AcuteCare Telemedicine Blog


Is That The Sound Of Ice Breaking?

Until recently, the state of Arkansas was ranked last among all states in a recent report by the American Telemedicine Association on telemedicine practice standards. Like many other states, Arkansas’s treatment of healthcare via telecommunication technologies included restrictions forbidding caregivers the opportunity to treat a patient remotely without first establishing a face to face relationship. While other regulations purposefully and effectively deal with commonly acceptable policies that hold virtual healthcare treatment to the same standards of care as traditional in-person encounters; control the prescription of certain drugs via telemedicine; require the responsible handling of medical recording; and doctor/patient transparency, the restrictions on non-pre service face to face encounters and the insistence on individual state licensing of physicians is arguably the two regulations which proponents of telemedicine feel are hindering the wider adoption of telemedical services across the country.

Recently issued proposed amendments to its existing regulations have been approved by the State Legislature. Arkansas Code 17-80-117, will allow a doctor to establish a valid relationship with a patient without the need for an in-person exam, if the doctor “performs a face to face examination using real time audio and visual telemedicine technology that provides information at least equal to such information as would have been obtained by an in-person examination.” The rule also requires the doctor to establish a face to face follow-up visit when and if it is medically necessary.

The sound one hears from this action may just be the noise regulatory ice makes when it is breaking under the pressure of consumer demand and the application technological common sense. While the proposed changes do nothing to alleviate the cost and inconvenience of individual state physicians licensing requirements, the removal of the face-to-face, pre-telemedicine service requirement could open up the virtual care landscape in states where the face-to-face regulation still exists.

The Arkansas Board held a public hearing involving the proposed amendment to Regulation 2.8 and new Regulation 38 in June and encouraged telemedicine companies and healthcare providers looking to offer telemedicine services in Arkansas to review the proposed regulations and consider submitting comments.

Adoption of the proposed changes to Arkansas rules governing telehealth services may be seen as a water-shed action for healthcare professionals who believe consumers will benefit from both increased healthcare access and reduced cost when telemedicine is permitted to more freely expand across state lines.



Technology & Telehealth At The Center of Healthcare Debate

Many industry pundits are predicting that 2016 will be the year that technology and healthcare will become the center of the healthcare industry. With advances being made to modify century old regulations and processes governing the established patient/doctor relationship, telehealth services are positioned to become main-stream in the delivery of care all across the country. Rapid adoption of technology driven health services is expected to accelerate as payment for services, interstate licensing and accreditation issues, currently complicating expansion, are resolved. “2016 is the time for telehealth,” said Nathaniel Lacktman, a partner at Foley & Lardner who specializes in telehealth. A major factor, he said, is that providers are taking on more financial risk for managing the health of enrolled populations. “What a provider can do on the front end is use telehealth to make the patient more likely to interact with a clinician,” he said.

As an increased number of states are allowing physicians to provide telehealth services across state lines through collaborative licensure arrangements, insurers across the industry are discovering the cost advantages of reimbursing for virtual care. However, a recently published survey conducted in 2014 by The American Academy of Family Physicians indicated that while 78 percent of respondents believed that telehealth would improve access to healthcare, only 15 percent actually used telemedicine during the year. The survey also pointed to other barriers to wider acceptance which include the need for additional training for caregivers, continued reimbursement issues, cost of the technology and potential liability issues. 

“Telehealth use is in the early stages of adoption,” states the paper. “Many of the barriers to wider adoption may be addressed by policy changes. Strategies to address the top two barriers identified by this survey include health care stakeholders offering new opportunities for training in the use of telehealth services and payers increasing awareness of their current reimbursement for telehealth services, as well as developing new ways to reimburse the services.”

On the consumer side, awareness appears to be a major factor in the level of use. While consumers are quick to buy into the benefits of a marriage between technology and their interactions with care givers, the mechanics of actually making a virtual connection, and when it is appropriate, has many potential users pausing at the first step. Providers will need to embark on a strategy to guide patients through the process of making that first connection and reinforcing the experience.

It’s safe to say that telehealth and technology will continue to dominate healthcare conversations in 2016.



Do State Medical Boards Need To Be More Forward-looking When Developing Telemedicine Rules?

Telemedicine has been around for several decades but 2015 is predicted as the year delivering healthcare through telemedicine reaches the tipping point. Patients are becoming more aware of the benefits of telehealth for routine medical services. Dr. James Kiely, Partner, AcuteCare Telemedicine LLC says, “State medical boards are struggling with finding a balance between patients’ demands for new models of care and patient safety as more consumers are embracing the convenience and lower costs of virtual visits and readily seeking routine and minor healthcare services through their smart phones, laptops and pads instead of face-to-face encounters with their doctors.”

The U.S. Congress and individual state legislatures are moving quickly to address payment, safety and quality of service concerns that accompany the new delivery model, which promises to increase access to medical specialist and lower the cost of routine visits to emergency rooms and physicians. The individual state medical boards, the governing bodies of healthcare delivery regulations and practice standards, are a bit more deliberate and inconsistent in setting forth new rules and regulations relative to the practice of telemedicine.

While one universal theme consistently centers on the premise that practicing telemedicine must use the same standard of care as healthcare services provided in person, collective commonality ends there. Although the majority of board efforts include guidelines, exceptions and standards of performance that address the important safety and quality concerns while permitting the practice of telehealth, some individual state board responses differ considerably.

The recent vote to accept proposed rule changes by the Texas Medical Board (TMB) might not be aligned with the majority of state medical boards. The new policy, which does not apply to mental health services, includes language that says physicians cannot prescribe a medication without first establishing a “defined physician-patient relationship.” That includes establishing a diagnosis through an examination performed during a face-to-face encounter.  This may be an effort to limit inappropriate dispensing of medications (e.g. broad spectrum antibiotics and narcotics), but appears to be sufficiently restrictive enough to effectively block the practice of most telehealth within the state.

In response to a legal challenge brought by telemedicine company Teladoc, federal Judge Robert Pitman, for U.S. District Court in Austin, Texas, issued a temporary restraining order and preliminary injunction to keep the TMB rules from going into effect. Teledoc, which operates in 48 states and performed nearly 300,000 virtual patient visits in 2014, challenged the legality of the TMB’s new rules. The American Telemedicine Association (ATA) expressed concern that “any policies addressing telemedicine not be overly prescriptive and inadvertently thwart the benefits of new technologies for improving care, expanding access and reducing costs.”

Given the more cooperative reactions of other state legislatures and medical boards, in regulating virtual healthcare across the country, the strict reaction of the TMB has proponents of telehealth questioning the reasoning behind the Boards restrictive posture. What is it about the delivery model that the Texas Board knows and fears that the rest of the medical community is missing? It is not that telemedicine is untested. In more than a decade of practice it has survived the scrutiny of industry experts and numerous regulatory bodies and has demonstrated its value to improving access and lowering costs while encouraging patients to take a more active personal role in their own medical care. Telemedicine is not a different kind of care, but rather a different method of delivering care.

The actions of the TMB certainly impact the implementation of telehealth programs nationwide, however they do not follow the actions of most state medical boards across the country. Nathaniel Lacktman, a partner at the law firm of Foley & Lardner and the leader of the firm’s telemedicine practice believes that the case could have implications for a number of other state boards as they develop rules surrounding telemedicine. Lacktman stated, “The court’s ruling may be a signal to state medical boards to be forward-looking and open-minded when developing rules, particularly when it comes to regulating new and innovative ways of providing healthcare to patients.”

Telemedicine is becoming a standard of care for specialty practices including neurology, cardiology, and psychiatry, among others. The hope is that each individual state medical board creates legislation supporting a healthcare solution that is designed to balance improved patient outcomes and increased access to quality care.



Elements Essential to Establishing a Successful Telemedicine Program

Several studies in recent years have indicated that the use of telecommunication technologies in the delivery of health care will rise dramatically as new technology is improved and its utilization perfected. Patients seeking healthcare through the use of fixed and mobile digital devices will reach 7 million by the year 2018. This predicted high demand for mHealth has existing providers scrambling to design an effective, high quality delivery model that meets the requirements of increasingly savvy consumers/patients. The projected increase in users of telemedicine services is also attracting a new wave of investor-supported entrepreneurs, eager to embark into the practice of virtual medical care. These new technologies make it possible for healthcare providers to monitor, measure, and interface with patients remotely while making it easier for patients to manage their own healthcare.

As healthcare companies and providers seek to implement telehealth solutions, it requires certain critical, essential elements necessary to the successful engagement of a connected-care-telemedicine practice:

Devices – The popularity and utilization of personal computing came about only after the deliberate evolution of devices that were simple and easy to use by inexperienced consumers. A telemedicine practice must use remote presence devices that are easy to use for the patient and promote a high level of confidence in the exchange of information with their physician.

Platform – Utilizing a platform that integrates telemedicine connections into a secure electronic medical record system will be essential to insuring quality and continuity of care. A software platform should be easily accessed by users and consistent with familiar digital formats and functions, but include cutting edge security measures in order to ensure the highest level of patient confidentiality.

Expert Practitioners – Telemedicine is not a new or different type of healthcare, but a different method of delivering the same quality of healthcare.  The physicians and care-givers must be equally skilled and proficient, not just in medicine, but also in technology.

Process Improvement – A successful telemedicine practice must establish key performance indicators that can be monitored and measured.  As the system is monitored and measured, telemedicine providers are able to make continual improvements to ensure the highest level of care.

The growth of telemedicine has become one of the most disruptive events in the delivery of healthcare in more than a century. Applying the technology to a well-established and confident system of care will come with certain challenges in its implementation. The impact will be derived, not by the technology or its devices, but rather from the healthcare professionals who incorporate these essential elements.



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.”



Patching the Current System Will Not Advance the Great Promise of Telehealth

The deliberate march towards meeting the Federation of State Medical Boards’ (FSMB) goal of streamlining medical licensing of physicians continues. The FSMB promises that a new compact of seven states will trigger changes that will ultimately help reduce redundant licensing requirements by creating one place where physicians submit basic information such as their education and credentials. Last month Idaho and Utah were the latest states electing to join Montana and West Virginia as this compact attempts to speed up the process of licensing doctors across state boundaries. While some question why only seven states are required for implementation of this compact, just three more states are now needed to initiate the process that promises to remove a formidable barrier to telemedicine growth nationwide.

Despite being one of the most promising technologies to improve patient care and lower the rising costs of healthcare, telehealth is surviving in a regulatory environment that was established during an era devoid of modern telecommunication devices and technology. State physician licensing is currently controlled by 50 state medical licensing boards, each with their own requirements, policies and credentialing criteria. The current licensing process is a substantial impediment to the advancement of telehealth across state lines, sparking an intense debate over the need for a traditionally unpopular nationalized licensing system.

In an attempt to ward off yet another federal intrusion into states affairs, last year the FSMB proposed a voluntary national compact on joint licensing for the states. The goal is to secure the cooperation of enough states to quiet any calls to replace state-based physician licensing with a national program. The reason for the compact is that the FSMB previously approved a telemedicine policy that defines the location of the practice of medicine as the state where the patient is located, not the physician. The model legislation calls for at least seven states to participate in the compact in order to form a governing commission made up of representatives from the participating states.

From the outset industry leaders and telemedicine supporters saw the effort as a weak attempt to stem the growing tide to replace an outdated and inefficient system. The FSMB compact does little to address the cost associated with acquiring a license in each state and in fact increases the costs by adding fees associated with handling and processing the information.

Washington Board of Osteopathic Medicine and Surgery Executive Director Blake Maresh says, “For some, the interstate compact offers a tested Constitutional precept that could creatively forestall federal intervention that might otherwise supplant the longstanding authority of state medical boards, for others the possibility of other state boards licensing physicians who practice in their states, coupled with the establishment of new governmental organizations, leaves them uneasy at best.”

It is certain that the authors of state and federal constitutions could not have envisioned the advance of modern technology and the impact of those advances on preserving and improving the lives of their constituents. Delivering the benefits of increased access to the latest and best medical care, improved patient outcomes and lower costs must trump preserving outdated constitutional precepts. We must intensify our focus on implementing new processes designed to advance the great promises of telemedicine.



The Georgia Partnership for Telehealth Spring Conference

The Georgia Partnership for TeleHealth (GPT) was founded on the advances in the continually evolving telecommunications technologies. Since its formation in 2008, GPT has grown to become one of the most robust, comprehensive telehealth networks in the nation. The hallmark of GPT is the Georgia Telemedicine Program, an Open Access Network, which is a web of statewide access points based on strategicGPT Image partnerships with successful existing Telemedicine programs, and the creation of new Telemedicine locations, to maximize opportunities for timely specialty services. When fully realized, the Program will enable all rural Georgians to access specialty care within 30 miles of their homes. GPT’s services and support can provide state of the art telehealth solutions for all Georgians.

On March 25, 2015 GPT will be sponsoring their 6th Annual Spring Conference in Savannah, GA. The conference is a great opportunity for healthcare professionals from all medical disciplines and specialties to learn how the most up-to-date telecommunications technologies are impacting the delivery of stroke care and other healthcare services. Attendees will experience telemedicine in an applied framework, build network relationships and gain exposure to the latest in telehealth hardware and software technology. The conference will include a Grant Writing Workshop and will feature presentations from foremost experts in teleneurology.

Dr. Keith A. Sanders will be presenting a talk at the conference entitled “Outcome Analysis Demonstrates the Value of Telestroke”. Dr. Sanders is Director and Founder of the Stroke Center of St. Joseph’s Hospital of Atlanta and former Chairman of the Ethics Resource Committee and a partner in Atlanta Neurology, P.C. and AcuteCare Telemedicine (ACT). “As medical practitioners, we are expected to apply the latest techniques and technologies to the treatment of our patients. However, it is incumbent upon us to analyze the outcomes to gauge whether there are meaningful benefits and share that knowledge with the greater medical community. Indeed, state-of-the-art telemedicine technology is advancing stroke care and saving lives,” says Dr. Sanders. “I’m looking forward to sharing my experiences improving outcomes and expanding access to quality, advanced stroke care with my fellow Conference attendees.”

The GPT Spring Conference will begin on March 25, 2015 and run through March 27, at the Hyatt Regency-Savannah at 2 West Bay Street, Savannah GA 31401. Online registration is now open. An array of exhibitor opportunities is now available. Additional information is available by contacting Samantha Haas at samantha.wainright@gatelehealth.org.