AcuteCare Telemedicine Blog


Removing Well Entrenched Impediments to Advancing Telemedicine Benefits

A recently published study in Telemedicine and e-Health found that despite numerous benefits to expanding telemedicine that there are three major barriers that remain to fully implementing the benefits of telehealth. Health care professionals agree that Telemedicine has and will continue to change care delivery and patient outcomes by expanding patient access, reducing service gaps, improving service quality, providing additional clinical support, delivering enhanced patient satisfaction and improved adherence to care standards.

Advances in powerful technology is transforming care facilitation, making real-time audiovisual communication more feasible and permitting physicians the ability to remotely consult with a patient via a robot and LCD screen.  Remote specialists and physicians can treat patients and save lives with the use of a broadband card, an internet connection from a cell phone tower and a laptop. This illustrates the amazing potential of telemedicine but the study found that serious human barriers to nationwide telemedicine still remain.

The study surveyed emergency and critical care remote presence telemedicine users from 53 healthcare institutions across North America and Ireland. One hundred-and-six surveys were completed. Sixty-eight percent of respondents were physicians, 17 percent nurses and nurse practitioners and 8 percent were administrators. The results indicated that three major human barriers for telemedicine in the areas of regulation and finance need eradication to fully implement the benefits of telemedicine.

     – Licensing for Physicians. A major benefit of telemedicine is the ability to consult remotely with physicians and patients across state boundaries, but today the current approach to medical licensing requires health providers to obtain multiple state licenses and adhere to diverse and sometimes conflicting state medical practice rules. The medical licensing process is not only complicated but also lengthy and expensive and it represents a major barrier to the expansion of telemedicine.

     – Credentialing. Credentialing can become very complicated especially for hospitals with hub and spoke models because physicians from each hospital have to have the credentials at every hospital.  The time it takes it to acquire all necessary documents and finish an application is time that could be used training medical staff to use telemedicine and bring the benefits of telemedicine to deserving patients. The current method for credentialing should be streamlined to facilitate easier credentialing at multiple facilities leading the way to wider telemedicine implementation and increased accessibility.

     – Reimbursement. A huge financial issue for telemedicine is the lack of reimbursement and capital expenditure for services. Similar to licensing issues, reimbursement models are different across the states with each having its own regulation for private payers with little or no consistency for telemedicine reimbursement.

Removing these impediments to the expansion of telemedicine remains a daunting task. Change never comes easy, particularly when it requires the cooperation of various bureaucratic agencies, multiple governing bodies and a wealth of well entrenched administrative procedures and regulations that were designed and implemented in a time when advanced communication technologies were little more than fantasy and science fiction. A continued focus on removing these barriers must intensify in order to bring the many proven benefits of telemedicine to patients throughout the country and the world.



Taking It to the Patient

Gadget and device gurus are working hard to fill the need for advanced tools to help medical care providers in the field bring the best medical care to the patient even in the remotest corners of the world.  Remote Diagnostic Technologies (RDT) in the UK, with funding from ESA’s Advanced Research in Telecommunications Systems Program has developed a robust portable device for monitoring vital signs and providing communications for medics in the field. The Tempus Pro combines the diagnostic facilities found in standard hospital vital signs monitors with extensive two-way communications, packaged in a compact, rugged, highly portable unit that can be tailored to user needs. The key to the unit’s success is that it is a fully functional, hospital-grade vital signs monitor and takes less than an hour for an experienced medical professional to learn the basic functions.

In the United States, a University of Virginia Health System (UVA) team is working with local rescue squads to diagnose stroke patients before they reach the hospital, enabling more patients to receive lifesaving treatment and have a full recovery. UVA clinicians are raising $10,000 to equip two additional local ambulances with the iTREAT mobile telemedicine kit. The goal: Connect paramedics through a secure video link with UVA’s specially trained stroke neurologists and emergency medicine physicians, who can diagnose stroke patients while they’re in the ambulance and enable treatment to begin as soon as patients arrive at the hospital. Fast diagnosis and treatment is vital because the most effective treatment for acute ischemic stroke patients — the clot-busting drug tPA — is only safe and effective if delivered within three hours of when symptoms begin. Due to delays in reaching a hospital and receiving a diagnosis, less than 5 percent of all stroke patients receive tPA. Promising faster care for a variety of patients and treatments, The iTREAT technology is in the testing stage with local rescue squads, with the hope of using it to care for Central Virginia patients in early 2014.

A debate as to what or who spawned the revolution in using communication technology to advance a new medical care delivery model, the need or the gadget, is unimportant.  Teaming the hospital based life-savers and their dedicated field associates with savvy techies is creating an environment where patients are receiving better and faster advanced life support no matter where they are located. Telemedicine is taking to the patient!



Clearing the Hurdles for Advancing Multistate Telemedicine

For the most part, the laws that govern the practice of medicine in the United States are state laws. One of the few things those laws agree on is that jurisdiction of those laws is based on the patient’s location, not the doctor’s. With the fast paced expansion of telemedicine technology and new mobile health opportunities bursting on the medical delivery scene, some well-established procedural hurdles are slowing the advancement of multistate practice of telemedicine. It is not that these procedures are necessarily bad it’s just that their creation and implementation are from a time when few could even imagine or foresee the advancements in the telecommunication technology of today.

The benefits of telemedicine to the delivery of healthcare, is becoming obvious to even the most resistant of detractors. “It’s relatively easy to do [telemedicine] if you’re going to stay within your particular state,” said Nathaniel Lacktman, a senior counsel at Foley and Lardner, “But if you really want to expand your reach, and be revolutionary or just make a whole lot of money, you’re going to need to go cross-border. Because of that you will be subject to the laws of that particular state. Across the country, where the patient is located, those are the laws that govern.” The six most common regulatory and procedural hurdles to expanding multistate telemedicine include:

Licensing

The American Telemedicine Association estimates that getting doctors licensed in additional states for telemedicine costs physicians $300 million per year. While some exceptions to state licensure laws have recently been put into place for telemedicine, most are not broad or consistent. For example, every state has a remote exception for post-surgical consultations. But some of those require the consultation to be free, some can only be hospital to hospital, and different states have different definitions of a consultation.

Scope of Practice

Every state board has the duty to enforce standard of care in their specific community and one of the most vexing standard of care provisions for telemedicine is the notion of doctor-patient relationships. Many states allow doctors and patients in an established relationship to meet virtually, but require the relationship to be established in an initial face-to-face meeting. To gain the most in quality and cost benefit from the practice of telemedicine, few face to face encounters between a patient and a doctor or specialist will occur prior to telemedicine treatment or consultation.

Credentialing

To practice hospital-to-hospital telemedicine, many hospital bylaws and state laws require physicians to be credentialed as if they were employees in the remote hospital, sometimes including maintaining their own health insurance, participating in staff education, and other requirements that don’t quite seem to apply.

The Centers for Medicare and Medicaid services have introduced a proxy rule for credentialing that could alleviate some of that pressure but in general practice, the myriad of credentialing requirements is overwhelming most attempts to efficiently overcome this barrier. Perhaps we can all agree on some common standardization of credentials to avoid unwanted implementation of federalized, “one size fits all” intervention.

Remote Prescribing

Remote prescribing is also covered under scope of practice, but with additional complications. Individual state pharmacy board’s standard of care, often have their own rules and the prescription of controlled substances can be regulated differently in different states. “There’s a whole set of rules on remote prescribing, what you’re allowed to do, what you’re not allowed to do,” Lacktman said. “Rule of thumb: prescribing is more restrictive than consults.”

Contracting

Contractual arrangements for physicians and other healthcare provider professionals differ greatly from one state to another. Attempting to practice across all states collectively is a minefield of differing contractual laws. For a business employing multiple doctors, the arrangement for paying doctors has to conform to all the states’ fee-splitting laws, practice of medicine laws, and anti-kickback statutes, which essentially prohibit doctors from buying and selling referrals.

As is often the case, the most admirable and beneficial accomplishments in any endeavor are rarely easy, but overhauling the well-entrenched, well-meaning bureaucratic regulations of the past is extremely daunting at the very least. It will require dedication and vision of all who seek to improve the delivery of healthcare to all Americans, no matter where they reside.



Growth of Telemedicine is Global and Becoming Common Place

Though the United States has been dominating the global telemedicine market, Europe and developing nations are rapidly catching up. The global telemedicine market is expected to grow at a compound annual growth rate of 19 percent, driven mainly by growth opportunities in Europe, but the enthusiastic growth may be tempered by the lack of standardized classifications. However, the increase in remote monitoring of patients is expected to keep driving the market, which is also boosted by the increase in telesurgery. The shift is occurring mainly because of the increase in the number of patients with chronic diseases and the increasing availability of online healthcare services.

The remote delivery of healthcare services over the telecommunications infrastructure, or telemedicine, is a topic of interest to the vast majority of Italian general practitioners (GPs), with 73 percent stating that they are prepared to use the technology according to a study conducted by the Italian Family Doctor’s Association FIMMG. Over half of the doctors surveyed, 52 percent, are in favor of using these new technologies if they help to develop organizational aspects of the profession, while 30 percent state that telemedicine could even improve the doctor-patient relationship.

Global virtual doctor visits could become as common as face-to-face appointments because health insurers, hospital systems and employers view it as a way to clamp down on rising medical costs. They hope that by giving patients easy access to a primary care physician, it will discourage them from visiting a costly emergency room when they get sick. The trend in the US is expected to escalate as an influx of new patients, caused by the implementation of the Affordable Care Act (ACA), promises to put a strain on some doctors’ offices for treatment of routine illnesses.  Health giants UPMC and Highmark Inc. are rolling out new services that allow patients to video-conference with doctors through computers, tablets and smartphones.  “We think more and more people, as they become more familiar with telemedicine, will see this as something that is just going to be commonplace,” said Natasa Sokolovich, executive director of telemedicine at UPMC.  Convenience is the big selling point of telemedicine services to patients.  Rather than having to wait days or weeks to schedule an appointment at a doctor’s office, a video conference could be scheduled within minutes or hours, and the patient wouldn’t have to leave their home.

While such convenience is enticing to an increasingly busy society, some doctors and medical care providers are warning that an E-visit can’t entirely replace face-to-face consultations in a physician’s office environment. Nonverbal cues can be very important in accurately diagnosing patients, said Dr. Bruce MacLeod, president of the Pennsylvania Medical Society. “Some details could be missed in a video conference.”

But as the availability and quality of telemedicine advances globally, a increasing majority of patients are willing and eager to invite the technology into their relationship with their health care providers.  The desire to make medical care more accessible and less-costly is global. Whether E-visits replace face to face medical care completely or just become some relative portion of interaction between patients and physicians, the medical services delivery model is going to be altered dramatically for the future.  The rate of acceptance of communication technology in the medical care process will be driven more by necessary changes to the well-established regulations, licensing requirements, and cost reimbursement policies from within the health care community. 



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.



Positive Patient Outcome Advances the Telemedicine Delivery Model

Recently a team of researchers from UCLA completed a major study on the use of tissue plasminogen activator, or tPA, on stroke victims within 4.5 hours after the stroke occurs. That study of more than 50,000 stroke patients, as reported in a recent issue of JAMA, The Journal of the American Medical Association, confirms that the sooner tPA is administered, the better chance of recovery.  In response to the study, AcuteCare Telemedicine (ACT), an Atlanta-based company that’s billed as the largest practice-based provider of teleneurology is making an aggressive push to help smaller hospitals and networks that don’t have immediate access to neurologists.

Their efforts have proven to be life saving for one Ozark, Alabama resident and recent stroke victim.  The collaboration between ACT and the Southeast Alabama Medical Center (SAMC) is having its desired effect for SAMC patients, providing once unavailable, advanced life saving treatments to stroke patients. The Stroke Care Network, established in Dothan, Ala., in collaboration with ACT, the Southeastern Alabama Medical Center Foundation and the Alabama Partnership for Telehealth provides stroke services for a 240-square-mile swath that includes southeast Alabama, southwest Georgia and the Florida Panhandle.

The collaboration was initiated when Cecilia Land, SAMC’s division director for rehabilitation services discovered an increase in the areas mortality and morbidity due to stroke. “We recognized an immediate need to establish a stroke care network, providing patients with access to 24×7 teleneurology,” said Land.  SAMC officials hope to add more “spokes” to the network, in the form of hospitals and clinics, and also want to use the network to educate communities on the importance of wellness and identifying precursors to a stroke.  Dr. Keith A. Sanders from AcuteCare Telemedicine hopes to extend ACT’s telemedicine platform to other specialties, such as telepsychology, and he expects more hospitals and health networks will buy into the system as executives see the benefits of sharing specialist services without having to house them on-site.

This most recent life-saving patient outcome from the collaboration between ACT and SAMC is proof that the new telemedicine health care model is an excellent vehicle to advancing the availability and quality of telestroke care to SAMC patients and to underserved patients all around the country.



VETS Act Expands Veterans Access to Care

A bi-partisan bill, introduced by Representatives Charles Rangel (D-NY) and Glenn Thompson (R-PA) and cosponsored by 21 Members of Congress, would permit U.S. Department of Veterans Affairs health professionals to treat veterans nationwide with a single state license. The bill, known as the VETS Act, builds on the unanimous congressional enactment of the 2011 STEP Act (Servicemembers’ Telemedicine and E-Health Portability Act,) which provides a similar provision for healthcare providers in the U.S. Department of Defense. A similar licensing rule for patients and providers of Medicare, Medicaid and other major federal health programs was included in a comprehensive telemedicine bill submitted by Rep. Mike Thompson (D-CA) in December 2012.

These bills are a simple way, while preserving the states’ role to license, to address shortages of medical specialists, to improve patient access to the best qualified physicians, and to accommodate mobile Americans and multi-state health plans,” said Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association.  Currently, most providers who practice interstate telemedicine must be licensed both where the patient and provider are physically located. In some states, medical boards are even imposing stricter licensing requirements for telehealth providers than they do for in-person care, such as requiring a prior face-to-face examination for each and every case.

The Veterans Administration is consolidating many medical specialties in regional facilities that are often located a considerable distance from veteran patients who need regular treatments for injuries suffered in the defense of the country.  In some cases these patients need to travel into another state to receive specialized care, resulting in significant inconvenience and expense to VA beneficiaries.  The ability to treat these patients across state lines by use of telemedicine technology promises considerable benefits to patients and the VA care providers.

For the Veterans Administration who is currently experiencing a backlog of more than 500,000 requests for benefits, removing or lowering regulatory barriers will surely enhance the accessibility of care for patients living in areas remote from VA treatment centers while generating operational efficiencies for the VA.