AcuteCare Telemedicine Blog


Universally Consistent Telemedicine Guidelines Still Out Of Reach

Recognizing the strong growth and innovative approach in telemedicine practices, the American Medical Association (AMA) enacted a set of guidelines for care provided by telecommunications earlier this year. The guiding principles seek to address the concerns and issues within the medical community relative to the development and implementation of telemedicine programs. The AMA guidelines support the “use of telecommunications in the delivery of healthcare while ensuring favorable standards of care; patient safety; quality and continuity of care; transparency; and the responsible handling of patient medical records and privacy.”

The action by the AMA appears to address the many valid concerns among the medical community while providing much needed flexibility, if telemedicine is to fulfill its many promises to increase availability of specialized medical services to rural communities, reduce costs of medical care and have a positive impact on the anticipated future shortage of physicians.

More recently, the Georgia Composite Medical Board enacted a new regulation governing the standards for telemedicine practice for physicians practicing in the state of Georgia. Much like the AMA guidelines, the regulations establish consistent standards of practice for providing treatment and consultation through the use of telecommunication technologies. The regulations were enacted after more than two years of evaluation and discussions by the state Board. The requirements, like those of the AMA, appear to successfully address many of the same concerns and issues.

The Georgia regulations require that all providers of telemedicine services, which include physicians, physician assistants (PAs) and advanced practice registered nurses (APRNs), hold a valid Georgia state license. However, one area of inconsistency between other proposed individual states requirements and the AMA guidelines is the requirement relative to prior in-person examination.

The AMA prefers not to specify whether the prior face-to-face examination requirement, before rendering treatment via telecommunication, must be performed in person or by a video encounter. The Georgia regulation specifically requires an in-person relationship prior to the any telemedicine service, but enumerates several exceptions and qualifiers which defer the requirement in specific instances. In many other states, including Tennessee, a much more defined requirement of pre-telemedical care relationship is mandated.

Perhaps the most prevalent impact of technology on our society is its effect on breaking down pre-existing divisions, both geographical and social. State lines, geographic hurdles and physical market limiting factors are obliterated by advances in telecommunications. If the full benefits of telemedicine are to be realized, consistency and clarity in regulations and guidelines must prevail.

Few in the healthcare community advocate for blanket federalization of regulations. The industry can do more to enact a core set of standards and practices that successfully address the bulk of concerns and issues of each entity while assuring every patient, regardless of where they reside, receives the best quality and most efficient medical care available.



A Specialty Designed For Virtual Care

According to a recent article in the Scientific American, Alaska patients are more likely to find an astronaut than a geneticist. William Oefelein, who piloted the space shuttle Discovery, retired there, but the state of more than 700,000 people does not have a single medical geneticist to call its own. Instead, patients must wait until one flies in from Oregon around 4000 kilometers away. Six times a year a geneticist or two comes to Alaska and visits a few clinics, seeing about eight patients a day, diagnosing genetic causes for developmental delays such as fragile X syndrome or discussing hereditary cancer risk.

New advances in telecommunication technology are improving access to medical specialties for residents of regions well away from established urban centers, especially for specialties that do not always require hands-on interaction between a patient and a practitioner.  A virtual meeting with a geneticist is not as personable as a face to face encounter but those who are utilizing telemedicine to reach out to their patients from afar are reporting high satisfaction rates of among patients who are tapping such services. This may not be surprising to many because in an age when virtual chats are relatively commonplace, videoconferencing for genetic consultation, or telegenetics, is becoming a logical extension of what people already do with their Webcams and smartphones. The patients are already familiar with the technology and have racked up considerable experience socializing and shopping via the internet.

The lack of reasonable access to medical specialties is not limited to the state of Alaska. In nearly every state there are enclaves of population that are located five to six hours away from advanced or specialized medical centers, it is clear that the need is out there and the patients are willing and able to avail themselves of the convenience. The fact that more services like telegenetics are not more commonly available is not always due to usual obstacles like insurance reimbursements, licensing requirements or lack of necessary band width and supporting technology. To be successful, the programs require the willing participation of doctors and clinicians on the patients end in order to help facilitate a successful encounter. Even in this fast-paced, high-tech environment there are many healthcare practitioners that continue to be reluctant to treat patients in the virtual world. The problem would appear to be one of acceptance in some cultures.

Telemedical consultation by physicians in specialties in which there is little need for physical contact with patients is one area where new communication technologies would appear to be made to order. The obvious advantages of decreasing the costs and increasing the access to care are evident, even to the casual untrained observer.



Managing Diabetes Remotely With Telemedicine

Diabetes afflicts more than 22 million Americans, or 7% of the total population, and the number of people diagnosed every year is skyrocketing. At a cost of $245 billion in 2012, the disease’s toll on the economy has increased by more than 40% since 2007, according to a recent report from the American Diabetes Association.

Mississippi, which ranks second after West Virginia in the percentage of residents affected by the chronic disease, is taking steps to reduce devastating effects on the state economy and the overall health of Mississippians. Early this year, Gov. Phil Bryant, the University of Mississippi Medical Center and three private technology partners announced a plan to help low-income residents manage their diabetes remotely through the use of telemedicine. The goal is to help them keep the disease in check and avoid unnecessary hospitalizations while remaining as active and productive as possible. To make the project possible, Bryant signed a first-of-its-kind law requiring private insurers, Medicaid and state employee health plans to reimburse medical providers for services dispensed via computer screens and telecommunications at the same rate they would pay for in-person medical care.

The new reimbursement law will also pave the way for similar telemedicine projects for other chronic diseases, said Dr. Kristi Henderson, the University of Mississippi Medical Center’s chief of telemedicine, who is heading the project. Initially the project, called the Diabetes Telehealth Network, will enlist 200 people with diabetes in one of the state’s poorest regions, the Mississippi Delta, who will be given Internet-capable computer tablets loaded with software that will enable medical professionals at the University of Mississippi and a hospital in the region, North Sunflower Medical Center, to remotely monitor patients’ test results and symptoms. A third technology partner will provide technical support for the wireless telecommunications services needed to transmit the medical data.

The price tag for Mississippi’s telemedicine project is about $1.6 million. But to expand the program or recreate it somewhere else, Henderson said, would cost much less because the groundwork would be done. “We want to prove a model and replicate it.”

Nationwide, one in every five health care dollars is spent caring for people with diabetes, according to the American Diabetes Association. Mississippi’s telemedicine law, said Gary Capistrant, public policy director at the American Telemedicine Association, goes further than any other state to remove what the telehealth industry considers its biggest impediment, lack of insurance reimbursement.

Numerous states and medical groups already have expressed an interest in the project, Henderson said. “If we can do it in Mississippi, where chronic disease is at its worst, where poverty is at its worst, and where transportation and workforce issue are at their worst, we can make it work anywhere.”



Telemedicine and the Medical Licensing Debate

The number of patients served by telemedicine has grown from a few thousand in the mid-1980s to an estimated 10 million people today. The majority of the growth occurred in the last decade, according to the American Telemedicine Association. Despite the rapid adoption of telemedicine practices by healthcare institutions, practitioners must meet individual state medical licensing requirements.

Some states argue that easing licensing requirements could jeopardize patient safety. If doctors practice without obtaining a license in that state, regulators maintain that they have no power to conduct an investigation or explore a consumer complaint. In addition, doctors would not benefit from any legal protections the state may have against malpractice lawsuits. Advocates of telemedicine argue that because doctors take standardized national exams, with many requirements set by federal agencies such as the U.S. Department of Health and Human Services, states should recognize other state licenses. The debate is not without merit, on either side of the issue.

In a time past, interstate commerce experienced similar obstructions to improving the nationwide consumer product and service delivery model. Implemented in an era before advanced transportation technology and the interstate highway system carriers of goods and services across state lines were required to have individual state licenses, adhere to 50 different sets of roadway regulations and pay transportation taxes and fees in every state where transportation service was provided. The very formidable barriers to streamlining interstate commerce were successfully circumvented by a new national regulatory and licensing system. The move successfully addressed the individual state concerns and resulted in massive improvements to the nationwide delivery of good and services to all consumers, no matter where they resided.

Today, as major telecommunications and health care firms look to create nationwide telemedicine businesses, state medical licensing boards are set to consider an “interstate medical licensure compact” that would give doctors and patients legal protections in any state that signs on. The proposal, to be considered at the annual meeting of the Federation of State Medical Boards (FSMB) this month, would expedite the licensing process for doctors who want to practice across state borders. The compact, which was developed by a task force of 22 state medical boards, may represent the first step in resolving the issue. Lisa Robin, chief advocacy officer for the federation, expects there will be some early adopters. “I believe there will be some proliferation.”

The medical industry is facing significant challenges in the coming decades, such as physician shortages, spiraling costs of care, specialist accessibility and the entry of millions of new patients to the market as the Affordable Care Act (ACA) is fully implemented. In order to implement a long-term solution, technology standards and medical licensing requirements share equal importance in the debate.



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!



Telemedicine In Europe: Another Euro Disney Experience?

It seemed like a “no-brainer. Take the most successful family entertainment experience (Disney World), clone an exact copy, pack it all up, and implant it to the center of European culture and voila, another mega Disney entertainment success story!  Well, not exactly. It seems as though the European culture frowns on fast food, long lines and many other conveniences and inconveniences that Americans have become accustomed to enjoying and enduring.  The initial Disney experience required many millions of dollars and years of tweaking and modification to the American Disney World model before it became anything nearly as successful. It forever set-forth another example as to how Europeans differ in their perceptions and customs relative to other world societies.  So where does entertainment and telemedicine have commonality?

Decade’s after Disney’s surprising experience significant advances in telecommunications technologies have brought about vast improvements to societies all around the world, across all industries, commerce, media, personal communication and even to the well-established healthcare delivery model.  And while some resistance to changes in healthcare delivery, brought on by the telemedicine and telehealth revolution, have been experienced the vast majority of cultures around the world are envisioning and welcoming significant benefits to the quality and availability of medical services derived from the revolution.  Even deeply traditional governmental regulation and policy barriers are falling aside, albeit slowly in some cases, giving way to a new era of medical care delivery.  But in Old Europe, as telemedicine revolutionizes medical care around the rest of the world, Germans are happier paying a visit to the doctor, and those who could benefit most from the technology will just have to wait.

By international standards, Germans have plenty of doctors: 3.84 for every 1,000 patients. In the US, the number is 2.46. But such statistics shed little light on how doctors are distributed throughout a country. “In some rural regions, we have a situation where a consultation might require a day’s travel for the patient,” says Wolfgang Loos, chairman of the German Society for Telemedicine. One of the solutions, he says, is that a doctor could consult patients via live video streams to the patient’s home. Digital medicine is taking hold in the field of stroke prevention and care, small hospitals and care clinics are networked and can consult specialists through video conferencing whenever they have questions. Patients with chronic heart issues can access a different form of telemedicine: some measuring instruments are connected to centralized medical networks, and if a patient’s value suddenly worsens, a nearby doctor is alerted. But telemedicine faces a number of particularly German hurdles.

Doctors in Germany, as stipulated in the “prohibition of remote treatment” (a German physician’s code of conduct), doctors are not allowed to diagnose a patient remotely without having dealt with that patient before, at least once in person.

Beyond code of conduct restrictions, patients in Germany are accustomed to, and expect, a direct line of personal contact with their general practitioner and specialist. And while most German physicians recognize huge potential in the field of telemedicine, they continue to view “direct contact between doctor and patient as indispensable.” A custom many early detractors of telemedicine in America promoted, only to be rebuffed by patients once the convenience of virtual consultations was experienced.

There are also technical barriers that inhibit telemedicine in Germany. In many regions, high-speed Internet access is lagging, making video conferencing or the transmission of large patient data files nearly impossible. The areas lacking broadband access are often the same rural regions, say its advocates, which would benefit most from telemedicine.

It appears that cloning even the most advantageous of instruments and practices of technology will need some tweaking and modification in order to be universally accepted and successful.



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.