog box opens as usual asking if the patient wants to accept the call. With push notifications this can happen even if the phone is in the patient’s pocket.
  • A provider wants to call in a colleague for a consultation. Pressing the button for that colleague will cause his or her phone to beep and display the request even if the phone is asleep. Pressing a button for a specialty will try each of the on-call specialists, whether their phone is in the foreground or background.

Each user can opt in our out of push notifications and they can be turned on or off for an entire institution. And of course the SBR product continues to provide the previous notification methods, such as customizable email templates, pager alerts, and text messages.

Interpreter Services

We have partnered with InDemand Interpreting to provide interpreters within any SBR Health virtual visit.

Whether you are running an international medical program or serving a local population with limited English proficiency a single click gets you one of InDemand’s medically qualified interpreters within seconds.

No reservation or advance notice is required. You can call the interpreter before you connect with the patient or add an interpreter at any point in a patient visit.

To add an interpreter, go to the Requester tab to select the language from the 28 that are offered.

Within 10 -15 seconds an interpreter will be added to the call.

This feature is available to all SBR Health customers but does require establishing an account with InDemand. Contact your SBR representative for details.

SBR Health at Brigham & Women’s Hospital

 

As virtual doctor visits take off, debate over who should pay heats up

Melissa Bailey, writing in the new Pulse of Longwood column for the Boston Globe’s Stat News leads the piece with a description of how the SBR Health virtual visit platform is being used in endocrinology at Boston’s Brigham and Women’s Hospital. Not only does the patient love it, but the doctor says it’s improved patient attendance.

American Telemedicine Association Presentations

The 20h annual American Telemedicine Association conference starts tomorrow in Los Angeles and we are proud to announce that several of our customers are giving presentations this year:

Understanding How Patient Centered Design Improves Provider Adoption: Mayo Clinic and Mass General Hospital

Sarah Sossong, MPH
Director of Telehealth.
Massachusetts General Hospital

Steve Ommen, MD, Medical Director
Centers for Innovation & ConnectedCare.
Mayo Clinic

Neurosurgery-Aneurysm Virtual Visits: Linking Providers to Patients in Home Settings

Sarah Pletcher, MD, MA
Medical Director.
Dartmouth-Hitchcock Medical Center

Robert Singer, MD,FACS
Staff Physician.
Dartmouth Hitchcock Medical Center

Ellyn Ercolano, MS
Telehealth Outcomes Analyst
Dartmouth Hitchcock Medical Center

How a Major Urban Health System Leverages Telemedicine

Steve Dean, MS
Telemedicine Administrative Director.
Inova Health System

Theresa M. Davis, PhD, RN, NE-BC
Clinical Operations Director.
Inova Health System

Albert Holt, MD, MBA
Medical Director TeleICU.
Inova Health System

Rina Bansal, MD, MBA
Medical Director Telemedicine Institute
Inova Health System

Applying Care in Novel Models of Non-Acute Teleneurology

Adam B. Cohen, MD
Teleneurology Director
Inpatient Neurology Director
Massachusetts General Hospital

VillageCare

We would like to welcome VillageCare Wellness Innovations to our family of customers. VillageCare recently received a Health Care Innovation Award from The Center for Medicare and Medicaid Services Innovation Center (CMMI) to pilot “Treatment Adherence through the Advanced Use of Technology” (TAAUT). This program aims to increase patient activation and treatment adherence for people living with HIV and AIDS by providing a multi-faceted intervention involving a social platform for behavior change, virtual visits, text reminders and peer support.

From the VillageCare site:

VillageCare Wellness Innovations expects to improve adherence in the most cost-effective manner by delivering education and support through technology. Participants will be able to access a customized private social network, virtual video support groups, treatment adherence professionals for questions, and text messaging for medication and appointment reminders. In addition, peer mentors will provide one-on-one encouragement and mentoring for behavior change.

“VillageCare has long been a leader in care for people living with HIVAIDS in the New York City area,” says Emma DeVito, President and Chief Executive Officer for VillageCare. VillageCare developed the first comprehensive AIDS Day Treatment program in New York and since then, has continued to create effective and innovative care models. “We are excited for the opportunity granted to us to develop a new and innovative way to encourage adherence and wellness for those living with HIVAIDS.”

The overall goal of the program is to improve viral loads and CD-4 counts, thereby simultaneously improving health and reducing overall health spending for the population. VillageCare was awarded just over $8.7 million to create and operate this program for three years. CMS will be conducting evaluations during and upon completion of the pilot program. More information may be found by visiting www.villagecare.org.

The project described is supported by Grant No. 1C1CMS331353-01-01 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Boston Globe on Telemedicine in Mental Health

Last week, the Boston Globe ran an article Virtual therapy expanding mental health care, that mentioned how two of our customers, Partners HealthCare and HealthLinkNow were using our product to provide virtual therapy sessions.

The article quotes Janet Wozniak, a child and adolescent psychiatrist who is the associate director of the Bressler Program for Autism Spectrum Disorders at Massachustts General Hospital:

For Wozniak’s patients, mainly children and teens on the autism spectrum with psychiatric disorders, simply coming to the office can be harrowing. So when the opportunity arose to take part in a pilot program for telepsychiatry, Wozniak was hopeful. She approached a few families she thought might be interested — ideally, those who lived far from the hospital and had some degree of “computer savvy.” All they needed was a computer or tablet with a camera, speakers, and Internet connection to download the hospital’s telemedicine software. Skype and other similar applications aren’t strictly compliant with HIPAA privacy rules and regulations, and so while some practitioners — like Carmichael, who alerts her patients to this potential drawback — do use Skype, MGH uses its own software.

The software cited is SBR Health’s ResourceManager.

The article also quotes Peter Yellowlees, Chairman of HealthLinkNow:

Anyone who’s used Skype, particularly for romantic reasons, knows that you can have very intimate conversations. The extra distance might actually allow more self-revelation,” noted Peter Yellowlees, a professor of psychiatry at the University of California Davis, who conducts research on online consultation services and uses video-conferencing technology in his own practice. “I’ve had many people tell me things on video that they wouldn’t necessarily share in person.”

We are proud to say that HealthLinkNow isn’t using Skype, they are using SBR Health.

 

 

Mental healthcare without boundaries

In recent years, video communications (e.g. videoconferencing and telehealth) capabilities have gone from being expensive, hardware-based resources to inexpensive, cloud-based resources. Now, the driver for wide-scale adoption in healthcare is not what this technology costs, but rather how smoothly and seamlessly it can be integrated into existing clinical workflows, IT systems, and business environments.

So how does one get started? Well, the first inclination may be to reach out to your local telecommunications or media services company. However, high-quality video no longer requires special hardware or expertise. You can now get high-quality, high-definition video on devices that you, your organization, or your employees already own (newer smartphones and tablet computers) and which many would-be patients/consumers now have or could readily obtain. As a rule of thumb, any mid to high-level personal or laptop computer sold in the last ten years is probably “video-conference” ready.

Here are two approaches: a “minimal” list of requirements and a recommended “ideal” setup:

Minimal Requirements Ideal Requirements
Computer Any video and audio-equipped computing device or smartphone Laptop or desktop computer  (min. 1.8GHz Pentium i5/i7 processor and min. 4GB memory)
Camera Built- in camera External HD camera (e.g., Logitech HD Pro Webcam C920
Audio Built-in audio External speakerphone or headset such as Jabra Speak 410 or Plantronics Savi w740
Internet DSL or 4G connection (Minimum 500mb/sec. upload/download speed Home-type cable/broadband connection, with  1Gb/sec. upload/download speed and less than 50ms latency

Once you’ve got the requirements in place, the next step is to provision a video conferencing service. (Note: if you’re using a PC, think of the PC as a phone, and the video service provider as the phone company, or carrier.) Generally, you can purchase HD video conferencing from a service provider for less than $50/month. This would provide a fully encrypted, HIPAA-compliant solution. And, because many video service providers will sign business associate agreements,  (check this out—hipaa or CFR?) eliminating privacy and security issues.

One such video-as-a-service (VaaS) provider is Connexus (www.connexusvideo.com), a solutions provider in both traditional as well as “new paradigm” video communications technologies.  Connexus’ president, Jonathan Schlesinger, states that one of the most import issues to consider when utilizing video in telehealth is what happens if a call gets interrupted for technological reasons: What are the patient support and recovery procedures?

“You want to make sure you have good procedures in place in the event a call gets interrupted,” explains Schlesinger. “Therefore, while VaaS providers can get you provisioned with a service and started in virtual healthcare delivery in literally a few minutes, it is important to spend a good deal of time to put together a strategy for urgent psychiatry situations as well as routine therapy use.” Indeed, if a patient says they are suicidal and shuts off their connection, organizations will be liable and need protocols in place to handle situations such as these.

Resources to help

These service providers – and other organizations like them – provide high quality Video as a Service (VaaS), plus needed support.

Company Telephone URL Uniquness
Connexus 800-938-8888 www.connexusvideo.com Self service
ID Solutions 877-880-0022 www.e-idsolutions.com Extensive support options
Quest 800-326-4220 www.questsys.com Full healthcare data services
Yorktel 732-413-1839 www.yorktel.com Custom solutions
Xtelesis 888-340-9835 www.xtelesis.com Cost-effective solutions

From a technology readiness point of view, Amnon Gavish, the SVP Vertical Market Solutions at Vidyo (www.vidyo.com), talks about other important but less known technology related considerations. “One of the things we have seen is that the quality (defined as high definition and low latency) of video is much more important in mental health interactions than in other telemedicine scenarios, as mental healthcare encounters are typically much longer than a traditional 5-10 minute primary care or specialist interaction. These are longer consultations so key factors in the effectiveness of using video are supporting a smooth conversational flow and consistency of experience. If the experience becomes cumbersome and video issues affect the quality of a session, the effectiveness of the session can be compromised causing the physician and patient will lose interest in meeting in this manner.”

Gavish also cautions you need to ensure the patient on-boarding is quick and foolproof. One way to do this is to have the patient bring his or her home computer to an initial session, during which you can ensure it is properly set up to receive a telehealth visit. Another option is to ask your telehealth solution provider if their software can provide a single-click or web-based software installation and test process, so you won’t have to provide user support.

Whenever you’re going to work with a patient at home, Gavish advises that “you need to do an excellent job at teaching them how to select and set up their equipment and ensure they have adequate lighting and privacy to ensure a good-quality experience.” Because it is typical to begin a therapeutic relationship with a face-to-face encounter at the provider’s office, there’s almost always an opportunity to explain important requirements, provide educational materials, and help patients ensure that they’re ready to receive a telehealth appointment.

Utilizing cloud based video visit services minimizes your financial exposure. “There are enormous business advantages with VaaS as you are able to scale up with a very, very low cost,” states Schlesinger. “Putting together the brick and mortar infrastructure for that type of footprint would be cost prohibitive, but if an organization makes that investment later, the virtual practice will help them to determine where to locate based on the volume of calls they have made.”