AcuteCare Telemedicine Blog


Looking Backwards to See Ahead – Part 5: Contracts & Technology

This is the final blog in a series chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at a past Annual Meeting of the American Telemedicine Association (ATA). What follows is an amalgam of facts, experience and opinions culled from that fantastic symposium and honed by hindsight. Today’s blog will focus on legal and technology issues.

As stated in Part 4 of this series, Running the Business, there are a myriad of issues confronting physician-entrepreneurs when establishing a telemedicine service. Physicians are trained to provide medical care, yet this is a technology business. Therefore, an overview of contracts and technology is paramount.

Contracts have to be written to fit the specific needs of each client. However, it is appropriate to have a boilerplate document that addresses both general contract features (e.g. non-malfeasance, non-compete, etc) as well as telemedicine specific features (e.g. the type of encounters covered, the times covered if not 24/7, etc). The contract should stipulate that the telemedicine provider will determine appropriate use of telepresence. If used for routine consults, a maximum number of encounters to be provided per time period can be stipulated in lieu of a sliding fee schedule. It is probably good practice to make it the obligation of the client hospital to maintain HIPAA compliance (e.g. not having the patient in an ED hallway) and assure patient identity prior to consultation (requiring the RN to show you the patient’s wristband ID [never thought of that, did you?]). The contract should also clearly state who is responsible for technical support (see technology below).

A few more legal issues bear mentioning. CMS may allow the originating site (i.e. telemedicine corporation) to do one time M.D. credentialing versus repeating at every client hospital. While CMS doesn’t apparently distinguish between corporations and health care centers, this credentialing allowance is likely in deference to university hospitals proving remote presence. It would ultimately be up to the client hospital to accept the remote provider’s credentialing process in lieu of their own.  Every business partner who has access to patient related data must have a HIPAA oriented contract. A written statement should be obtained from one’s malpractice provider documenting coverage for each state in which treating physicians are licensed.

There are ever expanding options for remote presence technology. Purchase or leasing of proprietary hardware by the client hospital has been the standard. This is attractive because the telemedicine provider makes more money and the hospital experiences lower upfront costs. In the long run, this is actually more expensive for the hospital, and obscures whether the service is providing medical care or simply technology. There are less expensive alternatives, including subscribiptions to web-based software for use with the clients preexisting resources (i.e. PC, webcam, ethernet, hospital IT department). However, choosing this technology will affect reliability; IT departments may not have dealt with the paradigm of providing 24 hour, secure, immediate, unfaltering access for physicians from remote sites.

The better alternative is the purchase of hardware and software from vendors dedicated to telemedicine technology and IT support. It has been demonstrated that client hospitals with a financial investment in the technology are more likely to use it. This leads to more encounters and a reinforcement of the value of the entire endeavor. The technology available varies from fairly fixed COWs (Computers On Wheels) to fully autonomous robots that can move independently between and within rooms, with one-time costs ranging from $25-60,000. Hospitals may then choose the technology based on budget, IT support, software and value added features (e.g. stethoscopes, government grant subsidies, etc). Hardware should undergo scheduled replacement (i.e. laptops every 3 years). Either a dedicated T1 line or reliable Wi-Fi are mandatory. Regardless of the technology employed, patient interaction should be standardized across sites by a telemedicine provider. This normalizes the decision process and improves remote partner (RN, MD) facilitation of exam at the bedside. A written protocol (e.g. NIHSS) is also useful. Finally, as technology continues to proliferate, the future holds great potential for interoperability of these systems with electronic health records, further revolutionizing patient care through telemedicine solutions.

Establishing a telemedicine service is a challenging yet extremely rewarding endeavor that will ultimately contribute to an overall higher standard of patient care. Armed with new insights culled from these experiences, AcuteCare Telemedicine is moving towards the future with consideration for the procedures and mechanics that are obligatory for success, yet not part of standard medical school curricula. 


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