AcuteCare Telemedicine Blog


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.



Honoring Our Veterans With Telemedical Technology

As we honor our American Veterans this month, it is fitting to examine how Telemedicine, the exchange of medical information via electronic communications, has vastly changed the way deployed soldiers receive access to health care and how the new communication system promises to offer better access to care for veterans in the future as well.

When Dr. Ronald Poropatich first joined the military 30 years ago, the digital cameras and web cams required for the use of telemedicine barely existed. Yet, during his career as the deputy director of the Telemedicine and Advanced Technology Research Center in the United States Army, Poropatich helped revolutionize health care for soldiers by bringing telemedicine technology to army bases and field hospitals around the world including in Somalia, Iraq and Afghanistan.

Today, soldiers in Iraq or Afghanistan can get second opinions on tricky medical situations from doctors located halfway around the world and can receive diagnoses from medical specialists, even when none are stationed at their base.  Telemedicine has advanced greatly, allowing soldiers to email photos of electrocardiograms (EKGs) or skin rashes back to physicians back in the U.S., and receive feedback within hours.

This technology has allowed the military to spot medical conditions that would have otherwise been missed or quickly garner second opinions on cases that have the potential to warrant costly evacuations. Telemedicine has also provided a way to treat soldiers for conditions like post-traumatic stress disorder, or depression, while preserving their privacy.

The survival rate, if you can get to a combat support hospital level 3 facility in Afghanistan, is a fantastic 90 percent, but that means a lot of guys and gals are surviving horrific wounds once thought to be fatal.  So providing a telemedicine lifeline to veterans once they are back home is imperative in order for veterans to communicate with health care providers outside of in-office visits.  Accessing their care through the use of a cellphone or webcam, recovering soldiers will be more likely to stick with rehabilitation programs and outpatient treatment, ultimately ensuring better mental and physical health outcomes in the long term.

Perhaps the best way to honor our veterans is to provide them the best of medical care through the use of Telemedical Technology.



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 Availability and Quality of Stroke Care to the Underserved

The recent collaboration between AcuteCare Telemedicine (ACT), the leading practice-based provider of Telemedicine services for hospitals in the southeast United States, 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 and includes five “spoke” hospitals located throughout southeast Alabama, southwest Georgia and the Florida Panhandle.  The efforts have proven to be critical for stroke victim patients who were once underserved by the latest in life-saving technology.

The adoption and expansion of Telestroke, other acute Teleneurology support and Telemedicine applications has a significant beneficial impact for healthcare organizations, clinicians and patients alike.  Timely access to specialty Neurological consultations via Telemedicine, help many patients avoid the debilitating effects of strokes and other Neurological emergencies due to late diagnosis or delayed administration of “clot-busting” drugs.

Dr. Gwynn, ACT, Director and Founder of the Stroke Center of Northside Hospital and recent Chairman of the Department of Internal Medicine, says, “The new telemedicine health care model is an excellent vehicle to advance the availability and quality of telestroke care to patients who remain underserved throughout the region and all around the country.” In response to their success AcuteCare Telemedicine is making an aggressive push to help other hospitals and networks that don’t have immediate access to neurologists and other specialties.

Dr. Keith A. Sanders from AcuteCare Telemedicine and Director and Founder of the Stroke Center of St. Joseph’s Hospital of Atlanta, says, “We are planning on extending our successful telemedicine platform to an additional two hospitals before the end of 2013 and to an additional 3 hospitals during the first quarter of 2014 as more hospitals and health networks recognize the benefits of sharing specialist services without having to house them on-site.”