AcuteCare Telemedicine Blog


Clearing the Hurdles for Advancing Multistate Telemedicine

For the most part, the laws that govern the practice of medicine in the United States are state laws. One of the few things those laws agree on is that jurisdiction of those laws is based on the patient’s location, not the doctor’s. With the fast paced expansion of telemedicine technology and new mobile health opportunities bursting on the medical delivery scene, some well-established procedural hurdles are slowing the advancement of multistate practice of telemedicine. It is not that these procedures are necessarily bad it’s just that their creation and implementation are from a time when few could even imagine or foresee the advancements in the telecommunication technology of today.

The benefits of telemedicine to the delivery of healthcare, is becoming obvious to even the most resistant of detractors. “It’s relatively easy to do [telemedicine] if you’re going to stay within your particular state,” said Nathaniel Lacktman, a senior counsel at Foley and Lardner, “But if you really want to expand your reach, and be revolutionary or just make a whole lot of money, you’re going to need to go cross-border. Because of that you will be subject to the laws of that particular state. Across the country, where the patient is located, those are the laws that govern.” The six most common regulatory and procedural hurdles to expanding multistate telemedicine include:

Licensing

The American Telemedicine Association estimates that getting doctors licensed in additional states for telemedicine costs physicians $300 million per year. While some exceptions to state licensure laws have recently been put into place for telemedicine, most are not broad or consistent. For example, every state has a remote exception for post-surgical consultations. But some of those require the consultation to be free, some can only be hospital to hospital, and different states have different definitions of a consultation.

Scope of Practice

Every state board has the duty to enforce standard of care in their specific community and one of the most vexing standard of care provisions for telemedicine is the notion of doctor-patient relationships. Many states allow doctors and patients in an established relationship to meet virtually, but require the relationship to be established in an initial face-to-face meeting. To gain the most in quality and cost benefit from the practice of telemedicine, few face to face encounters between a patient and a doctor or specialist will occur prior to telemedicine treatment or consultation.

Credentialing

To practice hospital-to-hospital telemedicine, many hospital bylaws and state laws require physicians to be credentialed as if they were employees in the remote hospital, sometimes including maintaining their own health insurance, participating in staff education, and other requirements that don’t quite seem to apply.

The Centers for Medicare and Medicaid services have introduced a proxy rule for credentialing that could alleviate some of that pressure but in general practice, the myriad of credentialing requirements is overwhelming most attempts to efficiently overcome this barrier. Perhaps we can all agree on some common standardization of credentials to avoid unwanted implementation of federalized, “one size fits all” intervention.

Remote Prescribing

Remote prescribing is also covered under scope of practice, but with additional complications. Individual state pharmacy board’s standard of care, often have their own rules and the prescription of controlled substances can be regulated differently in different states. “There’s a whole set of rules on remote prescribing, what you’re allowed to do, what you’re not allowed to do,” Lacktman said. “Rule of thumb: prescribing is more restrictive than consults.”

Contracting

Contractual arrangements for physicians and other healthcare provider professionals differ greatly from one state to another. Attempting to practice across all states collectively is a minefield of differing contractual laws. For a business employing multiple doctors, the arrangement for paying doctors has to conform to all the states’ fee-splitting laws, practice of medicine laws, and anti-kickback statutes, which essentially prohibit doctors from buying and selling referrals.

As is often the case, the most admirable and beneficial accomplishments in any endeavor are rarely easy, but overhauling the well-entrenched, well-meaning bureaucratic regulations of the past is extremely daunting at the very least. It will require dedication and vision of all who seek to improve the delivery of healthcare to all Americans, no matter where they reside.



Study Confirms Predictions Of Telemedicine Benefits for ICU’s

Supporters of telemedicine have long predicted that the application of telemedicine services in Intensive Care Units (ICU’S) would have a beneficial effect on costs and patient outcomes and the first large-scale multi-center study of the effects of use of telemedicine in the intensive care unit for adult care is indicating significant improvements in patient care and lower costs.

The results of the study were released in the CHEST Journal Online First, a publication of the American College of Chest Physicians. The study, “A Multi-center  Study of Telemedicine Reengineering of Adult Critical Care,” looked at the impact of the program on 118,990 critical care patients, across 56 ICUs, 32 hospitals and 19 health systems over a five-year period, and demonstrated reductions in both mortality and length of stay.

Among the key findings were that, compared to patients receiving conventional ICU care, patients using the telemedicine ICU program were:

  • 26 percent more likely to survive the ICU;
  • Discharged from the ICU 20 percent faster;
  • 16 percent more likely to survive hospitalization and be discharged; and
  • Discharged from the hospital 15 percent faster.

Craig Lilly, M.D., professor of medicine, anesthesiology and surgery at the University of Massachusetts Medical School and director of the eICU program at UMass Memorial Medical Center, said, “The study demonstrates that if you use really high-quality tools and motivated and talented people, that you can shift the paradigm; you can save lives and you can save money at the same time.” He added that the study is large enough, that it provides some insights as to ICU telemedicine works, and where its use makes sense. He noted that not everybody that implemented the ICU telemedicine tools did it in the same way. By using the validated survey instrument, the researchers were able to identify factors that made a difference in better patient care.

“Today, personnel accounts for 56 percent of the $2.8 trillion healthcare spend in the U.S., and coupled with the current shortage of clinicians, many hospitals are unable to offer on-site intensivist physicians, 24 hours a day, seven days a week,” said Brian Rosenfeld, Vice President and Chief Medical Officer, Philips Healthcare Telehealth. “This study provides further evidence that health systems employing coordinated telehealth in their care models will increase provider productivity, while improving outcomes and reducing costs.”



Stepping up and Getting Out in Front of the Revolution

Historically the healthcare industry has been notoriously slow to adopt innovation but one health insurance company is stepping out in front of their industry when it comes to demonstrating a willingness to pay for telemedicine services, recognizing the potential for cost savings and simplification of services.

At this year’s Connected Health Symposium in Boston, John Jesser, VP of Provider Engagement Services for WellPoint, explained that his company is partnering with American Well Systems, a telemedicine services vendor, to set up the program for its members. Before the program was set up, patients who needed to see a physician during off-hours had limited options: Visit the ER and spend about $600; see a physician in an urgent care center for about $150; or wait until the doctor is back in the office. WellPoint introduced a new choice for its members, which only costs about $49.

Patients are able to use a laptop computer, mobile device or tablet to connect with a primary care physician.  The encounter takes about 10 minutes to initiate, is HIPAA compliant and the service can be paid for with a credit card.  Medical history is available to the attending physician.  In addition to WellPoint, a number of other insurers including; Aetna, Highmark and Cigna are experimenting with similar programs for their member policy holders.  Following South Carolina’s State legislators recent introduction of SB 290 and HB 3779, requiring private insurers to cover telemedicine services, BlueCross BlueShield of South Carolina and Blue Choice HealthPlan of South Carolina announced that they would start paying for some telemedicine services.

But a recent tally from the American Telemedicine Association indicates that nationwide coverage will be a slow journey.  As of October 2013, there were only 20 states, and the District of Columbia, that required insurance companies to pay for some form of telemedicine services: Arizona, California, Colorado, Georgia, Hawaii, Kansas, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Montana, New Hampshire, New Mexico, Oklahoma, Oregon, Texas, Vermont, and Virginia.

Insurers and state lawmakers aren’t the only ones with reservations about telemedicine. Ron Dixon, MD, the Director of the Virtual Practice at Massachusetts General Hospital (MGH), says, “I’ve found trying to get telehealth moving at MGH has been impeded by the way insurers pay for things. It’s been a big barrier to get it rolled into the way physicians actually practice.” He also believes that doctors resist offering telemedicine care because they simply have too much to do. “If you are going to get doctors involved, there has to be a win for them, and the win is usually time. It’s not always about the money.”

Massachusetts General Hospital has built a tool that allows existing patients to get their follow-up care online. The hospital pays providers for the service, and while the fees they receive are less than what they get for in-person visits, it also takes them less time to see a patient online, so it tends to balance out.

If the full benefits of telemedicine services are to realized, more insurers and practitioners will need to step up and overcome their reluctance to technologies that promise to revolutionize the traditional healthcare delivery model.



SAMC Recognized For Outstanding Stroke Care

The Southern Alabama Medical Center (SAMC’s) Stroke Care Network was recently named “Partner of Year” at the Alabama Rural Stroke Award Health and Telehealth Summit.  The award was presented by the Alabama Partnership for Telehealth (APT) during the October summit in Prattville. Jason DeLeon, MD, Emergency Medicine; Cecilia Land, division director SAMC Rehabilitation Services and Levonne Outlaw, SAMC Stroke Network Coordinator accepted the award.

“This is an award that we give out to the partner who we feel has done the most outstanding job when it comes to not only using, but advancing telemedicine,” said Lloyd Sirmons, executive director of APT.  “SAMC has done a great job, not only building their program, but advancing telemedicine in the state of Alabama.”

AcuteCare Telemedicine (ACT), the Southeast region’s largest practice based telemedicine provider, joined in collaboration with SAMC earlier this year to remotely diagnose and treat acute care neurological patients and to offer advanced cost-effective solutions that deliver improved stroke patient outcomes throughout the expanded SAMC Network of participating hospitals.  The SAMC Stroke Care Network ensures that patients in surrounding rural communities have access to the most experienced stroke care available. “SAMC sets the standard in the state when it comes to providing stroke care in rural areas,” said Dr. DeLeon.

On hand to present the award were Matthews Gwynn, MD, Acute Care Telemedicine, SAMC TeleNeurology Providers; Lloyd Sirmons, Alabama Partnership for Telehealth; Ron Sparks, Alabama Department of Rural Development and David White, Alabama Governor’s Office.