AcuteCare Telemedicine Blog

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. 

The Times, They Are A-Changin’

Health care reform must not add to our deficits over the next 10 years — it must be at least deficit neutral and put America on a path to reducing its deficit over time. To fulfill this promise, I have set aside $635 billion in a health reserve fund as a down payment on reform. This reserve fund includes a number of proposals to cut spending by $309 billion over 10 years –reducing overpayments to Medicare Advantage private insurers; strengthening Medicare and Medicaid payment accuracy by cutting waste, fraud and abuse; improving care for Medicare patients after hospitalizations; and encouraging physicians to form “accountable care organizations” to improve the quality of care for Medicare patients.

            President Barack Obama

June 3, 2009

By the end of this decade, medical care will be delivered as never imagined by more than a few. No longer will you pay a doctor for his services. Instead, you will belong to one of thousands of Accountable Care Organizations (an ACO).

Your money will be paid to an entity whose job it will be to provide medical services to you and thousands of others from cradle to grave. You will pay a fixed fee that will be pooled and distributed as determined by the ACO to providers such as neurologists and other physicians. If they meet certain criteria, like fewer hospitalizations and lower medication costs, they will get bonuses. If not, they will simply be fired.

You will likely be tied to a long-term contract in order to control your behavior so that you get healthier and the ACO can show benefit to regulators. Otherwise the lengths that the ACO will go to in order make you healthier -like education or fitness programs-will show up on some other ACO’s achievement table. There are a few entities that approximate this type of program, such as Kaiser Permanente and the Harvard Pilgrim Plan, but unlike with future ACOs, participants float in and out, which is a disincentive for investing money in patients.

How will this affect the delivery of neurological care? According to the American Academy of Neurology, only about 7000 neurologists actually practice in the US, about 25 per million people. More and more are dropping out of hospital work because of high medical liability risk, poor reimbursements and the high demand in office practices because of the shortage. Consequently, neurologist availability will be a challenge for ACOs as Americans develop stroke and other diseases of the elderly in ever greater numbers. Not all ACOs, will be able to employ them, especially in smaller towns and rural areas.

Because nearly all of neurology relies heavily on patient history and observational exams (what the neurologist sees rather than touching or listening to the organs) and because treatments rely almost solely on medications rather than operations or procedures requiring proximity, telemedicine offers an excellent solution.

With salary, benefits, and other expenses, the cost of recruiting and retaining a neurologist is extremely high. If the neurologist is paid based on membership figures, a smaller ACO may not be able to support even one neurologist to handle the clinic, let alone cover hospitals for emergencies.

Alternatively, the services of a company like AcuteCare Telemedicine can be obtained for a small fraction of the cost, and can cover a larger number of patients in many different regions of the country sequentially or even simultaneously. Telemedicine specialists would only be called when needed, and because many ACOs would be employing the group on a fractional basis, the cost to each one would be far lower than that of hiring even one neurologist full time. Furthermore, studies show that patient satisfaction and stroke outcomes are as high as in-person consultations in urgent care situations.s

Teleneurology and the development of ACOs will have a mutually beneficial relationship in the coming years. Practitioners of this field will find a welcome home in these organizations and will help solve the coming shortage of neurologists in a new era of medicine.