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.