AcuteCare Telemedicine Blog


State Medical Boards Take Different Approaches to Regulating Telehealth

The recent headlines about the Texas State Medical Board’s (TMB’s) proposed new rules concerning the practice of telemedicine is managing to capitalize the national Telehealth debate. The TMB’s approach has ignited strong emotions and raised the intensity of conversations about the role of telemedicine throughout the medical community. The TMB, among other state medical boards, propose similar restrictions on the practice of telehealth, however the Indiana State Medical Board (ISMB) differs in its approach.

In April, the ISMB approved a trial program which allows Indiana residents to access virtual doctors and receive treatment without first having to establish an in-person relationship with the care provider. Before the pilot program, state medical officials allowed virtual appointments only between doctors and patients they had previously treated in person. The ISMB officials will evaluate how the new rules impact patient care and decide later this year whether to make the change permanent. Under the new rules, doctors can write antibiotic and other prescriptions, except for controlled pain medicines, for patients experiencing symptoms of flu, sinus infections, sprains, rashes and bronchitis. Doctors who practice telemedicine must be licensed in the state of Indiana.

The American Telemedicine Association (ATA) estimates that about 450,000 patients will see a doctor through the Internet this year for a primary care consultation. The number of patients who want to participate in virtual visits with their doctor is expected to increase as newer, easy-to-use mobile applications and devices become available. Convenience and cost savings are listed among its top reason for the increase in interest.

The American Medical Association (AMA) is looking at the ethical issues associated with virtual doctor visits due to the growing demand for the service. A recent survey found that 64 percent of participants would be willing to have a virtual doctor visit. The AMA states, “Rather than a blanket prohibition against diagnosing and prescribing, a more nuanced and sustainable approach would permit physicians utilizing telehealth/telemedicine technology to exercise discretion in conducting a diagnostic evaluation and prescribing therapy within certain safeguards.”

While similar in their concern for the quality and safety of patient care, the contrast between the TMB and the ISMB approach to implementing regulations governing virtual medical care could hardly be more different. While the TMB appears to be slamming the door on telemedicine as the new healthcare delivery model, the ISMB’s pilot program is a practical response which may just open doors to a better healthcare delivery model for their citizens.



Do State Medical Boards Need To Be More Forward-looking When Developing Telemedicine Rules?

Telemedicine has been around for several decades but 2015 is predicted as the year delivering healthcare through telemedicine reaches the tipping point. Patients are becoming more aware of the benefits of telehealth for routine medical services. Dr. James Kiely, Partner, AcuteCare Telemedicine LLC says, “State medical boards are struggling with finding a balance between patients’ demands for new models of care and patient safety as more consumers are embracing the convenience and lower costs of virtual visits and readily seeking routine and minor healthcare services through their smart phones, laptops and pads instead of face-to-face encounters with their doctors.”

The U.S. Congress and individual state legislatures are moving quickly to address payment, safety and quality of service concerns that accompany the new delivery model, which promises to increase access to medical specialist and lower the cost of routine visits to emergency rooms and physicians. The individual state medical boards, the governing bodies of healthcare delivery regulations and practice standards, are a bit more deliberate and inconsistent in setting forth new rules and regulations relative to the practice of telemedicine.

While one universal theme consistently centers on the premise that practicing telemedicine must use the same standard of care as healthcare services provided in person, collective commonality ends there. Although the majority of board efforts include guidelines, exceptions and standards of performance that address the important safety and quality concerns while permitting the practice of telehealth, some individual state board responses differ considerably.

The recent vote to accept proposed rule changes by the Texas Medical Board (TMB) might not be aligned with the majority of state medical boards. The new policy, which does not apply to mental health services, includes language that says physicians cannot prescribe a medication without first establishing a “defined physician-patient relationship.” That includes establishing a diagnosis through an examination performed during a face-to-face encounter.  This may be an effort to limit inappropriate dispensing of medications (e.g. broad spectrum antibiotics and narcotics), but appears to be sufficiently restrictive enough to effectively block the practice of most telehealth within the state.

In response to a legal challenge brought by telemedicine company Teladoc, federal Judge Robert Pitman, for U.S. District Court in Austin, Texas, issued a temporary restraining order and preliminary injunction to keep the TMB rules from going into effect. Teledoc, which operates in 48 states and performed nearly 300,000 virtual patient visits in 2014, challenged the legality of the TMB’s new rules. The American Telemedicine Association (ATA) expressed concern that “any policies addressing telemedicine not be overly prescriptive and inadvertently thwart the benefits of new technologies for improving care, expanding access and reducing costs.”

Given the more cooperative reactions of other state legislatures and medical boards, in regulating virtual healthcare across the country, the strict reaction of the TMB has proponents of telehealth questioning the reasoning behind the Boards restrictive posture. What is it about the delivery model that the Texas Board knows and fears that the rest of the medical community is missing? It is not that telemedicine is untested. In more than a decade of practice it has survived the scrutiny of industry experts and numerous regulatory bodies and has demonstrated its value to improving access and lowering costs while encouraging patients to take a more active personal role in their own medical care. Telemedicine is not a different kind of care, but rather a different method of delivering care.

The actions of the TMB certainly impact the implementation of telehealth programs nationwide, however they do not follow the actions of most state medical boards across the country. Nathaniel Lacktman, a partner at the law firm of Foley & Lardner and the leader of the firm’s telemedicine practice believes that the case could have implications for a number of other state boards as they develop rules surrounding telemedicine. Lacktman stated, “The court’s ruling may be a signal to state medical boards to be forward-looking and open-minded when developing rules, particularly when it comes to regulating new and innovative ways of providing healthcare to patients.”

Telemedicine is becoming a standard of care for specialty practices including neurology, cardiology, and psychiatry, among others. The hope is that each individual state medical board creates legislation supporting a healthcare solution that is designed to balance improved patient outcomes and increased access to quality care.



Elements Essential to Establishing a Successful Telemedicine Program

Several studies in recent years have indicated that the use of telecommunication technologies in the delivery of health care will rise dramatically as new technology is improved and its utilization perfected. Patients seeking healthcare through the use of fixed and mobile digital devices will reach 7 million by the year 2018. This predicted high demand for mHealth has existing providers scrambling to design an effective, high quality delivery model that meets the requirements of increasingly savvy consumers/patients. The projected increase in users of telemedicine services is also attracting a new wave of investor-supported entrepreneurs, eager to embark into the practice of virtual medical care. These new technologies make it possible for healthcare providers to monitor, measure, and interface with patients remotely while making it easier for patients to manage their own healthcare.

As healthcare companies and providers seek to implement telehealth solutions, it requires certain critical, essential elements necessary to the successful engagement of a connected-care-telemedicine practice:

Devices – The popularity and utilization of personal computing came about only after the deliberate evolution of devices that were simple and easy to use by inexperienced consumers. A telemedicine practice must use remote presence devices that are easy to use for the patient and promote a high level of confidence in the exchange of information with their physician.

Platform – Utilizing a platform that integrates telemedicine connections into a secure electronic medical record system will be essential to insuring quality and continuity of care. A software platform should be easily accessed by users and consistent with familiar digital formats and functions, but include cutting edge security measures in order to ensure the highest level of patient confidentiality.

Expert Practitioners – Telemedicine is not a new or different type of healthcare, but a different method of delivering the same quality of healthcare.  The physicians and care-givers must be equally skilled and proficient, not just in medicine, but also in technology.

Process Improvement – A successful telemedicine practice must establish key performance indicators that can be monitored and measured.  As the system is monitored and measured, telemedicine providers are able to make continual improvements to ensure the highest level of care.

The growth of telemedicine has become one of the most disruptive events in the delivery of healthcare in more than a century. Applying the technology to a well-established and confident system of care will come with certain challenges in its implementation. The impact will be derived, not by the technology or its devices, but rather from the healthcare professionals who incorporate these essential elements.



The Challenge of Connecting Telemedicine to Electronic Health Records

Much of the debate about telemedicine and the effect it is imposing on the established healthcare delivery model has been centered on the doctor/patient relationship and the adherence to maintaining a high standard of care, regardless of the method of interaction. While the importance of the patient and physician in the new electronic relationship is well understood, there is a third component essential to the successful integration of telemedicine. The ability to access patient’s medical information is critical to extending continuity of care for patients as well as improving transparency between telemedicine providers and healthcare organizations. Organizations are already integrating electronic health records (EHRs) systems but telemedicine adds another layer of integration.

To successfully access patient data, telehealth providers will need to achieve interoperability between various information technology systems and software applications and must be able to communicate, exchange data, and use the information that has been exchanged seamlessly across all types of digital communication devises. Tom Bizzaro, vice president of health policy for First Databank says, “We have to universally acknowledge the value of interoperability within healthcare IT systems. Indeed, sharing data across systems can help to improve care quality and efficiency in the country’s health system and lead to success of value-based reimbursement models. However, all players – providers, payers, patients and vendors alike – need to truly embrace the value EHR interoperability, putting it above any proprietary concerns.”

In speaking about the future of the connected healthcare system, Steve Cashman, CEO of HealthSpot, said “The future of the connected healthcare system lies in solutions that deliver care to patients where it’s most convenient for them through unique partnerships that extend the care of traditional health systems and local medical communities through different forms of mobile health and telemedicine. By embracing new technologies, we can treat a greater number of people with more efficient and relevant means of care. With the addition of cloud-based electronic health records and coordination of care between traditional and connected healthcare models, we can build an even better experience for patients and providers. Building connected healthcare systems will also allow us to engage with patients on a deeper level, incentivizing them to seek care and empowering them to participate in preventative measures.”

Congressional House leaders recently unveiled a draft of the 21st Century Cures Act, which aims to “accelerate the discovery, development, and delivery cycle to get promising new treatments and cures to patients more quickly.” The original draft did not include language pertaining to telemedicine, but a new draft includes language about the interoperability of electronic health records and requires electronic health records to be interoperable by Jan. 1, 2018. The College of Healthcare Information Management Executives (CHIME) President and CEO Russell Branzell and Board Chair Charles Christian want better patient identification to be included in the new legislation in order to better secure access to patient information. The duo called it the “the most significant challenge” to safe health information exchange. A subsequent statement by CHIME to FierceHealthIT read, “Increasing access to patient data alone will not translate into better patient care. We would encourage the committee to emphasize both the need to increase access and exchange health information, along with the value of being able to use the data to improve care.” The American Telemedicine Association (ATA) CEO Jonathan Linkous, expressed his hope that Congress will adopt “at least a few measures” to expand access to telemedicine.

The shift to EHRs in large healthcare organizations and in clinical practice certainly proved challenging.  As telemedicine becomes a standard of care, EHR integration becomes a key component to long-term success.

As AcuteCare expands into various healthcare organizations, Dr. James M. Kiely, Partner, AcuteCare Telemedicine (ACT) comments on the complexity of integration with EHR systems. “Currently, we are able to enter patient data via a secure but separate, web-based portal or by using some very good software that allows data integration. Both solutions require manual staff intervention which can often be slow and cumbersome; the antithesis of what telemedicine is supposed to represent. As with EHR integration, it might take considerable time and effort to create a platform that simplifies the integration.”