Beyond the Legislation

What a year. After months of grueling debates, public clamor and hundreds of legislative proposals, national health reform legislation for the United States is almost here. The House and Senate versions of the legislation will be reconciled and a final bill will be signed by the President early next year. Some have predicted a quick resolution of the differences between the House and Senate bills but my guess is that there will be several sticky problems forcing the debate to drag on for a few more “fun” weeks.

Once we have recovered from the year-end legislative blitz, and sampling too many holiday cookies, ATA will be developing a detailed analysis of the provisions in the House and Senate versions of the legislation (a combined total of over 3,000 pages) for how they affect the use of telemedicine. However, from a preliminary analysis of both bills it appears that Congress has ceded a large amount of the details to the administration to develop. The bulk of the bills’ substance is on various financial approaches to extend care to the uninsured as well as other basic structural changes. There are very little across-the-board modifications made to the types of services currently covered or the way in which they are delivered.

So don’t look in the legislation hoping to find a wholesale endorsement of telemedicine or any other new service or delivery mechanism.

It is not that Congress disagrees with these approaches. Instead, both the House and Senate bills provide for a number of demonstrations and have set up numerous independent processes and panels to evaluate them, implement the successes and spread the word about how they can be adopted, all without having to go back for Congressional approval. Consequently, the latest buzz-phrases in Washington are now “comparative effectiveness research” and “regional extension centers.”

Why did this happen? My guess is that the multitude of voices and horde of lobbyists and other interests advocating different approaches and services probably scared the staff and Members of Congress away from making any firm decisions. In fact, most pundits agree that Congress will be reluctant to bring up any other healthcare proposals next year after the major health reform legislation is finally passed.

This approach holds a lot of potential for telemedicine. In fact, it might accelerate what we have been trying to achieve. For example, the health reform bills include plans to test out “independence at home,” “accountable-care organizations” and “care coordination” approaches. These could end up endorsing remote monitoring and pave the way for its reimbursement. In other places, the bills call for a new CMS Innovation Center, Independent Payment Advisory Board, Patient-Centered Outcomes Research Institute and, in the House bill, a Telehealth Advisory Committee. These independent bodies could bring about significant changes in Medicare and even affect private insurance plans in ways that will help integrate telemedicine into the normal delivery of care.

But the real work is just starting. Soon, attention will turn to how the administration will implement the reform measures. Many of the proposals require regulations. Demonstrations will get underway. Various advisory panels will be appointed and given formal authority and directives. Studies will be launched.

But this will all be done in a different environment than what we have been seeing this year. There is a completely different set of lobbyists and interest groups that focus on the administration, rather than Congress. Some interests that have powerful Congressional allies are weak when it comes to the federal agencies. It is hard to predict how this will affect the final outcome of health reform on any specific topic. The press attention will shift away and the decision making will be made by the agencies largely outside of the public spotlight. This includes officials within CMS, which is still operating without an appointed director.

If we are lucky, we may get someone in the leadership at CMS that understands technology. But even then, it will be an important task for ATA and our members to get the embattled workforce at the agency to embrace new ways of delivering care.

This is the largest piece of legislation passed in many years and its full impact will not be felt, or understood, for a long time. As members of ATA, you can expect to hear many details over the coming months and may be asked to weigh in on a number of pending issues as the details of the legislation are put into place.

Standards of Care - Key to Telemedicine’s Growth

ATA recently announced new telemental health practice guidelines. Such guidelines and associated efforts to create Standards of Care for telemedicine are important from several perspectives:

Payer Acceptance

Private insurers, employers sponsoring their own employee health insurance plans, government agencies and consumers are all payers of health care. A commonly expressed concern by many payers is that telemedicine is still an unproven practice and needs additional time and research before being considered for payment. Interestingly, such views are not as strong in closed systems such as the VA or in countries with socialized medicine. The real fear is uncontrolled spending, fraud and abuse.

The development of practice guidelines can help payers control utilization as well as assuring a degree of uniformity in the delivery of telemedicine. ATA has been contacted by a couple of payer organization about our progress in developing practice guidelines.

Avoiding Legal Negligence

According to law (and Wikipedia) the standard of care is the degree of prudence and caution required of an individual who is under a duty of care. A breach of the standard is necessary for a successful action for negligence. For medicine, a standard of care is a medical or psychological treatment guideline, and can be general or specific. It specifies appropriate treatment based on scientific evidence and collaboration between medical and/or psychological professionals involved in the treatment of a given condition. The legal standard of care for medicine varies from state to state, but the further use of telemedicine may result in national standards of care, at least for the most common uses.

Recently, a law suit was filed against a hospital for negligence for NOT using teleradiology. In this and a similar case, the suit claimed that patient was harmed because the hospital failed to use teleradiology to provide imaging services. The suits claimed that, because of the widespread use of teleradiology by many hospitals, the lack of access to a radiologist violated the established “standard of care.” While the cases were all settled out of court, the point has been made and hospitals everywhere should be considering such use to avoid a similar legal challenge in the future.

The development of practice guidelines for telemedicine applications, especially those accompanied by a documentation of empirical evidence, moves us closer to having that application recognized by medicine, and by the law, as a standard of care. Certainly the existence of practice guidelines alone is not sufficient proof of the existence of a standard of care. But it certainly places one more stake in the ground. If such practice guidelines are also endorsed by the relevant medical society, it goes a long way in establishing the legitimacy of such use.

Regional and Worldwide Partnerships in the Delivery of Health Care

Health care delivery in America is still largely local, or at least regional. Internationally, health care delivery is mostly confined to the boundaries of the country. Physician shortages, increased costs and global travel are setting the stage for a shift in how care is delivered. Practice guidelines will help assure that no matter who is providing care in whatever location, there will be uniformity in the care delivered. It will also allow new forms of partnerships between various healthcare providers and payers.

Telemedicine Ballyhoo

The road from hype to real is bumpy. Many telemedicine applications are, finally, now on that road, some ahead, some far behind. To shepherd the applications along some tough decisions needs to be made.

Gartner, a consulting firm has created a “hype cycle,” a graphic representation of the sudden growth, adjusting dip and final adoption of specific technologies. Several people, including myself, have indicated that many applications of telemedicine are starting to enter such a hype cycle. M-health is one clear example where the amount of public comment and exposure has accelerated. Other services have clearly moved beyond early adoption and into the mainstream of health delivery bypassing any public hype. Two examples are teleradiology, used by a large percentage of hospitals, and remote cardiac monitoring, serving 4 million patients in the U.S. The practices are sound, the effects are clear and there are structures in place to appropriately regulate providers. But much of these services have been growing without any public attention.

For those involved in telemedicine for any length of time, the idea of telemedicine being the latest hype in health care is amusing. ATA started in 1993 and it has taken years to get telemedicine recognized by the medicine and technology communities.

So the rise in press coverage over the past two years has been amazing. The chart shown here depicts the increase in the number of articles per month about telemedicine or telehealth, growing from 600 in January 2008 to 2,200 in October 2009.

This increased attention comes with both the good and the bad. Increased attention by payers in the U.S. and other countries has spurred investments, changed policies and increased adoption. However, we need to be prepared for unwanted attention to inappropriate applications that pass themselves off as telemedicine.

Now that cheap-to-develop and easy-to-access applications are available directly to the consumer via such devices as mobile phones and Internet web pages, a host of quack applications have emerged. Just because it is remote healthcare doesn’t mean it is good healthcare.

ATA has opposed any attempt to have the U.S Food and Drug Administration regulate core computing technology and telecommunications devices used in telemedicine. A cell phone and a PC are not medical devices. However, there is a clear and growing need to regulate the growing list of pseudo-medical applications that are becoming widely available to consumers. The technology and telecommunications industry needs to get behind such regulation and should recognize their potential legal exposure by ignoring what is being offered to their customers.

Ford Produces an Electronic Health Record for Cars

Car owners can now get a text message of their car’s health. Why can’t we get something similar for ourselves?

The Ford Motor Company offers an option for car owners to develop and track a VHR – Vehicle Health Report for several of its models. The data links to a website, http://www.syncmyride.com/ using the customer’s Bluetooth-paired and connected mobile phone.

A comprehensive report is generated from the vehicle data that includes system information and uses diagnostic software to generate recommended actions for any vehicle warning indicators, open recalls, scheduled maintenance, and unserviced maintenance and wear items from previous dealer visits.

Users can select to receive a text message or e-mail when their report is ready. They can print the report, e-mail it to others or, in one click, be at their preferred dealer’s Web site with their health report information waiting to schedule service online. Depending on the user’s preference settings, SYNC can also deliver a text message alert to the user’s cell phone if a severe issue exists with one of the SYNC-monitored systems.

A sample VHR is available at http://www.syncmyride.com/Own/Modules/VHR/vhr_pdf_sample.pdf.

Here is the bottom line:

1. We now have access to better, faster and more consumer-firendly information including automated diagnostics for our car than for ourselves.
2. Most of the current HIT hullabaloo focuses on agreeing on a simple electronic health record that is still primarily intended for use by a health professional, that is mostly only for static data and without any built-in capabilities for decision-support diagnostics.
3. Electronic medical record? Electronic health record? Personal health record? We can’t even agree on a name.

Efforts to move forward have been stopped in their tracks with statements such as: "you don't understand how complicated this is" or "we need to make sure privacy is completely protected" or “we need to make sure it is compatible with every other system” or "we need to investigate the ownership of the medical data." Many say an electronic health record can't be done without millions of government dollars and years of work.

Yet somehow Ford, the company that almost went out of existence last year, came up with a solution!

Of course, this is not the first time the problems of developing an interoperable, consumer-friendly and secure record were overcome. Years ago the financial industry linked together worldwide interbank networks, which are the magic behind ATMs. They are interoperable, work consistently with a very high level of privacy and security and developed with the consumer in mind.

Finally, it is interesting to point out that the ATM networks and now VHRs were implemented without years of government investigation, research and incentives.

Shaman-Based Triage for Telemedicine

In many parts of the world, large segments of the population still fervently believe in the powers of supernatural healers, a shaman, witch doctors and the like. This causes problems when modern medicine starts to be introduced into a culture with a history of such beliefs. In remarks at a recent meeting in Cartagena, Colombia, ATALACC President Silvio Vega recounted a story where telemedicine ran up against such a case in the indigenous community of Hato Chami in Panama. The town is too small and impoverished to afford a physician on site so a small office was set up with a video phone and a few other telemedicine devices and connected to a rural hospital in another part of the country. This provided a stark contrast between the traditional and the new, making it even harder to gain acceptance by the residents of modern healthcare.

Wary of modern technology, the town’s Ngobe-Bugle Shaman was provided a free office next door to the telemedicine office. Often the Shaman is the first one to see a patient and is a major opinion leader in the community. When a patient sees the Shaman and has a mild problem, not requiring advanced medical attention, he takes action and “heals” the afflicted. In more serious cases he can refer the case to the telemedicine office. Of course, that is especially true if the case involves a lethal snake bite or other problems that may end up being fatal! This implied endorsement by the local, trusted healer has enabled many people to accept the ways of modern technology. In this manner, the Shaman also maintains a good record with his followers.

If you have other stories of telemedicine blending the old with the new feel free to share them in the comments section.

A Report on the Status of Telemedicine from the Three C’s

Over the past ten days I have been on the road speaking and participating in a number of completely different telemedicine-related meetings including the Canadian Society of Telehealth in Vancouver, Canada, a cellular industry conference in California and the Cartagena Telemedicine Conference in Colombia. Talking with these three groups in the three “C’s” (Canada, California and Colombia) provided an interesting opportunity to get a bigger view of where telemedicine is going. Despite the global recession, the diversity of applications continues to grow and the enthusiasm is bigger than ever.

Canada

Overall, telehealth continues to grow in Canada, but there are noteworthy differences among the regions. The economic downturn has significantly affected the support of the Canadian government for Provincial telehealth programs. Consequently, some programs, especially those in the more rural provinces, have been forced to cut back. Alberta, facing the double issue of a reduction in federal funds and a decline in oil prices has reduced funding and postponed other proposed telehealth projects. On the other hand, the Ontario Telehealth Network (OTN) has grown despite the economic downturn. OTN, now operating with a staff of 200, runs a province-wide health call center for the citizens of Ontario and has significantly expanded its remote clinical services programs providing services to 660 sites across the province. A couple of the provinces have also made significant investments in home telehealth over the past two years. The meeting in Vancouver was filled with discussions and presentations about amazing number of sophisticated telehealth programs extending health care to the remote tribal and First Nation communities.

The meeting was the last official meeting of the Canadian Society of Telehealth (CST). The group has decided to merge into COACH, a Canadian health informatics organization where they will remain an identified group within the larger organization.

ATA has had a great relationship with many of the Canadian telehealth programs as well as CST. About 150 members of ATA are Canadians and I have had the pleasure of attending many of the past CST annual meetings. Dr. Ed Brown, the director of OTN, is on ATA’s Board of Directors and Dr. Mo Watanabe from Calgary is a past board member.

California

The Cellular Telecommunications Industry Association represents the operators, transmission companies, cell phone makers and application providers in the wireless market. The CTIA meeting in San Diego was focused on business and related applications. It was not the primary annual meeting of the association but was attended by at least 5,000 attendees. Wireless health care, mHealth, was a new focus at the meeting and was clearly a hot topic for attendees. I spoke on a panel sponsored by Mobihealthnews and ATA had a booth on the exhibit floor in an area sponsored by Qualcomm, under the direction of Qualcomm Vice President, and ATA Board Member, Don Jones. The area also included the participation of several wireless health companies.

An important highlight from the meeting was news that CTIA teamed up with Harris Interactive to conduct a nationwide survey that found 78 percent of the U.S. is interested in mobile health solutions and 15 percent of the U.S. is extremely or very interested in learning more about mHealth. About 19 percent of the people surveyed said that they would upgrade their current mobile phone plan to gain access to mHealth services, while some 11 percent admitted that they would even switch their wireless service provider to receive mobile healthcare services.

It was definitely a crazy time for ATA, even with three staff on site. Alice Watland, Del Tillman and I were overwhelmed with attendees crowding around the ATA booth asking for information about telemedicine. Many developers and technology companies are getting into the market with exciting new applications. A group of state legislators also were in attendance and ATA took the opportunity to have conversations about Medicaid, licensure and other regulations with several of them.

Two relatively new organizations interested in wireless health were also present at the meeting. The Wireless Life Sciences Alliance (WLSA) is a trade association that is described as an international think tank, although it has become much more in recent years. The WLSA is chaired by Rob McCray, who comes from major positions in the healthcare industry. Also, David Aylward, the Executive Director of the new mHealth Alliance, was also at the meeting. The Alliance is a partnership recently formed by the UN Foundation, The Vodafone Foundation and Rockefeller Foundation to support and advance mobile health initiatives in the developing world. ATA has had discussions with both organizations about possibly partnering on a variety of activities.

There are two take-away messages from the meeting:

1. The wireless industry clearly sees healthcare applications as an important new area for investment. Speakers at the meeting, from the Chairman of the FCC to the head of Verizon Wireless to the CEO of CTIA, mentioned the importance of health applications in their speeches.
2. ATA is in an important position with the exploding interest in wireless health. Recent ATA comments before the Federal Communications Commission regarding wireless broadband and “wireless body networks” were snatched up by many of the attendees. They are available under the Public Policy area on the ATA web site. ATA’s contribution in this area includes the fact that we represent health providers and traditional health institutions as well as our expertise and presence with a number of government bodies.

Colombia

The Cartagena Telemedicine Meeting, hosted by Jorge Velez, was attended by over 100 people from around the region. Silvio Vega, the current chair of ATA’s Latin America and Caribbean Chapter (ATALACC) provided an excellent overview of telehealth activities in the ATALACC region. I was shocked at the growth and diversity and have asked Silvio to prepare a written report to be posted on the ATA web site. There are several U.S. hospitals that provide healthcare using telemedicine to areas of South America. However, more important is that almost every country in the region has at least one telemedicine program of their own and many have several. The Health Ministry of Mexico announced that they will start coordinating 17 different telehealth programs that operate throughout Mexico, which include the participation of 148 educational institutions. Government funded telemedicine centers exist in Colombia and several other countries. Panama is using telemedicine for its prison population. A program in Venezuela has extended to 17 sites within the country and four more in neighboring Equator. Plus, private remote cardiac monitoring companies are witnessing significant growth and already consider South America a profitable market for their services.

I’m looking forward to the ATALACC meeting in Puerto Rico this December. It will be very interesting to learn more about the current state and the future directions of telemedicine throughout the Caribbean and Latin America.

Are We Walking-the-Walk?

An important question that was asked at the first meeting of the ATA’s new Institutional Council was whether any of the institutions provided telemedicine as part of the employee benefits for their own organizations. Scott Simmons of the University of Miami reported on their progress in extending telemedicine for employees of the University’s Medical Center. Someone mentioned that Cisco has started such a demonstration for their employees. But no other institution raised their hand.

Thus, Walk-the-Walk was born. Walk-the-Walk is a challenge to every organization that belongs to ATA, institution and corporation, to include telemedicine benefits for your own employees. It may not be comprehensive for all health services but at least provide some form of benefit should be provided - if not by us then who?

Some organizations may think they are too small; others may face challenges with their established health care providers or insurers. But it is surprising what can be done.

Even a small staff with limited resources can make a start. Within ATA, we are trying out an agreement with a local practice, DocTalker, to provide brief telephone-based consultations for ATA staff. This is provided in addition to our regular health insurance and allows a staff member to communicate with a health provider, remotely and almost immediately, at any time. Based on an initial in-person consultation, calls are usually no more than 15 minutes long and provided at a very inexpensive rate. In addition to providing telemedicine to employees of ATA, it may reduce use of more expensive urgent care centers and emergency rooms - and may even reduce our insurance premiums.

So, over the next year let us know if your organization starts to offer such benefits. We hope to keep track of the progress.

Maintaining Balance as We Leap Ahead

ATA was originally formed with an intention to be a medical society. Members were expected to submit their credentials upon joining ATA. This quickly changed as ATA's membership expanded to include both individuals and companies. In addition to individual and corporate membership categories, a new category, institutional membership, was created for hospitals and other non-profit healthcare organizations by then ATA President Ron Weinstein.

The governance of ATA has also reflected this diversity. Members of the board have included individual providers as well as representatives of corporations, governments, academia and provider groups.

Corporate Circle members formed an Industry Council to provide a forum for discussion as well as an advisory body for the Association. This year, ATA brought together representatives from our Institutional members into a new Institutional Council. Like the Industry Council, this new group will serve as a forum and advisory body for ATA. Members have suggested a number of topics for discussion including comparing various governance and administrative structures used for telemedicine operations within their institutions. A list serve and web page is under development and more discussion will be held before the group’s next meeting at ATA 2010.

In telemedicine, the players are always changing and growing. It is critical that ATA spread our wings to bring in new voices and new approaches to provide health care using telecommunications. In ATA's programs and in ATA's governance we strive to strike a balance between traditional hospital-based telemedicine networks; home telehealth organizations; outsourced, telemedicine-based specialty services; remote cardiac and vital sign monitoring companies, MHealth wireless service developers and a growing list of others.

Over the years people have sometimes come to me complaining that ATA was just a puppet of industry, or of the U.S. military, or academia, or the institution employing ATA's current President. It's always difficult maintaining a balance. But that is what ATA is all about. Many of the members and staff of ATA like to say we are part professional association, medical society and trade association.

But with all of the changes ATA has seen since its start in 1993, one thing has remained constant: all of ATA's members are focused on the individual and providing better care, whether it is a patient in another institution, a consumer using a wireless phone or someone homebound with a chronic disease. This is what sets us apart from such related fields as health informatics. With this shared commitment, together we can all learn a lot from each other.

The Conundrum of Internet Prescribing

For several years ATA has been drawn into controversies surrounding the online prescribing of medications. Some issues in this area are clear but many others are murky and have become even more blurred with biased statements by groups on both sides with an obvious self interest.

Over the past few years, ATA worked with Senate and House staff and related regulatory agencies on limiting online access to controlled substances. The 2008 Ryan Haight Online Pharmacy Consumer Protection Act includes language to protect telemedicine programs from federal efforts to close down sites that illegally sell controlled substances. The Administration is now finalizing their final regulations regarding the Act and they should be made public soon.

ATA has also been asked to comment on recent court judgments against physicians convicted of prescribing in states where they did not hold a license. Other issues related to state licensing, who can prescribe, and the bases for making a prescription are but a few of the issues in question.

It’s complex. Lawyers, politicians, regulatory agencies, advocacy groups and many others have weighed in on parts of the controversy. In some areas, state laws vary and contradict each other as do laws in other countries.

Clearly, ATA cannot and should not attempt to clear up all of the issues surrounding internet prescribing. However, as telemedicine and telehealth grows and the use of telecommunications to provide health services expands, it is important to identify areas of interest to our members with recommended policy solutions. A white paper outlining some of the issues has been posted on the ATA website at http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3335.

Telemedicine, Telehealth, Remote Monitoring and the Latest Congressional Health Reform Proposal

This week, the United States Senate Finance Committee announced its proposed health reform bill. This is the last of five proposals in Congress (two in the Senate, three in the House) to come forward. The proposals in the House are being combined into one bill and the same will probably happen in the Senate. Although it has already come under attack by many groups, the Finance Committee proposal, put forward by Sen. Max Baucus (D-MT), has been touted as having the best chance of actually going forward. So it’s important to take a look at the provisions and how they affect many of the areas of interest to ATA members.

The Finance Committee issued a document that describes the proposed bill in relatively plain language. It’s available at http://finance.senate.gov/sitepages/leg/LEG%202009/091609%20Americas_Healthy_Future_Act.pdf.

The comments and referenced page numbers here are based on this document.

Much of the bill takes a broad approach to health reform; financing, insurance options, etc., and it rarely gets into specifics on coverage issues. So it’s not surprising that the bill does not include the specific recommendations put forward by ATA. Nor does it include some telemedicine provisions that are included in the House bill, such as the establishment of a Telehealth Advisory Committee. But it does address many areas directly related to the use of telecommunications technology and health and opens the door for more specific provisions that might get added later.

• The bill calls on the federal Center for Medicare and Medicaid Services (CMS) and other parts of the Department of Health and Human Services (HHS) to compile data and launch pilot programs designed to reduce hospital readmissions. It is widely recognized that the use of remote patient monitoring is a safe and effective approach to reducing such readmissions. It gives the Secretary of HHS, working with a newly proposed Innovations Panel, the authority to include readmission rates as part of an incentive payment policy for health institutions. Language beginning on page 97 of the document addresses recommendations made by the Medicare Payment Advisory Committee (MedPAC) about readmissions. The bill calls for immediate data collection and enforcement actions related to this issue starting in 2012. As part of this approach, language on page 99 also calls for a new “Transitional Care” pilot program with an authorization of $500 million over three years. Remote monitoring is not specifically mentioned but the examples provided of appropriate services could lead one to conclude that remote monitoring is a logical approach.
• In setting up a new CMS Innovation Center (page 90) the bill directs the Center to test models of delivery that include the use of care-coordination for the chronically ill and the use of home telehealth technology. In each of the models to be evaluated, the bill calls on the Center to include “patient-based remote monitoring” as one of the approaches it tests in developing patient-centered delivery and payment models.
• Under Title II – Promoting Disease Prevention and Wellness, (page 69) the bill provides that Medicare beneficiaries would have access to a comprehensive health risk assessment by 2011. “The assessment could be provided through an interactive telephonic or web-based program or during an encounter with a health professional. The Secretary would also set standards for the electronic tools that could be used to deliver the assessment.”
• A Workforce Advisory Committee would be established (page 107) to address issues of provider shortages. The Committee is to develop a national strategy to address the issue. The language refers to the role of health information technology in addressing such needs.
• The bill endorses the use of a medical home (page 77) and includes references to using health technology to link services and the provision of service virtually.
• Demonstration Projects on Culture Change and use of Information Technology in Nursing Homes are proposed (page 183). The bill would require the Secretary to conduct two demonstration projects for nursing homes: (1) for the development of best practices for facilities involved in culture change; and (2) for the development of best practices in facilities for the use of information technology to improve resident care. The Secretary would be required to submit a report to Congress after completion of the demonstration projects. The report would evaluate the projects and make recommendations for legislation and administrative actions. The demonstration projects cannot exceed three years.

Much work remains and there are still opportunities to add or change certain provisions. Such provisions might be in the form of amendments to the bill in Committee, on the Floor of the Senate, in conference with the House or in report language that would accompany the Senate bill or the final joint bill. Also, language already in the consolidated House bill relating to telemedicine may be expanded and inserted in the Senate bill.

Stay tuned.

Telemedicine and Health Reform: a little progress, a lot of hope

Over the past few months you have heard a lot from ATA about the various machinations going on with national health reform. Starting out with high hopes we have witnessed the usual highs and lows of the legislative process. ATA has promoted a broad expansion of governmental support for telemedicine, only to have parts of it dashed by a few parties that refuse to consider what telemedicine can do for cost savings and improved quality of care. However, most of our problems are that telemedicine is lost under the shouting and publicity around the overall costs of health reform.

However, telemedicine has a lot of friends in high places.

Yesterday, the Federal Communications Commission held a workshop on healthcare and broadband. It amounted to a love fest for telemedicine. President Obama's Chief Technology Officer, Aneesh Chopra, gave a strong close. He stated: “We can’t move forward in advancing our nation’s health reform goals without the appropriate use of technology and telemedicine is a key component.” He went on to recount personal experiences and his perspectives on how critical telemedicine can be for the nation. Clearly, Chopra gets it.

In addition to Chopra, three important members of ATA were asked to speak at the meeting: ATA President Karen Rheuban, ATA President-Elect Dale Alverson and Chair of ATA’s Standards Committee Nina Antoniotti. All three gave outstanding presentations. Details of the meeting and a recorded version of the webcast are available at: http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3337#updates

How Big IS Telemedicine?

If I had a nickel for every time I was asked this question...

There are some interesting facts that have recently come out about the telemedicine market (explained below). However, much to the consternation of many reporters and entrepreneurs, there is no single answer to this question for four good reasons:

1. Transparency - Telemedicine is not a separate specialty. In fact, many successful applications of telemedicine are simply folded into the normal clinical practice. A patient may come in to see a dermatologist from the waiting room or online or the doctor may have a case sent via email. Unless there is a specific billing or administrative reason the services may never be coded to reflect the modality used in delivering the service. This is probably most apparent in radiology where millions of reads are provided each year and it never matters (and is seldom tracked) whether the radiologist is next door or a thousand miles away.
   
2. Multiple payers - Back to the radiology example: that read can be billed through Medicare, Medicaid, a hundred different private payers, or inside a closed system such as the U.S. Veterans Administration or another country's socialized health plan. Even if it were identified as a "remote" service, going to each payer and extracting the data would be impossible.
   
3. Equipment or service? - When someone asks about the market they could be referring to how much equipment is sold, the value of the health services provided, or the revenue generated by associated vendors such as telecommunications companies.
   
4. What is telemedicine? - Interactive videoconferencing, remote monitoring, consumer-based wireless health, remote interpretation of medical images and internet-based medical education are all part of telemedicine.

However, a few recent studies have revealed that we are now talking about a multi-billion dollar market with double digit growth. Here are three recent reports:

• Wireless devices that monitor patients' condition and report the data to health care providers are expected to show a 77 percent compound annual growth rate resulting in global revenue of almost $950 million by 2014, according to a new study from ABI Research. The group also concluded that over the next five years the market for wearable wireless sensors is set to grow to more than 400 million devices by 2014. Demand will come from the professional healthcare, home healthcare and sports and fitness markets, but these markets will develop at different speeds and will support different applications. The sports and fitness market represents more than 90 percent of the market today.


• According to a recent report from Parks Associates, the U.S. market for wireless home-based healthcare applications and services will grow at a five-year cumulative annual growth rate of over 180 percent and become a $4.4 billion industry in 2013.


• In 2008, the global videoconferencing market grew 24% to $2.4 billion, according to Roopam Jain, a technology analyst at Frost & Sullivan. The firm forecasts the market will more than double, to reach $5.7 billion by 2013.

Another study documenting savings from remote monitoring
– how many more do we need before change is made?

A study just published by the Journal of Medical Internet Research (J Med Internet Res 2009;11(3):e34) looked at the use of home-based telemonitoring on a group of patients using mobile phones. The study, conducted in Austria, was based on a group of 120 randomly selected CHF patients divided into a control and “tele” group. The results were predictable, “home-based telemonitoring using mobile phones improves outcome in CHF patients and reduces both frequency and duration of heart failure hospitalizations.”

Other research studies have reached similar conclusions. A study published last year about the use of remote monitoring in the Veterans Administration documents a 19% reduction in hospital admissions and 25% reduction in the days of care. A systematic analysis of telehomecare studies published last year (Telemedicine and e-Health November 1, 2008, 14(9): 896-904. doi:10.1089/tmj.2008.0009), concluded that total cost, cost per patient and cost per visit were all reduced by telehomecare.

So, with this growing string of academically sound research studies documenting significant savings from the use of remote monitoring, why haven’t governments and payers leaped at the use of such services? The well-worn conclusion, especially by researchers, is that more research is needed. However, a load of other healthcare policy decisions have been made based on considerably less documentation and much less experience.

One problem appears to be the age-old silo mentality that resides with governmental budget and private insurance analysts as well as separate department administrators.

For example, much of the savings from remote monitoring appears as reduced use of hospitals and emergency rooms. However, achieving such savings means a small investment in home telehealth services, traditionally pigeonholed within “home care” or “home health visits” by departments. Many analysts and administrators of those departments only see home telehealth as increasing costs. They don’t recognize or care about savings accrued in other areas.

It is the “that’s not my department” view that has retarded the use of telemedicine in many areas.

All of us who care about telemedicine and see what a difference it can make need to be aware of this issue. As health reform in this country as well as other countries is implemented, we need to explain that the benefits of telemedicine spread throughout the health care system. It can fundamentally change the way health care is provided and positively affect many different areas.

Telemedicine is Changing and ATA is Evolving

The world of telemedicine, is changing rapidly and radically. ATA is also undergoing significant change. I want to share a couple of these changes with you and explain why they are occurring.

Building on the foundation of programs and services established over 17 years, ATA is realigning our activities, our structure and even our look to ensure that the organization continues to be current, healthy and a change agent for the use of telecommunications technology in healthcare. Two weeks ago, ATA’s new board of directors, under the leadership of ATA President, Dr. Karen Rheuban, affirmed the critical need for ATA to set forth a bold vision for the delivery of healthcare in the future and move aggressively to make such a vision come true, both in the United States and around the world.

ATA’s Leadership: Over the past two years, the composition of the Association’s board of directors has changed dramatically. This reflects the evolving nature of telemedicine and the diverse roles it plays in the delivery of healthcare. Complementing the historic core of ATA’s board, which includes leading administrators of telemedicine programs, academic experts and healthcare providers, is a new group of world-renowned leaders in a number of parallel fields. They include:

• S. Ward Casscells, MD, former Assistant Secretary of Defense for Health Affairs
• Molly J. Coye, MD, MPH, President and Chief Executive Officer, CalRHIO
• Bernard Harris, MD, Founder of the Harris Foundation and CEO of Vesalius Venture Capital
• Don Jones, Vice President, Business Development Health and Life Sciences, QUALCOMM
• William Paschall, Director of Healthcare Applications, AT&T, Inc.
• Lord Roger Swinfen, Member of the UK House of Lords and Founder of the Swinfen Charitable Trust
• Reed V. Tuckson, MD, Executive Vice President, Chief of Medical Affairs, UnitedHealth Group
• Yulun Wang, PhD, Chairman & CEO, InTouch Health

Full bios ATA’s entire board is available at www.americantelemed.org/i4a/pages/index.cfm?pageID=3329

Communications: Web 2.0 and social networking are important tools for networking, training and innovation in healthcare delivery. ATA is an early adopter of such new technology in order to foster growth and change. This moves beyond using Facebook, LinkedIn and Twitter to communicate ATA’s message. It involves using technology to fundamentally transform the way information is created and decisions are made. ATA’s use of list serves, its presence on the Internet and use of social media are all expanding. For example, a variety of new content partnerships with Meltwater News, Homecare Technology Report and others will make both the front page and many inside sections of ATA’s web site much more dynamic and relevant to a variety of users. Changes in communication networks, open content and open databases will foster to new dialogues, sharing of information and create new ideas and products across a broad spectrum of interests.

Public Policy: Public policy has always been a key priority for ATA and this year it is more important than ever. But, like never before, it is apparent that we can’t do this alone. Development of an online petition, http://www.telehealth4us.org/, has provided a vehicle to gather outside support for telemedicine and has been wildly successful with hundreds of associations, healthcare providers and individuals signing on. We continue to reach out to additional provider and consumer groups, public interests and others to demonstrate broad-based support of telehealth legislation. We have also recently added a State Telemedicine Policy Center website focused on state government activity affecting telehealth - notably insurance laws, Medicaid and telehealth networks. We are steadily expanding it with our compiled information. We will need your collaboration to keep it current and accurate.

Let me hear from you.