AcuteCare Telemedicine Blog

Building Better Policy

Over the past several years, studies such as those conducted by the CDC and the National Institute of Health have constantly shown great disparity in levels of healthcare access across America. Particularly for poorer and rural areas, a lack of proper access has historically been extremely costly both in terms of human life and a greater economic impact. Policy makers, government officials, and leaders of health care organizations have recognized this divide, and are focused on identifying and eliminating barriers to patient access to provide a better, more uniform standard of effective healthcare across the country.

Thanks largely to leaps in technology and growing infrastructure, telemedicine is emerging as a highly effective solution with the potential to shape the future landscape of healthcare in America. The innovative, modern solutions offered by the growing telemedicine field combat the logistical challenges of the current state of healthcare, while having been proven to be more cost effective. Now, legislators are finally beginning to see the light.

On a state level, governments that have passed new telehealth legislation have seen positive results across the board. Powerful new applications and techniques have helped simplify and streamline remote patient consultation and monitoring, delivering better care with less economic impact with patient satisfaction rates nearing 100%. A dozen states, including Georgia, are leading the way on acknowledging telemedicine as an effective and efficient solution. So far in 2012, Maryland and Vermont have become the latest states to require private insurance companies to pay for telemedicine services.

The adoption of telemedicine marks a revolution in healthcare that carries great possibility for lasting impact. Creating a legislative environment in which telemedicine can flourish must continue to become a priority in a nation interested in reducing costs and saving lives.

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. 

A Timely Solution

In the few minutes it takes to read this post, two or more people will have suffered a stroke in the United States. In the Southeast, in what has become known as the ‘Stroke Belt,’ the rate of frequency is at its highest. The need to attack stroke from both a preventative as well as a curative perspective is critical if a  decrease in the incidence and the morbidity/mortality of stroke is to occur.

Over the course of the past few decades, several initiatives to lower the incidence of stroke throughout the nation and particularly in the Stroke Belt have been developed and implemented. Increased education, improved  blood pressure and glucose control,  advised dietary changes etc, have led to a decrease in incidences. What remains concerning, however, is the lack of acute stroke care treatment in many rural areas in states such as Georgia and Alabama. This deficiency is primarily due to excessive travel time necessary to gain access to physicians. Several rural counties in Alabama are altogether without hospitals. “Lack of access to health care is a reported problem in some areas of the state. Some counties have no physician in the entire county. It is difficult for poor rural areas to attract doctors

According to a report in 2010, 44 of 67 counties (in Alabama) did not have a single neurologist. “Some stroke victims have to travel across three counties to access a neurologist for care.” Stroke is the third leading cause of death in Alabama, with nearly 3000 Alabamians dying from stroke each year.

In 2010, only 2 hospitals in the entire state were certified by Joint Commission as Primary Stroke Centers. That number has since doubled, but still remains insufficient, as an overwhelming percentage of the population remains underserved. Although with preventitive measures and education in place, the incidence of stroke should continue to decrease, there will theoretically be no significant change in stroke related morbidity and mortality without timely and appropriate healthcare.

Unfortunately, poor quality health care is deeply and chronically rooted in the infrastructure, or lack thereof, of many of these rural communities. More than 30% of Alabama’s population is situated in these areas lacking equivalent government representation. Fundamental changes in, or the development of new infrastructures within these communities are requisite to create permanent changes in healthcare delivery.

Although not a solution to all of the health care concerns facing states like Alabama, telemedicine does offer an avenue by which cost effective, high quality care can be delivered to residents of rural communities. As pointed out earlier, there is a specific need for neurologic care, given the significant paucity in this area of the country. The implementation of teleneurology programs in these areas would lead to timely neurological consultations and care that would otherwise not be available. Where time equals brain cells in the case an acute stroke, expeditious treatment via teleneurology can literally be life saving. Teleneurology would help to improve not only quality of health in rural communities, but also quality of life. When a healthcare facility earns primary stroke certification (an initiative for which teleneurology programs can offer assistance), it typically sees a growth in ER volume and admissions, subsequently increasing revenue. Jobs can be created as a result of this growth, which in turn can help jumpstart  local economies.

Telemedicine alone will not solve all of the health care issues in rural Alabama and other similar regions in the stroke belt. However, these solutions can immediately fill a desperately missed need. Remember the two people in the United States who will have had a stroke in the time it took to read this article. The question is, will a neurologist have been able to reach them?