AcuteCare Telemedicine Blog


Telemedicine and the Medical Licensing Debate

The number of patients served by telemedicine has grown from a few thousand in the mid-1980s to an estimated 10 million people today. The majority of the growth occurred in the last decade, according to the American Telemedicine Association. Despite the rapid adoption of telemedicine practices by healthcare institutions, practitioners must meet individual state medical licensing requirements.

Some states argue that easing licensing requirements could jeopardize patient safety. If doctors practice without obtaining a license in that state, regulators maintain that they have no power to conduct an investigation or explore a consumer complaint. In addition, doctors would not benefit from any legal protections the state may have against malpractice lawsuits. Advocates of telemedicine argue that because doctors take standardized national exams, with many requirements set by federal agencies such as the U.S. Department of Health and Human Services, states should recognize other state licenses. The debate is not without merit, on either side of the issue.

In a time past, interstate commerce experienced similar obstructions to improving the nationwide consumer product and service delivery model. Implemented in an era before advanced transportation technology and the interstate highway system carriers of goods and services across state lines were required to have individual state licenses, adhere to 50 different sets of roadway regulations and pay transportation taxes and fees in every state where transportation service was provided. The very formidable barriers to streamlining interstate commerce were successfully circumvented by a new national regulatory and licensing system. The move successfully addressed the individual state concerns and resulted in massive improvements to the nationwide delivery of good and services to all consumers, no matter where they resided.

Today, as major telecommunications and health care firms look to create nationwide telemedicine businesses, state medical licensing boards are set to consider an “interstate medical licensure compact” that would give doctors and patients legal protections in any state that signs on. The proposal, to be considered at the annual meeting of the Federation of State Medical Boards (FSMB) this month, would expedite the licensing process for doctors who want to practice across state borders. The compact, which was developed by a task force of 22 state medical boards, may represent the first step in resolving the issue. Lisa Robin, chief advocacy officer for the federation, expects there will be some early adopters. “I believe there will be some proliferation.”

The medical industry is facing significant challenges in the coming decades, such as physician shortages, spiraling costs of care, specialist accessibility and the entry of millions of new patients to the market as the Affordable Care Act (ACA) is fully implemented. In order to implement a long-term solution, technology standards and medical licensing requirements share equal importance in the debate.



If “What” is the Point and “How” Gets Us to the Point, Does “Why” Really Matter?

Achievement of any goal or objective begins with the question: What’s the point?  The answer to the initial question sets forth the purpose for implementing an effort to move forward to an end, or an objective. How is the strategic means to achieving the objective and if the journey is successfully achieved, does it really matter “why” we set out on the mission from the beginning?

In a recent article by Ty Montague, CEO and co-founder of co: and author of “True Story: How to Combine Story and Action to Transform Your Business,” he expresses his views on the importance of “why” in terms of storytelling versus storydoing. Storytellers think of a story as the domain of the marketing team. A company’s story is thought to be separate from the corporate strategy and is most often expressed through advertising. Storydoers, on the other hand, think of their story as a strategic asset and a competitive advantage. The narrative of storydoing companies is advanced through every action they take and those companies tend to be on a mission to make the world a better place, a quest that transcends revenue development and maximization. Their customers see and feel this higher goal in everything the company does and it makes them magnetic, creating fierce loyalty in their customers. Leaders and associates of storydoer companies tend to find their work experiences richer and more deeply satisfying and growing evidence suggest that storydoer companies are more efficient businesses that perform better financially over time.

Perhaps the purest example of an industry of Storydoers is those who deliver the broad range healthcare services to their customers, or patients.  Undoubtedly healthcare is a business, a very expansive and lucrative business, and one which requires revenue in excess of cost, or profit, to survive, prosper and prevail in its mission.  But it remains an industry whose practitioners are overwhelmingly called to serve the profession because “why” really, really matters.

Dr. James M. Kiely, a partner in Atlanta Neurology, P.C., AcuteCare Telemedicine (ACT) and Medical Director of the Neurophysiology Departments at Northside Hospital and St. Joseph’s Hospital of Atlanta says, “I am so invigorated when I help a patient and help my Emergency Room (ER) colleagues. We make a real, immediate and meaningful difference every time we do our job. There are few people who can say that about their careers. I don’t like hyperbole but what we get to do every day for a living, rocks!”

“Why” matters.



Investing in People

Telemedicine has garnered more attention as of late as a truly game-changing emerging field on the cutting edge of healthcare. Perceptions of the field have become increasingly favorable, but there is still a long road ahead to becoming part of the mainstream lexicon of medicine for patients and providers.

Presently, one of the most significant barriers to entry for new companies in telemedicine is the level of investment required on the part of potential client facilities. Revolutionary technology does not typically come cheap, and as healthcare spending continues to swell (albeit at a slower rate than previously), most facilities are working diligently to combat rising costs rather than add new programs to already bloated budgets.

The good news is that practical new technologies, regardless of how disruptive or expensive at the outset, have a habit of eventually finding their way into adoption. A common adage proclaims that every few years, the power of technology doubles and its price tag is halved. This implies that facilities which have temporarily chosen to forego the extensive advantages that telemedicine programs offer based upon steep startup costs will ultimately find the same solutions to be far more cost effective in the not-too-distant future. However, late adopters of telemedicine services do run the risk of losing their competitive edge. This is especially true in light of the rapid changes ahead in the healthcare landscape; the integration of telemedicine can make a hospital more independent of, or attractive to, consolidation by larger healthcare systems, depending on the goals of the client.

When considering teleneurology as a discipline in particular, hospitals must recognize that an investment in telemedicine is far more than an investment in the newest, best equipment; it is the foundation of a relationship with physicians who are among the most knowledgeable and experiences practitioners in their field. AcuteCare Telemedicine is truly technology- agnostic, meaning that regardless of the price tag of the machines that we leverage to connect with a facility’s patients or staff, a partnership with our physicians means that behind the machinery is the expertise needed to drastically improve the quality of care a patient can receive. We place value in finding quality tools to accomplish our mission, but our accessibility is by no means restricted by them.

Many healthcare leaders are still hesitant to make the investment in something new, but the time has come that the highest level of expert care be available to everyone, everywhere. It is our vision that hospital facilities will share in our agnosticism towards technology and invest in the people who will improve healthcare’s next generation.



Christine Hale, M.D. Joins Acutecare Telemedicine Advisory Board

AcuteCare Telemedicine (ACT) announces the addition of Christine Hale, M.D. as a member of the ACT Board of Advisors. The partners of ACT believe Hale’s expertise and passion for improving healthcare delivery will aid the company in effectively extending the highest level of care to its client hospitals.

Hale’s impressive medical background includes receiving her M.D. from Johns Hopkins and completing her residency in Pediatrics at Duke University Medical Center. While at Duke, she also completed an M.B.A. with a concentration on Health Sector Management at the University’s Fuqua School of Business, giving her a unique skillset in approaching hospital operational issues with a medical perspective.

Presently working with McKinsey and Company in Atlanta, GA, Hale serves hospitals and hospital systems on a variety of organizational issues with an emphasis on strategic planning. She is a resource for numerous consultant teams interested in bettering healthcare delivery across the Southeast.

“Dr. Hale shares in ACT’s zeal and commitment to helping hospital facilities deliver higher quality care to patients in the most economically and operationally efficient means,” says James Kiely, M.D., Ph.D., Partner, ACT. “We are extremely pleased to have access to Dr. Hale’s knowledge and experience as a trusted, go-to resource in measuring our approach to providing the best possible services to client hospitals.”



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.