AcuteCare Telemedicine Blog


The Marriage Between Technology and Telehealth Providers

Telemedicine is fast becoming the most promising break-through in the delivery of healthcare in the last century. While the promise has many championing the cause for expanded and universal use, some challenging hurdles remain in the way. Legislatures and medical boards are busy modifying regulations, payment structures, licensing and credentialing at various pace but one particular road block could derail the telehealth train if a workable connection is not soon found.

The video connection with the doctor is meeting the patient’s expectation for quick healthcare, but the process can often be overwhelming to providers who must sync the new service to their existing EHR platform. The key to a solution lies in creating a new virtual care environment within the providers existing EHR. James T. McElligott, MD, medical director for telehealth at the Medical University of South Carolina, is among a handful of health systems around the country that are pioneering virtual visits on a sustainable and scalable platform. “If you try to do something outside of that platform, there are downstream effects that end up making things very difficult” for the provider.

While some of the industry’s largest providers of EHR platforms have been slow to answer the call for a solution, smaller companies are making the connection happen for an increasingly larger number of provider clients. “We see time and again that workflow integration and ease of use are crucial factors to physician adoption of telehealth technologies,” Eran Westman, Vidyo CEO.

In a recent article by Eric Wicklund and published in mHealth Intelligence, titled “Virtual Care Within the EHR May Be a ‘Game-Changer”, the author reports on how some innovative companies are integrating creative solutions to the challenges presented when attempting to marry telemedicine services and existing electronic health records (EHR).

The idea of an electronic medical recording system was imposed upon an unprepared and often reluctant provider market several years ago. Many of the early glitches’ and bugs, that traditionally come with the roll-out of any new software system have been addressed, but the memory of the “fixing” process is fresh in the minds of many early users, leaving them less than enthusiastic about integrating still newer technologies into their daily routine.

It is becoming very clear to many in the healthcare industry that the once casual attitude towards telemedicine is changing as more and more applications for telecommunication technology in the delivery of healthcare become a reality. The disruption will continue. Telemedicine and EHR’s are not going to go away. Negotiating a workable union may indeed be the all-important game-changer for expanding telehealth.



The Challenge of Connecting Telemedicine to Electronic Health Records

Much of the debate about telemedicine and the effect it is imposing on the established healthcare delivery model has been centered on the doctor/patient relationship and the adherence to maintaining a high standard of care, regardless of the method of interaction. While the importance of the patient and physician in the new electronic relationship is well understood, there is a third component essential to the successful integration of telemedicine. The ability to access patient’s medical information is critical to extending continuity of care for patients as well as improving transparency between telemedicine providers and healthcare organizations. Organizations are already integrating electronic health records (EHRs) systems but telemedicine adds another layer of integration.

To successfully access patient data, telehealth providers will need to achieve interoperability between various information technology systems and software applications and must be able to communicate, exchange data, and use the information that has been exchanged seamlessly across all types of digital communication devises. Tom Bizzaro, vice president of health policy for First Databank says, “We have to universally acknowledge the value of interoperability within healthcare IT systems. Indeed, sharing data across systems can help to improve care quality and efficiency in the country’s health system and lead to success of value-based reimbursement models. However, all players – providers, payers, patients and vendors alike – need to truly embrace the value EHR interoperability, putting it above any proprietary concerns.”

In speaking about the future of the connected healthcare system, Steve Cashman, CEO of HealthSpot, said “The future of the connected healthcare system lies in solutions that deliver care to patients where it’s most convenient for them through unique partnerships that extend the care of traditional health systems and local medical communities through different forms of mobile health and telemedicine. By embracing new technologies, we can treat a greater number of people with more efficient and relevant means of care. With the addition of cloud-based electronic health records and coordination of care between traditional and connected healthcare models, we can build an even better experience for patients and providers. Building connected healthcare systems will also allow us to engage with patients on a deeper level, incentivizing them to seek care and empowering them to participate in preventative measures.”

Congressional House leaders recently unveiled a draft of the 21st Century Cures Act, which aims to “accelerate the discovery, development, and delivery cycle to get promising new treatments and cures to patients more quickly.” The original draft did not include language pertaining to telemedicine, but a new draft includes language about the interoperability of electronic health records and requires electronic health records to be interoperable by Jan. 1, 2018. The College of Healthcare Information Management Executives (CHIME) President and CEO Russell Branzell and Board Chair Charles Christian want better patient identification to be included in the new legislation in order to better secure access to patient information. The duo called it the “the most significant challenge” to safe health information exchange. A subsequent statement by CHIME to FierceHealthIT read, “Increasing access to patient data alone will not translate into better patient care. We would encourage the committee to emphasize both the need to increase access and exchange health information, along with the value of being able to use the data to improve care.” The American Telemedicine Association (ATA) CEO Jonathan Linkous, expressed his hope that Congress will adopt “at least a few measures” to expand access to telemedicine.

The shift to EHRs in large healthcare organizations and in clinical practice certainly proved challenging.  As telemedicine becomes a standard of care, EHR integration becomes a key component to long-term success.

As AcuteCare expands into various healthcare organizations, Dr. James M. Kiely, Partner, AcuteCare Telemedicine (ACT) comments on the complexity of integration with EHR systems. “Currently, we are able to enter patient data via a secure but separate, web-based portal or by using some very good software that allows data integration. Both solutions require manual staff intervention which can often be slow and cumbersome; the antithesis of what telemedicine is supposed to represent. As with EHR integration, it might take considerable time and effort to create a platform that simplifies the integration.”



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. 



Telemedicine: Modern Breakthrough or Timeless Concept?

Telemedicine is the practice of medicine at a distance; interaction that occurs remotely with the physician removed from direct contact with either the patient or other physicians. Telemedicine can include all phases of the physician-patient relationship, from evaluation (including pathology) to diagnosis and treatment. Although  recent breakthroughs in telecommunications technologies have accelerated the advancement of telemedicine, the desire to seek medical counsel regardless of the proximity of the healthcare provider is a common thread throughout medical history. The mechanism has changed, but medicine has long worked to remove the barriers of distance and time.

As early as the Middle Ages, “telepathology” was employed in the form of sending urine samples over distance to physicians for analysis. Prescriptions were carried over miles to patients before the advent of postal services. With the postal service came written letters describing symptoms to physicians, who would reply with diagnoses and treatment plans. These are all examples distinctly foreshadowing the emails and blog centered care that is now gaining a foothold.

Eventually, a milestone was reached when the telegraph allowed transmission of x-ray images. By the late 1800’s, telephony allowed direct 2-way communication between physicians. Still, a physical connection was required, and physicians at sea or without telephone access were at a loss. The radio broke that barrier by the 1920’s, and by the middle of the century, television technology brought real time images into the equation.

Near the end of the last century the most rapid, indeed explosive, growth of telemedicine utilization resulted from the symbiosis of computer technology, wireless communication networks and the internet. The ease of access to telemedicine that modern communication technology provides has broadened the scope of services. “Telehealth,” the utilization of remote presence to monitor health conditions, rather than responding to acute emergencies, is essentially commonplace. Moreover, well-care and health education have benefitted as well.

Today, we do not think twice about calling patients or colleagues on a phone, logging onto a computer for laboratory results, or reviewing radiology images on a TV screen. Soon, electronic health records (EHR’s) will be the norm. There are even technologies on the horizon which will become a partner with the doctor in establishing a diagnosis. The question for our future is when does new remote presence technology become standard of care? Inevitably, we will lose the “tele” and acknowledge that we are completely free of distance as an obstacle to patient care.