AcuteCare Telemedicine Blog


2013 – The Year Telemedicine Breaks Out?

After more than 40 years of development, tweaking and testing, telemedicine appears to be approaching a major break out by joining the mainstream medical establishment to innovate the delivery of medical care in the United States. Considering the banking, entertainment and publishing industries years of success in delivering products and services efficiently to customers through telecommunication technologies, the growth and acceptance of telemedicine has been a long time coming.

According to the American Telemedicine Association, a leading problem is the red tape and top-down regulatory reticence demonstrated by various government agencies. The leading barriers to the deployment of telemedicine in the U.S. have almost all involved government policy: reimbursement by Medicare and Medicaid, state-based standards of care and professional licensing, device regulation and telecommunications policy.

With rising medical care costs, the shortage of medical practitioners and the increasing demand for health care services, the pundits of delay may soon need to get out of the way or risk getting run over.  Last year more than five million Americans received remote evaluations of medical images and more than 10 million patients directly benefited from some form of telemedicine.  Could 2013 be the year to end the bureaucratic procrastination?

The campaign for change has begun as State legislators, Patient Groups, Medical Societies, Private Health Service Payers and Health System Leaders are banding together to promote and accelerate change.  State government will most likely be leading the way towards reforming state funding of telemedicine services and regulations that govern the medical industry.  Sixteen states have already adopted legislation requiring private medical service payers to reimburse for telemedicine and several more states are expected to follow in 2013.

The Federal government can be expected to take some steps towards acceptance and participation but, as is usually the case, Washington will likely move at a much more deliberate pace, taking every opportunity to secure a position of playing catch-up. As the cost benefits and increased availability of specialized medical services through the practice of telemedicine continue to become apparent to many more thousands of patients, the barriers to nationwide innovation of medical services will continue to fall at an increasing rate.

To all those who are blocking the path to progress, it is time to get out of the way and become part of a technological solution.



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.



Now is the Time

Like any other year, the beginning of 2013 brings a great deal of optimism about what surprising changes and exciting opportunities and a new year will bring, not just to healthcare, but to our everyday lives. We are living in an age of constant innovation and untamed enthusiasm for what is new. Every day, we read news about the pioneering of new solutions for age-old problems and find ourselves astonished by what we can accomplish with the collective knowledge of generations past and a zeal for moving towards the future.

Telemedicine is a prime example of an entire industry fueled by this fervor for innovation, and the resulting advances it has brought to the way we think about healthcare are nothing short of remarkable. Unfortunately, the level of investment in terms of initial costs and putting trust in new technologies has been enough of an obstacle to prevent many facilities to postpone the adoption of telemedicine.

Embracing telemedicine is about far more than flashy new technology and the promise of saving costs; it is about taking steps forward to make our world a better place. For example, the latest tragedy to make national news out of Newtown, CT served as a stark reminder that there are still great strides that need to be made in order to address the needs of individuals with psychiatric conditions. Fortunately, through telepsychiatry programs and the drastic improvements in patient monitoring capabilities afforded by telemedicine, it is easier than ever before to get help. Extending the attention and the care that is so desperately needed in cases such as these will undoubtedly help us prevent many such worst-case scenarios.

It is the hope of AcuteCare Telemedicine and other proponents of telehealth that the plethora of new equipment and methods available to providers will continue to propel healthcare towards an era in which every individual has unhindered access to the care they need. There has never been a more important time to push the many benefits of telemedicine into the spotlight, and take the first steps towards achieving this goal.



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.



Long Distance Learning

Along with other massive changes brought on by the increasing power and reach of the internet, the past decade has seen a drastic increase in the number of undergraduate and graduate degrees attained online. Today, more than 12,000 different “digital degrees” can be obtained from accredited U.S. universities, a figure that has grown by double digits annually for the last five years.

While the growth of the internet has enabled a plethora of such ‘distance learning’ opportunities for collegiate education, new technologies and practices in telemedicine are simultaneously reinventing the approach to professional education in hospitals and healthcare facilities around the world.

The educational aspects of telehealth programs demand the least effort and level of investment of any implementation of the discipline, but the benefits of adoption are immense, and can serve as the building blocks for increased engagement down the road.

Telemedicine actually allows hospitals to bring the education directly into the facility, offering professional training directly from the experts on the newest procedures and protocols, as well as serving as a 24/7 resource always available for consultation.  Bringing this type of program into a hospital not only helps administrators, physicians, nurses, and staff better perform their jobs and offer patients a better standard of care, but also creates champions of the telemedicine services, opening the door to a healthcare ecosystem that is far more responsive to innovation.

Introducing telemedicine to healthcare facilities through educational initiatives is also a great way to align the goals of the hospital and the provider to foster stronger relationships for the future. The facility wants to offer top quality care within the confines of a tightening budget, and the provider wants to help its client hospital save lives while reducing spending in the process to demonstrate its competitive advantage. The educational process is a great way to interface with the effective and efficient solutions that telehealth can offer. It is a major step towards a future where all hospitals have access to the resources they need to operate equally efficiently; a win for patient and provider alike.



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.



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.



You May Already Be Acquainted

As futuristic or experimental as telemedicine may sometimes seem, patients from all demographics may unknowingly already have been engaging and reaping its benefits for years. At its core, telemedicine is interested in utilizing advances in technology to increase the speed and accuracy of communications either between patients and their physicians or among physicians in collaboration. The resulting drastic improvements in these areas that are afforded by telemedicine are what matter most, not the seemingly unorthodox techniques that facilitate them.

Following this idea, any health care protocol that leverages the internet is a practical application of telemedicine. Therefore, when a doctor retrieves lab work from the web, or a radiologist sends an electronic version of a scan to a colleague, telemedicine is already at work. For would-be telemedicine patients, videoconferencing is what is most unfamiliar. However, Americans are becoming more and more accustomed to communicating with one another via two-way video technologies; for many, platforms like Skype or Apple’s FaceTime are now commonplace. As these tools make their way into our everyday lives, more patients will grow comfortable with their powerful applications in healthcare.

According to the American Telemedicine Association, telemedicine technologies and practices has played a role in the care of as many as 10 million patients in the United States to date. With continued education and increased awareness, that number should be expected to rise exponentially as more hospitals adopt telehealth as a primary mode of monitoring patients and other individuals benefitting from remote supervision, such as the elderly or disabled. Several federal innovation grants resulting from the passage of the Affordable Care Act have also been awarded to telemedicine programs nationwide for their capability to reduce unnecessary hospitalizations.

There are obstacles, primarily related to patient and provider perceptions and fears about costs and reliance on new technologies, but telemedicine has often proved itself adaptable and efficient in the face of such doubts. Raising awareness and granting patients the confidence that they are already familiar with telemedicine’s advantages will be a major step in pushing healthcare forward.

 



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.