AcuteCare Telemedicine Blog


Mobile Healthcare and Monitoring on the Brink of Revolution

Wireless in-home health monitoring is expected to increase six-fold in the next four years. A recent study by InMedica indicates that 308,000 patients were remotely monitored by their healthcare provider for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and mental health conditions worldwide in 2012. While congestive heart failure accounts for the majority of remote monitoring, it is expected that diabetes will supplant COPD with the second largest share of telehealth patients by 2017.  It is predicted that more than 1.8 million people worldwide will utilize mobile monitoring in the next four years.

Telemedicine is seen as a significant tool among healthcare providers for reducing hospital readmission rates, track patients chronic disease progression or provide advanced specialized medical treatment to patients in remote areas.  Four main factors are driving the demand for increased use of telemedicine and telehealth; Federal Readmission penalties introduced by the U.S. Center for Medicare and Medicaid Services (CMS);  healthcare providers desires to increase ties to patients and improve quality of care; insurance providers who are looking to increase their competitiveness and reduce in-patient pay-outs by working directly with telehealth suppliers to monitor their patient base; and an anticipation for future increased demand for telehealth services by patients.

Of the billions of dollars spent on health care each year, 75% to 80% of it goes for patients with chronic illnesses such as diabetes, heart disease, asthma and Alzheimer’s disease.  With rising costs and the anticipated shortage of physicians and healthcare providers over the next decade, utilizing the telemedicine technologies is becoming increasingly important to the routine delivery of medical services and monitoring of chronic diseases.

Even telepsychiatry, the use of secure Web-based video conferencing technology, and ambulatory patients, those who have been diagnosed with a disease at an ambulatory care facility but have not been hospitalized are expected to experience significant increased utilization of telemedicine among healthcare professionals in the next four years.  A plethora of emerging mobile technology, such as wearable wireless monitors to smartphone attachments will offer consumers the ability to track everything from core vital signs to impending heart attacks by discovering problems with heart tissue are on the horizon, offering a revolution in digital medical technology.

Speaking to those resisting the new mobile technology, Dr. Eric Topol, a professor of genomics at the Scripps Research Institute, recently encouraged the medical community to end paternal medicine, where only the physician has access to healthcare information, and to embark on a new beginning where patients own their data.  Dr. Topol compared the new mobile technology to the Gutenberg press and the way it revolutionized the way information was shared throughout the world.

We are embarking into a new era where patients have the mobile tools to better enable them to participate in their own medical diagnoses and treatment.



Botox – The Poison that Heals

Ounce for ounce, a molecule made by the bacterium Clostridium botulinum is the most potent neurotoxin on earth. A tiny amount ingested or introduced to the body through wounds has been enough to paralyze all the muscles in a human for more than long enough to allow suffocation from respiratory failure. The structure and biology of this large molecule, primarily made of protein, was deciphered just in the last century, but its ability to quickly and easily get into humans made it of great interest to scientists and physicians around the world.

Over time after its discovery, physicians came to understand that there could actually be medicinal qualities to this poison. One such interesting properties of botulinum toxin was its mechanism to weaken muscles by being taken up by the nerve endings attached to those muscles. This shuts down the nerve endings and their communication with muscles which keeps the muscles from contracting. When exposure is due to a bacterial infection, the toxin is widely distributed, coming into contact with nerves throughout the body, including those of the chest and diaphragm, resulting in breathing paralysis.

But what would happen if a tiny amount of the toxin was isolated and injected right at a site of a muscle in doses that were too small to have any effect elsewhere? Using a small dose would preclude weakness developing throughout the body and produce effects just locally. In fact, this is exactly what happened; an ophthalmologist who was a previously involved with the Army project injected eye muscles of children with crossed eyes (strabismus), weakening the muscles that were pulling too far and straightening out the gaze. The results were very good with few or no side effects.

Ultimately, many other indications came along, all based on the theory that relaxation of muscles can have a desired effect. By far the most publicized application of Botox in particular has been for the treatment of wrinkles – popularized as a fountain of youth in a bottle. Shortly after, it was discovered that patients with chronic headaches, including migraine, who received Botox for wrinkle treatment in the foreign were alleviated, incurring fewer headaches.

The mechanism of action regarding headaches is unknown. Some scientists suggest that the relief results from the interaction of Botox with sensory nerves as well as its known effect on motor nerves. There is evidence of this, but it remains a mystery how it works. Studies clearly show that it does not get into the brain or spinal cord and so does not affect pain centers there. The muscle relaxation itself probably doesn’t play a huge role, though there are sensory receptors within muscle fibers that may be influenced.

The story of this poison that heals is truly fascinating and represents one of the most important medical advances in the last two decades. The future could be even more interesting, as it may be possible to use the properties of some parts of the botulinum toxin to bring other molecules into nerves and have effects on them. This may have implications in trying to restore function and vitality to weakened nerves from many diseases. But for now, millions of people have found that Botox is at least worth a shot.

Read a more detailed history and perspective on Botox here.



Philanthropy at Work

Aiming to improve the quality of healthcare delivery in a critical region of the United States, the Amerigroup Foundation, the philanthropic arm of Amerigroup Corp., is providing a $50,000 grant to improve access to care in rural areas of Georgia. The grant was presented to the Georgia Partnership for Telehealth (GPT), an organization working to provide specialized healthcare services in underserved parts of the state through the use of telemedicine.

Georgia is part of a group of states in the southeast US comprising what is known in neurology circles as the ‘Stroke Belt,’ or ‘Stroke Alley,’ named for citizens’ propensity toward higher risk and morbidity of stroke due to several lifestyle factors. One such factor for elevated risk is larger ‘desert’ areas where rural residents do not live within an acceptable distance of a facility where they can receive proper treatment in cases of stroke. Funding programs such as this most recent grant by the Amerigroup Foundation can mean tremendous strides toward building the awareness and infrastructure needed to correct these less-than-ideal conditions, including instating telemedicine programs to eliminate the obstacle of distance between patient and doctor.

Teleneurology brings technology and expertise that are incredibly powerful tools in the fight against stroke. With time so precious, telemedicine programs are saving the lives of rural dwellers who previously had extremely limited options. The partners of AcuteCare Telemedicine are pleased to see the patronage of organizations concerned with creating better, more accessible care being put to good use.

 



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. 



Checking in From the 2012 ATA Conference

AcuteCare Telemedicine (ACT) Sales Executive Michael Woodcock attended the 2012 American Telehealth Association Conference, the world’s largest telemedicine, telehealth, and mHealth event in San Jose, California.

Greetings from San Jose!

The 2012 ATA Conference has been very impressive. This year’s conference has drawn a record number of attendees (4,500) and more than 175 vendor exhibits. The exposition features several booths with groundbreaking new products and services. Attendees have been encouraged to share news and notes and interact with the conference on social media platforms, which is demonstrative of the kind of technical innovation on display here.

In addition to the exhibitions, there have been a large number of interesting presentations and discussions on a wide variety of topics relating to telehealth and telemedicine. I have attended highly informative Industry Executive Panels on growth sectors in telemedicine, reimbursement issues facing the industry, and perspectives on the state of mobile applications and their compliance with HIPAA as they relate to telemedicine.

Some of the highlight sessions included Model Telemed Programs (a Georgia Partnership for Telehealth presentation from Paula Guy), a feature presentation on Telemedicine and its profitability, and a keynote address by Apple co-founder and tech advocate Steve Wozniak. There are too many presentation topics to list, but suffice it to say the conference is a comprehensive, in-depth look at all facets of the industry. It is exciting to see the growing influence of telemedicine as a potent solution to many pressing healthcare issues.

A link to the full conference program can be found here.



A Lens to View Technological Innovation in Healthcare

Keeping up with new technology feels like a sisyphean task. One way to think about technological innovation in healthcare is considering whether the innovation brings services to the patient or requires that the patient be brought to it. The former distributes care, while the latter centralizes it. Both have advantages; by distributing care, it is possible for many resources to contribute to care, and by centralizing care, treatment is focused at one site. Recognizing this technological dichotomy allows savvy hospitals to maximize their return on investment.

Dramatic improvements in radiology over the last 35 years exemplify centralizing care. New MRI and CT scanners dramatically improve our ability to diagnose complex conditions, but the machines’ bulk and expense mean that patients must be brought to them. The same rings true for the latest catheter-based therapies for heart and brain disease, requiring that the patient be brought to the specialized providers.

By contrast, telecommunications innovations distribute care, leading to improved patient outcomes regardless of locality. Translation services are a shining example: in the past, finding someone to translate a language like Amharic or Hmong was daunting, and in an emergency situation, it was simply unavailable. Thanks to new standards set by the Joint Commission, more attention will be paid to proper translation services. The Joint Commission standards reflect federal nondiscrimination laws regarding care of patients with limited English proficiency and recommend that patients be addressed in their preferred language. Now, thanks to successful providers such as CyraCom, dual handset phones can be brought to the bedside and certified translators in hundreds of languages are available in seconds

Telemedicine provides the best example of the power of distributive technological innovation. In stroke care, having experienced stroke neurologists readily available via telemedicine means that stroke patients have unlimited access to state of the art care. Being able to remotely conduct a video interview with the patient and family, examine the patient, and review the brain CT scan equates to faster and better care. AcuteCare Telemedicine’s stroke neurology experts, based in Atlanta, GA, contract with hospitals that need this type of coverage. By distributing care, these hospitals successfully avail their patients with top notch care and reduce treatment times, all while conserving a vital resource: the fossil fuel needed to physically bring the neurologist to the hospital.

 



Looking Backwards to See Ahead – Part 4: Running the Business

This is another blog in a series chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at 2011’s 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 several issues relevant to establishing and running a telemedicine service.

There are myriad of issues confronting physician-entrepreneurs when establishing a telemedicine service. Often these are not immediately evident, although some may be the focus of business development meetings. This blog reviews the topics of business size, communication/documentation, ROI considerations, and coding/billing issues.

The size of a company will directly impact its ability to stay true to its mission. Our firm belief is that the future of telemedicine is in regional providers partnering with both local hospitals and government or not-for-profits. There are larger providers of teleneurology, and their scale may be a corporate advantage; a large staff of part-time physicians to fractionate call burden as well as development of proprietary hardware & software (the cost of which is hidden in a monthly service charge). However, their size is not beneficial to patients and hospitals. In reality, the size of these “McTelemedicine” services paints them as something hospitals fear; impersonal, computerized doctors. The need to focus on healthcare solutions tailored to the specific needs of the healthcare region has been addressed in a recent blog.

Communication must occur in a timely fashion. Otherwise, the telemedicine consult is for naught. Dictating is necessary for documentation of the initial encounter in the permanent medical record, but will be delayed even if transcribed as “priority.” Faxing or emailing is faster, but not always practical. In order to reduce error & liability, especially for critical care issues, direct communication with the local treating physician and nurse is paramount. In cases of acute stroke, providing the medical opinion of whether tissue plasminogen activator (tPA) should be given is sufficient. The actual order for administration of tPA should be given by a physician actually present to review that the dose was properly calculated and administration was expedited.

Return on investment (ROI) will depend on maximizing revenue and avoiding costs – this is relevant to any business. The perspective of both the telemedicine provider and the client hospital must be taken into account. For example, revenue may come to the client hospital through the increased use of value added ancillary services (e.g. radiology, PT, Rehab). One must also identify cost drivers, areas of poor market share (e.g. EMS bypass), obstacles to access, and obstacles to productivity (e.g. difficulty luring a local neurologist because of ER coverage responsibilities). The telemedicine provider may also benefit from the addition of value added services such as reading neurophysiology studies (EEG, sleep, EMG) or lateral expansion through the development of ancillary specialties such as tele-ICU, telepsychiatry or telecardiology.

Coding or billing expertise is not typically required for remote presence consultation, as it is a service provided to the hospital and reimbursed by the hospital accordingly.  Proven increases in revenue and improved patient outcomes absolutely justify this business model. However, in some situations, a physician may bill directly for their services, for example, if the hospital is rural or designated a disadvantaged Metropolitan Statistical Area (MSA). When coding these encounters, Medicare regards telemedicine as face to face time. Using a GT modifier prevents charge bumping if a patient is subsequently seen by a community physician on the same day. Records must also state “Services provided by telemedicine.” One cannot bill Medicare Advantage in an MSA unless there is a contract with the Medicare Advantage carrier.

Medicaid may reimburse encounters within an MSA, but Medicaid does NOT have to follow Medicare rules. Treat them like a third party payer. Keep in mind, the Medicaid staffer handling your reimbursement issues may require education. Finally, follow up telemedicine visits can be billed for 1 visit every 3 days.

Considering these issues, most of which were not immediately evident at the outset, has helped AcuteCare Telemedicine create impact in the market place. ACT not only hightlights the clinical value of its physicians but also addresses the comprehensive business needs of the organizations it serves.