AcuteCare Telemedicine Blog


Advancing the Benefits of Telehealth and Telemedicine

Dr. Teresa Myers, a family practice physician in Copley, Ohio, describes what she can see on her computer screen during a telehealth conference. “You know what HD television looks like. You can actually see the pimples on the actors’ faces,” she says. “I had a patient who was able to shine her iPhone flashlight to the back of her throat. I could see the exudates [pus-like fluid]. If you see that, you can be pretty sure.” A few more questions, as well as having the patient take her temperature and feel and describe her lymph nodes, and Myers felt confident diagnosing strep throat and prescribing an antibiotic.  The consultation started less than five minutes after the patient logged in, cost $49 and lasted 10 minutes. The patient never left home, learned a few things about examining her own body and, two days later, said she felt much better when Myers followed up.

The rural health care workforce is stretched to its limits in most states. Despite programs operated by state, federal and local governments aimed at recruiting and retaining primary care professionals to these areas, the need outpaces the supply in many communities. Also, many of the current primary care physicians are nearing retirement and the numbers to replace them are insufficient.

For many states with large rural populations, telehealth has emerged as a cost-effective alternative to traditional face-to-face consultations or examinations between provider and patient. Telehealth is the use of technology to deliver health care, health information or health education at a distance. Real time telehealth communications allows the patient and physician to connect and interact through video conferencing, telephone or video health monitoring device.  Store and forward telehealth refers to the transmission of data, images, sound and video from one care giver to another.

Forty-two states currently provide some form of Medicaid reimbursement for telehealth services and 17 states require private insurance companies to cover telehealth services. While individual states appear to be well out in front of the federal government on supporting telehealth innovation, the federal government is finally moving to catch-up with the recent introduction of “The Telehealth Enhancement Act of 2013 (H.R. 3306).”  The bill promises to strengthen Medicare and enhance Medicaid through expanded telemedicine coverage and calls for the adoption of payment innovations to include telehealth and to make other incremental improvements to existing telehealth coverage. Another Congressional bill, “TELE-MED Act of 2013” (H.R. 3077) would permit certain Medicare providers in a state to provide telemedicine services to Medicare beneficiaries in a different state.

The convergence of medical advances, health information technology, and a nationwide broadband network are transforming the delivery of health care by bringing the health care provider and patient together in a virtual world, especially those in disadvantaged areas. Telemedicine has the potential to improve health care access and quality to patients in urban and rural America alike, but a variety of barriers, such as reimbursement and licensing issues, continue to stand in the way of more aggressive, widespread adoption.

The recent progress by state and federal governing bodies to recognize the significant advantages of increased telehealth services for all Americans with the introduction of new and meaningful legislation to address and remove established barriers to expansion, is encouraging to those in the health care community whose fundamental goal is to provide the best quality medical care to their patients no matter where they live.



CMS Expanding Telemedicine Coverage

The Centers for Medicare and Medicaid Services have proposed rules that would provide telemedicine services to nearly 1 million new Medicare beneficiaries.  CMS proposes to increase the number of beneficiaries eligible for telemedicine by modifying their urban/rural definitions and proposes several new reimbursable telemedicine services.

The first change would extend reimbursable telehealth services to “originating sites” serving nearly one million rural beneficiaries living in large metropolitan areas. Currently, Medicare uses a strict county-based classification to enforce its rural-only rule for telemedicine coverage. The new rule would create a more precise urban/rural distinction based on geographically smaller census tracts.

The second proposed change would increase coverage for transitional care management services under Current Procedural Terminology (CPT) codes 99495 and 99496, involving post-discharge communication with a patient and/or caregiver. Reimbursement of these services will help healthcare providers deliver improved in-home care to at-risk beneficiaries and significantly reduce needless hospital readmissions.

Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association cautiously supports the change and in a statement said, “This is one small step in the right direction.  For 15 years the federal government has placed strict restraints on the use of telehealth while employers, private payers, states and many other nations have moved boldly forward, improving the quality and reducing the cost of care. It is time to unleash the power of modern technology and allow Medicare beneficiaries, regardless of whether they live in a rural area, underserved inner-city, in a clinic or at home to be eligible to receive the benefits of telehealth.”

The proposal is currently open for comment and ATA encourages all telemedicine advocates to express their support.  The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership work to fully integrate telemedicine into healthcare systems to improve quality, equity and affordability of healthcare throughout the world.



If You Build It, Will They Come?

A recent report from the Pew Research Center measuring the number of adults using technology to track their health has presented some surprising findings.

The results of the Pew Internet & American Life Project survey, which were recently reported in iHealthbeat and supported by The California Healthcare Foundation, found that of 3,014 adults interviewed by phone, just 21 percent of the respondents actively used technology to track their health care. What may be even more surprising is that just 19 percent of those surveyed who owned smart phones, or just 7 percent of all respondents, had acquired an app to monitor their health. Susannah Fox, lead author of the report was surprised by the results and commented, “We’ve been looking at health apps since 2010, and health app uptake has been essentially flat for three years.”

A look at the science of the report, particularly the definition of “adults,” could give some more understandable insight as to the results and may produce answers for some of the “surprise” as to the outcome. Considering that most, older adults have a seemingly natural long acceptance curve when it comes to adopting technology and gadgets, and considering the well-entrenched privacy attitudes about everything to do with personal health information, the results may not be all that unexpected.

Purveyors of new communication technologies operate in environment where todays new devise and idea is often well into obsolescence by tomorrow; such rapid progression of invention to development is unmatched by other industries and beyond the understanding of most consumers. Expecting an equally aggressive acceptance rate by the markets is unreasonable, even when the benefits of convenience and utilization are so obvious to so many.

Given the generally slow acceptance rate of consumer health products, a three year period of market penetration may not be a reasonable benchmark to measure the success or failure of health care applications. Only more time will reveal if the “acceptance curve” will sharpen and the adoption and usage rates grow more dramatically.

“Build it and they will come”. Perhaps, but it may just take a bit longer for their arrival.



Breaking the Rules

The Georgia Composite Medical Board recently voted against implementing a rule requiring that any patient must be seen by a physician before receiving care from nurses or PAs via telemedicine technologies, a requirement that realistically cannot be met in most non-telemedicine encounters. It was a small but important victory for practitioners and patients alike.

Prior to being voted down, the proposed rule was drawing widespread criticism from proponents of telemedicine, and for good reason. The motivation for suggesting the rule was to ensure that all mid-level providers caring for patients via telemedicine were being properly supervised by doctors who are more familiar with the technologies. Certainly, taking steps to guarantee the quality of care and safety of patients, especially when dealing with new tools and methods, is of utmost importance to everyone involved in the care process. However, the rule would have been damaging to the improved access to care that is a hallmark of telemedicine, placing an additional an unnecessary step between patients who need immediate attention and the care they require.

With the increasing shortage of physicians, not just in Georgia, but nationwide, telemedicine has opened avenues for the delivery of quality care to individuals living in rural and underserved locales where providers simply are not available. As more practitioners educate themselves on the virtues of telehealth, the reach of doctors, nurses, and other healthcare professionals will extend further than ever before.

Telemedicine will ultimately enter our vernacular and be known simply as ‘medicine.’ In the meantime, as our technology and methodology continue to evolve, we must be careful to steer clear of implementing laws such as the redundant rule proposed in Georgia to avoid setting precedents that will preclude telemedicine from playing its role in assisting our healthcare system reach new heights.



Check Your Head

In the wake of countless notable events including the deaths of several professional athletes in the past 5 years, new light has been shed on an epidemic which we are beginning to learn may be far more widespread than initially thought.

Researchers at Boston University recently published the largest study of chronic traumatic encephalopathy (CTE) to date. CTE, a progressive degenerative brain disease thought to stem from concussive trauma to the head, has been known to affect boxers since the 1920s, but only recently has gained notoriety as a serious concern for athletes of all ages across many sports. In these latest findings, 68 of 85 donated brains from deceased veterans and athletes with histories of head trauma showed visible evidence of the disease, including a staggering 34 of the 35 brains from former professional football players.

CTE

The greatest concerns sparked by our growing understanding of CTE’s causes and pathology are without a doubt related to the protection of younger children participating in sports and other activities where risk of injury to the brain is involved. The work of the BU researchers has led to drastically improved protective equipment and restructuring of rules and regulations to minimize the number and force of hits to the head, but it is nearly impossible to remove the potential for these injuries from sports at any level.

Thus, the best possible measures that can be taken are to prevent any repeat injury of the brain. Taking the lead, the NFL has instituted mandatory on-field concussion screening following hard hits. The NHL has also ordered that players with potential head injuries spend time in a ‘quiet room’ off the ice. Youth leagues are particularly concerned with preventing any participant who may have sustained an injury from getting back into the game and facing further danger.

Telemedicine offers the potential for significant further contribution to these efforts. With the help of technology, expert neurologists can always be on hand to examine potential head injuries, and monitor patients in the aftermath of an injury, aiding the recovery process. Thanks to telemedicine’s advances, logistics and associated costs are no longer obstacles to immediate and accurate concussion diagnosis and treatment.

The fight against CTE and other trauma-induced brain disease starts long before the first injury happens, but when it cannot be entirely prevented, telemedicine could play a role in ensuring fewer players incur more severe consequences later in life.



Stroke Treatment Gets a Boost

Fifty years ago, the only advice medical textbooks gave physicians for someone suffering with a stroke was to put him to bed and keep him comfortable, hoping that with time, the brain would heal as best it could. For 30 years, promising techniques preceded disappointing trials. First, heparin was going to be the savior, and for most of the 70s and 80s, it almost served as a standard, but better studies eventually showed that the treatment was not just worthless, but in reality dangerous, causing more brain hemorrhages than no treatment at all. Later, drugs that were intended to clear out “free radicals” were going to save the ischemic penumbra, part of viable brain tissue around a central core of dead cells, but all studies showed that either the medication didn’t get to the target, didn’t work, or could even be toxic to the brain.

In the mid 90s, tissue plasminogen activator (TPA), long used for heart attack victims to break up the clots inside arteries of the heart, was shown to be effective in doing the same in arteries of the brain. For the first time, physicians had something to offer patients that actually made a difference. About a third of patients who received TPA had better three month outcomes than those that did not. This success rate was quite good, but patients with severe strokes still did not respond as well because, in most cases, thrombi in the large arteries were not effectively dissolved.

Only in the last few years have studies been done to consider the effectiveness of a thrombectomy, the process of physically pulling out a thrombus inside an artery in the brain or neck, The early devices available to physicians are fairly good at the task, but a substantial number of patients continue to suffer from residual blockages of the arteries following the procedure.

A report of clinical trials using two new types of thrombectomy devices, called Solitaire and Trevo Retriever, show both of these new devices as being up to five times more effective than their predecessors in opening up arteries. Advances this drastic are rare in medicine, but physicians should be optimistic about the potential for these instruments in improving outcomes. Provided that patients can have access to skilled practitioners in time, within eight hours or sooner, the treatment of stroke may be about to enter a dramatic new phase.

Stroke is the most serious disabling condition in adults, resulting in hundreds of thousands of permanent injuries and deaths every year. This decade may witness the greatest advances in the history of stroke treatment. There are still further trials to run, but with these exciting new prospects, the importance of stroke neurologists like the doctors of ACT being present in every emergency room, either in person or by remote presence, cannot be overstated.



ACT Partner Taylor Regional Hospital Embraces Technology for Better Care Standard

AcuteCare Telemedicine (ACT) partner Taylor Regional Hospital in Hawkinsville, GA is on the cutting edge of revolutionizing healthcare in underserved areas in rural parts of the Southeastern US.

Lacking the fiscal and logistical resources to implement the comprehensive services found at larger facilities in urban centers, Taylor Regional has openly embraced a wealth of new technologies to drastically improve the quality of care it offers patients within its surrounding communities.

Choosing ACT’s 24/7 teleneurology services was an elegant solution to a major deficiency facing the hospital. Taylor Regional has no neurologists on staff, and the nearest available specialists are located more than an hour away. Prior to the partnership with ACT, the hospital lacked the capability to effectively diagnose and treat stroke-causing clots, often having to transfer patients to a larger hospital, compromising crucial ‘door-to-needle’ time and reducing potential hospital revenues.

Through the adoption of beneficial programs such as the telemedicine services offered by ACT, the hospital has not only taken strides forward in treating patients internally, but has also enhanced communications with other facilities, connecting with other physicians for consultation and collaboration as well as streamlining transfer processes to ensure patients receive timely and expert care.

Most recently, the teleneurology services provided by ACT resulted in the administration of tissue plasminogen activator (tPA) in two separate cases of acute stroke at the facility in the month of August 2012. The two successful administrations of the clot-busting agent are a significant achievement, serving as a milestone for a teleneurology partnership that has now successfully extended this potentially-life saving service to residents of the counties surrounding Taylor Regional.

“We are very pleased with our partnership with ACT. The neurologists are extremely professional and eager for our telemedicine program to make a real difference in the care we are able to extend to our stroke patients,” commented Lynn Grant, Emergency Room and ICU Nurse Manager, Taylor Regional. “ACT is available 24/7, taking the time not just to be there for the patients, but for our physicians, nurses, and staff, answering questions and educating about the technology and techniques that are helping us save lives. Having this service is very rewarding.”

“Taylor Regional Hospital is on the cutting edge of emergency stroke care in rural Georgia. ACT has been particularly impressed with their clinical judgment, leadership and organization,” said Dr. James Kiely, Partner, ACT. “Their community is well served.”

For more information about ACT, visit www.acutecaretelemed.com.