AcuteCare Telemedicine Blog


Telemedicine, Bringing Improved Medical Care to India’s Rural Poor

In the United States, much has been said about how Telemedicine technologies are offering improved access and medical care to rural locations, particularly access to specialized medical care providers. But in many countries such as India, the opportunity to advance medical care to rural areas has a much more profound meaning to those in need of health care services.

India is administratively organized into state towns, district towns, block marketplaces, and then villages and healthcare, as such, is distributed along that supply chain with each level of infrastructure offering a lower standard of care.  Even in some of the fastest growing regions of India, as many as 85 percent of the 100 million residents only have access to healthcare that is at the bottom of the quality spectrum.  Private, better quality medical services may be located hundreds of miles away and take hours or days to reach by rural patients and are only available for those who have the money to pay.

Enter World Health Partners (WHP), an international nonprofit organization that provides health and reproductive health services in low-income countries by harnessing local market forces to work for the poor. Leveraging existing social and economic infrastructure, WHP utilizes the latest advances in communication, diagnostic and medical technology to build an ecosystem atop the existing private sector to bring improved medical services to even the most rural areas of India.

WHP is teaming up with out of the way, unlicensed, village health practitioners, or Quacks as they are known in India, to connect poor, rural patients with doctors located in Patna and Delhi.  For an investment of about $1000.00, each of the more than 433 quacks currently in WHP’s network of telemedicine practitioners can set up a Wifi network, laptop computer and the necessary equipment to make it all work, or at least work most of the time.  The system is not perfect and experiences frequent break downs but it saves time, money, and in some cases can save lives, for rural families that would otherwise have to travel hours to larger cities.

World Health Partners is working towards setting up 16,000, mostly privately owned and operated, telemedicine centers throughout India’s most rural provinces in hopes of bringing the convenience and benefits of telemedicine to the poorest of India’s population.  In addition, the concept is being scaled to be exported to countries and regions well beyond India, with hopes of reaching millions of world’s neediest populations.



Beam Me Up, Doc!

Telemedicine, the rapidly developing application of clinical medical services utilizing today’s advanced communication technology, is moving forward at an escalating pace. Challenges to its wide spread implementation are being overcome with advancements and refinements to the technology. As physicians and patients concerns over the effectiveness of care and information security are addressed, the promises of lower cost, more accessible, quality, health care conducted via the internet is gaining popularity among healthcare providers and patients alike.

With the concept of telemedicine now having been successfully established, AcuteCare Telemedicine is utilizing the modern communication technology to enable personal neurology consultation when doctor and patient are in different locations. ACT makes urgent stroke care accessible for more patients and cost-effective for hospitals and clinicians. Expanding clinical services where physicians electronically treat patients directly without a clinician being present with the patient is the most logical next step in the technology’s progression.

Patients and physicians in Hawaii are now able to enroll in Hawaii Medical Service Association (HMSA) Online Care program where patients receive care from participating doctors who are scheduled to be reachable at that moment. HMSA says thousands of patients have registered, and in New York, about 10,000 individuals, most of them residents of the New York metropolitan area, can already get an online emergency consultation with emergency room physicians.

Jay Sanders, president emeritus of the American Telemedicine Association says, “Probably the most powerful aspect of telemedicine is improving access and improving the convenience of a lot of elements of healthcare, so, whether you’re talking about folks who would have a hard time getting to a specialist or whether you’re talking about someone who is in a jam and needs to see a doctor before they go on a business trip, telemedicine clinics are very valuable. These technologies are unlikely to replace office or hospital visits entirely”, says Sanders. “But they are tools physicians can add to an evolving ‘electronic black bag,’ as he calls it—the updated equivalent of the battered leather case brought along on house calls in a bygone age.



Telemedicine in the Wake of Natural Disaster

As October 2012 came to a close, the arrival of Hurricane Sandy served as a haunting reminder that we can never underestimate the destructive and disruptive power of nature. The “superstorm” wreaked havoc on some of the most populous areas in the United States, not just causing billions in physical damage, but severely testing our infrastructure and its vital role in our society.

Considering the major implications that storms or other disaster events on this scale have for the healthcare industry, the days leading up to, during, and following Sandy were a demanding exercise in preparation, planning, and execution. The storm left countless citizens in need of medical attention, and threatened the adequate treatment of those already receiving care.

As one major resource put under the stresses of a disaster-level storm, hospitals and other healthcare facilities quickly became incapacitated by overcrowding, understaffing, a broken supply chain, and in select cases, power failures that crippled essential equipment. A small contingency of Mobile ERs were dispatched across the region, but a lack of pure manpower hindered the effectiveness of the efforts. Despite their mobility, the interrupted transportation systems within the affected communities prevented many from reaching the help they sorely needed.

Telehealth is an ideal candidate for addressing the challenges of these kinds of circumstances. The infrastructure of telemedicine is capable of delivering expert direction and attentive care to victims of natural disasters. The question of manpower becomes a negligible issue, as doctors and other respondents can call in from anywhere, and thanks to ever increasing internet access, the reach of the care administration is not limited by the victims’ location.

If emergency management agencies and telecommunications service providers are willing to work hand in hand with healthcare professionals, we now have the tools and knowledge to ensure that in future disaster scenarios, people can always have the support they need.



Opening the Dialogue to Better Care

Amidst much confusion and debate about plotting the best course towards achieving the so-called ‘triple-aim’ of increasing quality, improving patient satisfaction, and reducing costs, the healthcare community is struggling with communications amongst payers, vendors, and providers. Creating initiatives that encourage the development of more efficient, more sustainable healthcare requires the participation of all these entities in an ongoing conversation.

For physicians, making the ecosystem more intelligent is not exactly a simple proposition. Focused on delivering care, doctors typically do not have affinities for nor access to the kinds of information readily available to payers and vendors, such as performance metrics, analytics, and risk management considerations. Fostering an environment in which this data and knowledge can be openly shared is a pivotal step in helping doctors operate smarter.

As eHealth and the growth of telemedicine begin to significantly impact the delivery of care, the healthcare industry must address questions as to how physicians can better access these insights and be stimulated to embrace best practices, as well as how plan members can be similarly empowered to make better decisions. The answers come in the form of more open dialogue. Each party needs to share a similar, if not identical perspective on what constitutes quality to effectively collaborate.

With an ever-expanding arsenal of tools and knowledge at their disposal, physicians must call upon available resources in the form of industry partners to take advantage of this opportunity. The result will be a more intelligent system that benefits the entire network.



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.