Telehealth and Emerging Technology: Practical Applications, Challenges, and Considerations for Rural Hospitals

CINDY JACOBS, RN, JD PARTNER, JACOBS RIGGS AFFILIATE FACULTY, UW SCHOOL OF LAW

LEAH ROSENGAUS, MSC INTERIM DIRECTOR, TELEHEALTH SERVICES UW MEDICINE

June 25, 2019 OBJECTIVES

• Identify high‐value telehealth applications and use cases for rural medicine • Discuss the reimbursement landscape, regulatory considerations and challenges for telehealth • Connect to available resources in WA State 4 Notable Technology Trends

Impact 1. Maturation of Mobile Technology We must distill the flood of data & strategically think how to best apply. Telehealth a component of 2. The Age of Data & Intelligent Computing a broader ecosystem.

3. Telehealth Industry Maturation & Evolution

Telehealth is primed for growth

4. 5G Wireless Expansion

3 Technology Innovation – An Ever‐Evolving Landscape

Standard Use Cases Emerging Trends On the Horizon

Patients access health Remote monitoring of AI increases provider efficacy information at their fingertips ‐ chronically ill or isolated (i.e. virtual assistant) My Chart, virtual symptom patients at home or other Bots for symptom tracking & checker, etc. locations healthcare delivery

Self‐service tools to streamline Smart glasses revolutionize interactions – mobile Artificial intelligence used for care delivery, training & scheduling, personalized patient triage & diagnosis patient safety education

Wearables enable self‐ Augmented reality enhances 24x7 virtual diagnosis & management & give clinicians care delivery & experience treatment via phone, video or access to real‐time patient and supports provider online chat information education

Virtual provider‐to‐provider Drones increase access & Digital communities facilitate consultations via phone, video augment healthcare supply social support & education or store‐and‐forward chain

Waiting rooms & clinics Body scanners gather vital Virtual provider education & revolutionized by “smart” signs like temperature, pulse training technology” & patient oximetry, etc. engagement tools

4 UW Medicine Telehealth Program

5 UW Medicine Telehealth

Turn‐key 20+ Specialties Programs and Supports 19,000 Virtual Consults per Year

Over 100 19 Programs Partner Sites Advocacy: Chair of the WA State 5‐State Region Telehealth Collaborative

6 Active Programs Highlights

» eConsult improves access by 30%+ measured by the % of patients seen ≤ 30 days for pilot specialties

Provider toProvider Providerto Patient » UW Medicine Hep C ECHO > 89% cure rate

» UW Medicine’s TeleStroke program completes » Project ECHO: 8 specialties » Virtual Urgent Care: ACN & public > 270 consults per quarter » eConsult : 14 specialties including » TelePrimary Care psychiatry » TeleMaternal Fetal Medicine » TeleAntimicrobial Stewardship » TeleBurn Our Goals » TelePsychiatry » TelePsychiatry » Expand existing programs & launch new offerings, enhancing relationships with patients » TelePain » TeleAmputee & our physician community. » TeleStroke » TeleJail » Continue advocating to alleviate challenges & growth barriers such as reimbursement. » TelePost‐Acute Care » TeleNutrition » Drive innovation through development & » Grand Rounds » TeleUrology assessment of new ideas.

7 Programs of Particular Interest to Rural Providers

8 Project ECHO®

Multidisciplinary education and case consultations help clinicians care for patients in their own community

Program Overview Available Specialties

» UW Medicine was the second » HIV ECHO program in the United » Hepatitis‐C States » Tuberculosis » ECHO is now live in 23+ » Geriatrics counties including 80+ U.S. » Antibiotic Stewardship sites and 50+ global partnerships » Dialectal Behavioral Health » Transgender Health » Pain Virtual ECHO Sessions

» 1 session/week, on average, per discipline » 10‐15 min educational session, CME credit available » Physicians present de‐identified cases, sent to UW Medicine in advance » Multi‐disciplinary case consultation & treatment plan development » Session materials made available

9 TeleAntimicrobial Stewardship (TASP)

Helping establish and strengthen antimicrobial stewardship programs at 41 partner institutions

Benefits Services Provided  Lower costs by reducing inappropriate antimicrobial • Weekly didactic video conferences covering case use in hospitals discussions with a focus on your institution  Improve patient safety through appropriate dosing • Curriculum that keeps staff up‐to‐date on anticipated and use of antimicrobials at your institution federal regulations and accrediting organization  Prepare for current TJC and expected CMS mandates requirements •  Learn quality improvement techniques Continuing education credits for physicians, nurses and pharmacists  Share best practices among participating organizations • Access to protocols and procedures • Regular access to infectious disease experts who have written IDSA guidelines and won awards for their own programs

10 TeleStroke

Connect directly to the certified comprehensive stroke program at Harborview Medical Center Consultations Expertise • Enter live video consultation with a vascular neurologist within 5 minutes • 15 years of TeleStroke experience • All aspects of consultation are • UW Medicine physicians complete >270 automatically documented and telestroke consultations per quarter available for review • Washington’s first Joint Commission • Access to UW Medicine’s Transfer certified comprehensive stroke program Center and Airlift Northwest at Harborview Medical Center

Education • Access to training in cutting‐edge Platform stroke treatments and protocols • High‐quality platform successfully in use • Initial on‐site training and annual at hospitals nationwide site visits • Integrated diagnostics, imaging, • Weekly online lectures documentation & quality reporting • Quarterly teleconferences and • Cloud based, HIPAA secure CEU opportunities 11 UW Medicine Grand Rounds

• The latest in innovation and clinical best practice, Join us! provided by Department of Medicine faculty Thursdays • All are welcome to stream live 8am‐9am ─ Zoom webinar ID: 812 197 730 ─ Or download the Zoom app (select "join a meeting" and enter ID 812 197 730) • CME credit available ─ https://medicine.uw.edu/grand‐rounds • YouTube Channel with 200+ recorded lectures: ─ https://www.youtube.com/user/UWDeptMedicine/videos

12 CJ1 TelePsychiatry

Access to mental health care professionals with expertise in a wide‐range of disorders

Areas of Expertise • Our team completes more than 10,000 consultations per year in over 150 regional inpatient and outpatient settings. • Anxiety disorders • Neurocognitive disorders • Substance abuse disorders • Bipolar disorder • Perinatal mental health • Psycho‐oncology • Depressive orders • Psychopharmacology • Delirium • Obsessive‐compulsive disorder • Psychotic disorders • Trauma‐related disorders Direct Patient Care Services • Inpatient telepsychiatry consultations • Outpatient consults and implementation of Collaborative Care with primary care team Provider to Provider Services • Outpatient case reviews • Inter‐specialty case consultation for inpatients • Weekly psychiatry & addictions case conference series • Perinatal psychiatry consultation line • Child psychiatry consultation line

13 Slide 13

CJ1 Leah, should we provide information about the new DOH funding for telepsych? I added 2 slides with the information from the biennium budget. Cindy Jacobs, 6/7/2019 HB 1109—2019‐2021 Biennial Budget (enacted)

Funding for TelePsychiatry Services • To create and operate a tele‐behavioral health video call center staffed by UW School of Medicine’s Department of Psychiatry and Behavioral Sciences

• The center must provide emergency department providers, primary care providers, and county and municipal correctional facility providers with on‐demand access to psychiatric and substance use disorder clinical consultation

• Clinical consultation may also involve direct assessment of patients using video technology

• The center must be available from 8 a.m. to 5 p.m. in fiscal year 2020 and twenty‐four hours a day in fiscal year 2021

14 Considerations for Rural Hospitals and Providers

• Extreme variation in policies by payer and state, with piecemeal exceptions that chip away at restrictions • While rural providers have more flexibility with Medicare, requirements are still fractured and nuanced Reimbursement • The lead time for reimbursement is long

• Some platforms are designed to work in low‐bandwidth, but internet speed can still be an issue overall • Proxy credentialing may require a change in hospital bylaws Implementation

15 • Digital health solutions create opportunities for competition in new markets; national health systems and vendors are beginning to move into the WWAMI region • Forward‐thinkers are not necessarily traditional payers and providers, but technology companies

Industry Pace • All modalities of telehealth, including mHealth and digital health, are rapidly evolving

• Regulations lag behind technology—particularly at federal level • Inconsistent patchwork at state level

Legal/Regulatory Arena

16 Reimbursement and Regulatory Landscape

17 Medicare Reimbursement—most restrictive

Historic problem—may affect some rural areas that do not meet the definitions • Medicare beneficiaries eligible for telehealth services only if they are presented from an originating site located in: ─ A rural Health Professional Shortage Area (HPSA) located either outside a Metropolitan Statistical Area (MSA) or in a rural census tract; or ─ A county outside an MSA.

18 Other restrictions

• Must use an interactive audio and video telecommunications system that permits real‐ time communication between provider at the distant site and the beneficiary at the originating site. ─ Asynchronous telemedicine (store and forward) permitted only in federal telemedicine demonstration programs in Alaska or Hawaii.

19 Medicare Originating Sites

• Physician and practitioner offices • Hospitals • Critical Access Hospitals • Rural Health Clinics • Federally Qualified Health Centers • Hospital‐based or CAH‐based Renal Dialysis Centers (including satellites) • Skilled Nursing Facilities • Community Mental Health Centers • Renal Dialysis Facilities • Homes of beneficiaries with End‐Stage Renal Disease (ESRD) getting home dialysis • Mobile Stroke Units

20 FFS Billing‐ Medicare

• Originating Site (facility fee) ─ CPT Q3014 – “Telehealth originating site facility fee” ─ $25.76 in CY2018 (increase of 66 cents since 2016)

• Distant Site (pro fee) ─ Bill appropriate CPT code for services provided ─ Usually time‐based billing ─ Use new “POS (2)” code to designate services delivered by live video (GT modifier has been discontinued) • Append GQ modifier for store and forward, if allowed

21 Recent CMS changes

• New codes; not referred to as telehealth but as “communication technology” • Brief communication technology‐based service, e.g. virtual check‐in (HCPCS code G2012) • Established patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed • Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010) • Practitioner reviews patient‐transmitted photo or video information for established patient via pre‐recorded “store and forward” video or image technology to assess whether a visit is needed. • Remote patient monitoring • Interprofessional internet consultation RPM CPT codes

• 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set‐up and patient education on use of equipment.

• 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.

• 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. Interprofessional internet consultation CPT codes

• 99446: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 5‐10 minutes of medical consultative discussion and review • 99447: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 11‐20 minutes of medical consultative discussion and review • 99448: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 21‐30 minutes of medical consultative discussion and review • 99449: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 31 minutes or more of medical consultative discussion and review

• 99451: Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 or more minutes of medical consultative time

• 99452: Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes Federal legislation

CHRONIC Care Act became part of the Bipartisan Budget Act of 2018

• CMS is finalizing policies to implement the requirements for telehealth services related to beneficiaries with end‐stage renal disease (ESRD) receiving home dialysis and beneficiaries with acute stroke, effective January 1, 2019. • Adds renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites, no originating site geographic requirements for hospital‐based or critical access hospital‐based renal dialysis centers, renal dialysis facilities, and beneficiary homes. • Adds mobile stroke units as originating sites, no originating site type or geographic requirements for telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.

26 Federal legislation

• Medicare Advantage plans may provide additional telehealth benefits starting in plan year 2020. ─ Benefits that are available under part B, but ineligible for payment due to the current Medicare restrictions around telehealth; ─ Services that are identified as clinically appropriate to furnish using electronic information and telecommunications technology when a practitioner is not at the same location as the patient. • Eliminates the geographic requirements for ACOs delivering services via telehealth as well as for the treatment of ESRD and acute stroke. • Removes the facility type requirement for ACOs and stroke treatment and expands eligible sites for ESRD treatment to include the home and renal dialysis facilities.

27 HR6/Substance Use‐Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT for Patients and Communities Act) • Removes Medicare geographic restrictions after January 1, 2019 for purposes of telemedicine treatment of substance abuse disorders or a co‐occurring mental health disorder. • Establishes a new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) under Medicare Part B, beginning on or after January 1, 2020. • Signed into law October 2018 • CMS new implementation rule adds home as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co‐occurring mental health disorder for services furnished on or after July 1, 2019. Pending: HR6502/RUSH Act (introduced July 2018)‐‐Reducing Unnecessary Senior Hospitalizations

• TBD Medicare services that are normally furnished at a hospital emergency department may be safely furnished by a qualified group practice at a qualified skilled nursing facility, including via synchronous or asynchronous telemedicine.

• Stalled in 2018‐–to be reintroduced in revised form Washington State Telehealth Collaborative

• Established in 2016 with passage of S. 5619

• Mission: to provide a forum to improve the health of Washington residents through the collaboration and sharing of knowledge and health resources statewide and increasing public awareness of telehealth as a delivery mechanism

• Accomplishments: inventory of telehealth providers and programs, provider training slide set, best practices related to consent and documentation, 5 bills passed and signed into law related to originating sites, proxy credentialing, Project ECHO funding State Legislation

SSB 5385 payment parity (Passed Senate and House Committees and left in limbo in House appropriations—will still be there next session) • Requires health plans to pay the same rate for a health care service provided through [live/synchronous] telemedicine as an in‐person service. • Permits hospitals, hospital systems, telemedicine companies, and provider groups of 11 or more to negotiate and agree to a telemedicine reimbursement rate that differs from in‐person rates. • Requires reimbursement for facility fees to be subject to a negotiated agreement. • Removes the requirement that services provided through store and forward technology have an associated office visit. SB5386—signed by governor

• Beginning January 1, 2020, a health care professional who provides clinical services through telemedicine may complete a telemedicine training. • By January 1, 2020, the [state] telemedicine collaborative shall make a telemedicine training available on its web site for use by health care professionals who use telemedicine technology. • Training must meet certain standards. • If a health care professional completes the training, the health care professional shall sign and retain an attestation. SB5387—signed by governor

• Technical change to proxy credentialing provisions under RCW 70.41 (hospital licensing statute). • Adds “credentials and” to references to “privileges” (e.g., “credentials and privileges”). Speaking of Credentialing and Privileging…

34 Issues involved

• Licensing • Verification of medical staff credentials, including privileges • Considerations for rural hospitals ─ As originating site: What do you do with the distant site providers (telemedicine medical staff)? ─ As distant site: What do you do with your own providers (regular medical staff)?

35 State Regulatory Authority

• States traditionally have managed their own licensing schemes • Second only to reimbursement, licensure portability is the largest hurdle in telemedicine today

36 State Law Generally

• License required in state of patient “location” ─ Does this mean residence? • Some states have telemedicine licenses ─ Number of these states is decreasing—trend toward full licensing • Some states have limited consultation exemption ─ Same specialty? ─ Frequency? ─Payment? • “Why worry?” ─ Liability ─Triggers

37 Trends in the law—through 2018

• 36 states require full license to practice telemedicine • 28 states have consultation exceptions • 29 states joined the IMLC ─ All WWAMI states except AK

38 Other weird stuff

• Reporting out‐of‐state consultations ─Wyoming • Telemedicine business registry—Alaska special

39 Alaska business registry

• Article 5A. Sec. 44.33.381. Telemedicine Business Registry. ─ Before providing telemedicine services to a patient located in the State of Alaska, a business providing telemedicine services must register on the telemedicine business registry. • Website FAQ Section ─ “There are no exemptions for business that will be or are providing telemedicine/telehealth services to Alaska‐based clients. Business corporations, cooperative corporations, non‐profit agencies, religious organizations, and veteran clinics must obtain a valid Alaska business license if telemedicine services will be or are being provided. Boards or programs, however, may have exemptions for professional licenses. Please contact the assigned occupational licensing examiner for the profession of interest if you have questions about exemptions.”

40 Other State Law Licensing‐related Issues

• Provider‐patient relationship ─ In‐person requirements decreasing • Informed consent ─ Hot button—telemedicine is a treatment delivery method, not a treatment. ─ Is it a “material fact”? • “Standard of Care” ─ Hot button—see above • Tele‐presenters • Prescribing ─ In‐person requirements decreasing

41 WWAMI

State Physician License? Nurse License? Prescribing Medication Other

Alaska Yes. No presenter Yes Business Registry

Must be licensed to Yes. Consultation Idaho NLC prescribe without in‐ IMLC exception person exam

“Occasional” case “Abortion‐inducing Montana eNLC effective Jan. 2018 IMLC exception drugs” prohibited

Yes. Licensure exemption Same professional Washington does not apply to Yes accountability as in‐ IMLC telemedicine person

Wyoming Consultation exception Yes, NLC. IMLC

42 Interstate Licensing Compact

• Model physician licensing compact was developed by Federation of State Medical Boards • Expedited licensing pathway, not true reciprocity • Available only between/among states whose legislatures adopt the Compact ─ In WWAMI land, Washington, Montana, Wyoming and Idaho have adopted the Compact

43 Compact Core Principles

• Participation strictly voluntary for both physicians and state boards • Participation creates another pathway for licensure, but does not otherwise change a state’s existing Medical Practice Act • Requires the physician be licensed by and under the jurisdiction of the laws and board of the state where the patient is located • Regulatory authority will remain with the participating state medical boards, not national compact staff • State boards participating in an interstate compact are required to share complaint / investigative information with each other

44 How does it work?

• Always originated through/via current state of licensure—example: WY physician wants to practice telemedicine in WA • Apply and pay $700 to the IMLC • $400 goes to WY • $300 goes to IMLC general fund • Various handling fees also assessed

45 How does it work?

• WY issues an approval letter to WA • Pay normal $491 licensing fee to WA • $100 each for release of additional letters to additional states • Still must pay full licensing fee to the new state

46 Proxy Credentialing

• Historically, CMA and TJC required full PSV credentialing for any medical staff member. • TJC began to allow “proxy credentialing” for telemedicine around 2003. ─ CMS disagreed until 2011, then issued its proxy credentialing rule ─ TJC standard now conforms • RCW 70.41.230 also specifically allows proxy credentialing ─ Part of 2015 telemedicine bill

47 42 CFR 482.22

• When telemedicine services are furnished to the hospital’s patients through an agreement with a distant site hospital, the governing body of the originating site hospital may choose to have its medical staff rely upon the credentialing and privileging decisions made by the distant site hospital when making recommendations on privileges for the individual distant site healthcare professionals providing such services.

48 42 CFR 482.22

• Conditions (must include in agreement) • Distant site is a Medicare participating hospital. ─ Non‐hospitals also may be distant sites: “DSTE”—distant site telemedicine entity. A DSTE may be a physician group, a non‐Medicare‐participating hospital, or other non‐hospital telemedicine provider. ─ For CAHs, the regulations contain an exception to the requirement that CAH agreements for clinical services may only be with a Medicare‐participating provider or supplier, since DSTEs do not necessarily participate in Medicare. ─ DSTE must provide contracted services in a manner that enables the Originating Site hospital to meet all applicable Conditions of Participation, particularly those requirements related to the credentialing and privileging of telemedicine practitioners.

49 42 CFR 482.22

• Distant site provides a current list of its healthcare professional’s privileges. ─ Privileges are part of credentialing, but not co‐extensive ─ What are “Telemedicine Privileges” anyway? • Inherently held through the distant site • Originating site’s own regular medical staff would be telemedicine‐privileged to provide telemedicine services to that hospital’s own patients when it is the distant site, e.g., patient at home • Distant site healthcare professional holds a license issued or recognized by the State in which the originating site is located. • Originating site sends the distant site performance information for use in the periodic appraisal of the distant site healthcare professional. At a minimum, ─ All adverse events that result from the telemedicine services by the healthcare professional, and ─ All complaints the originating site has received about the healthcare professional.

50 Best‐kept secret‐‐or misplaced concern?

• Foley & Lardner 2017 Telemedicine & Digital Health Survey Report ─ Only 33% of respondent hospitals or provider groups use telemedicine credentialing by proxy. ─ The traditional credentialing process is far more time‐consuming and costly than credentialing by proxy. ─ Hospitals should consider how to take advantage of the streamlined credentialing by proxy process offered by both CMS and the Joint Commission. ─ It can reduce the onboarding and go‐live time from several months to several days, thus allowing telemedicine providers to start delivering services much more quickly.

51 Available Resources in WA State

52 Source: Washington State Telehealth Collaborative TELEHEALTH STANDARDS AND GUIDELINES • In an effort to help advance science and assure the uniform quality of services to patients, the American Telemedicine Association has developed several practice guidelines and technical standards for the field of telemedicine and telehealth. • They include core standards that address a wide target group within the health care sector as they apply to individual practitioners, group practices, health care systems, and other providers of health-related services for the purposes of health care delivery. • The association has also developed guidelines to address specific clinical practices: http://hub.americantelemed.org/resources/telemedicine-practice-guidelines • Best Practices in Videoconferencing-Based Telemental Health • Practice Guidelines for Live, On Demand, Primary and Urgent • Let there be Light: A Quick Guide to Telemedicine Lighting Care • Quick Guide to Store-Forward and Live-Interactive • Clinical Guidelines for Telepathology Teledermatology for Referring Providers • Guidelines for TeleICU Operations • Operating Procedures for Pediatric Telehealth • Core Operational Guidelines for Telehealth Services Involving • Principles for Delivering Telerehabilitation Services Provider-Patient Interactions • Practice Guidelines for Telestroke • A Lexicon of Assessment and Outcome Measures for Telemental • Practice Guidelines for Telemental Health with Children and Health Adolescents • Practice Guidelines for Video-Based Online Mental Health Services • Practice Guidelines for Teleburn Care • Videoconferencing-based Telepresenting Expert Consensus • Practice Guidelines for Dermatology Recommendations • A Concise Guide for Telemedicine Practitioners Human Factors: • Telehealth Practice Recommendations for Diabetic Retinopathy Quick Guide Eye Contact • Evidence-Based Practice for Telemental Health 53 Source: Washington State Telehealth Collaborative REFERENCE LINKS

ITEM DESCRIPTION SOURCE WEBSITE FEE Northwest Regional Telehealth Resource 1 Telehealth Training http://nrtrc.dev.uen.org/education/training.shtml No Center No https://mhealthintelligence.com/news/online-training- 2 Telehealth Training Healthtap (+ Category 1 cetification-offered-for-virtual-care-doctors CME credit) Yes 3 Telehealth Training & Certification Alaska Federal Healthcare Access Network http://www.afhcan.org/training.aspx (ATA Accredited) Yes 4 Telehealth Training & Certification Arizona Telemedicine Program https://telemedicine.arizona.edu/training (ATA Accredited) Telehealth Coordinator, Staff 5 California Telehealth Resource Center http://www.caltrc.org/knowledge-center/training/ No Coordinator Training 6 Learn Telehealth South Central Telehealth Resource Center http://learntelehealth.org/courses/ No 7 Telehealth Training Center for Connected Health Policy http://www.cchpca.org/jurisdiction/washington No https://www.americantelemed.org/main/ata- Yes (ATA 8 Telehealth Training American Telemedicine Association accreditation/training-programs Accredited) http://www.americantelemed.org/policy‐page/state‐ 9 Policy Resources American Telemedicine Association policy‐resource‐center?CLK=de701a27‐454f‐4494‐accb‐ No c62a905e8c81 Telehealth Resource Center Fact National Consortium of Telehealth Resource 10 https://www.telehealthresourcecenter.org/fact‐sheets/ No Sheets Centers National Telehealth Technology Assessment 11 Technology Assistance http://www.telehealthtechnology.org/ No Resource Center 54