Global Opportunities for Telemedicine

Over the past year ATA has increased its presence and its role internationally. This reflects the transformation of both the market and practice of telemedicine. The mission of ATA is to be an advocate and a voice for telemedicine with government and other bodies, provide education, promote research and establish standards. This remains the priority and core responsibility of the organization. However, as telecommunications breaks through the walls of health institutions, crosses the barriers of distance and goes across state lines, so too is telemedicine starting to traverse international boundaries. The United States is not alone in deploying telemedicine. In fact, other countries have been investing millions of dollars in the development of telemedicine services and networks. Their knowledge and experience are critical to the growth of telemedicine everywhere.

ATA’s corporate, institutional and individual members now come from 50 countries. Our meeting is truly international in attendance and with the presentations. The interests of many of ATA’s U.S.-based members are international. So it is no surprise that one of the priorities of ATA’s current President, Dr. Dale Alverson has been to look at opportunities for ATA to build international bridges.

I am writing this from Xiamen, China where, as a guest of the China Ministry of Health, I addressed the Ministry’s annual conference on health information technology. I am a lucky substitute for ATA Past President Karen Rheuban who had a scheduling conflict. There are over 1,300 people in attendance and include health administrators from China’s 31 provinces as well as from the national government, major hospitals, and leading technology vendors. China is starting to invest billions of dollars in improving health care delivery to its 1.9 billion people and the national government is playing a much stronger role. At the meeting, the China Ministry of Health revealed its next 5 year plan for health care which includes building a nationwide broadband backbone to support healthcare delivery including telemedicine.

A month ago, four of us representing ATA were invited to attend and speak at a health care conference sponsored by the Tehran University Medical School in Iran. Despite the current political differences between the U.S. and Iran, it is clear that there is a real and sincere interest to learn from each other about ways to use telemedicine to provide services to the most in need. The visit was an important opportunity to start to build bridges with the health providers in that nation.

These are not isolated activities. Many ATA board members work extensively with other countries providing technical assistance and providing direct health services using telemedicine. Over the past year, ATA President Alverson has traveled to Korea, India and Nepal to speak about his experiences in deploying telemedicine in New Mexico and has been working in Ecuador to improve their use of remote care. ATA has established a Virtual International Resource Center and have started developing Memorandums of Agreements with various organizations outside of the U.S. We have two international Chapters and an International Special Interest Group.

So where do we go from here? That is a question that will be discussed by the board of ATA as well as our members in the year ahead. We remain the American Telemedicine Association but it is clear that ATA has become international already and cannot ignore the developments in the world around us. It is important to seize the opportunity to learn and work with the global community as we all seek to use telecommunications to improve the healthcare of mankind.

Remote Cardiac Monitoring: The Debate Begins

An article in this month’s New England Journal of Medicine (NEJM) (http://www.nejm.org/doi/full/10.1056/NEJMoa1010029) reported the results of a six month clinical trial which evaluated the effectiveness of a telephone monitoring service for patients that suffered heart failure. The authors of the study, based at Yale University, reported that this service had no impact on the health of the patients when compared with a control group.

In the weeks to come, this article is certain to generate a lot of comment and debate. It provides some important results and we need to assess the issues fairly. But we may see a considerable amount of unwarranted conclusions and unfair criticism of remote cardiac monitoring, of telemedicine and even of the study itself. As we have seen before, once the facts and scientific analyses end, the generalizations and misstatements begin.

Beware of the headlines. The study was narrowly focused with biases in its design that do not allow broad generalizations. I have included below some facts about the study, and a few of the lessons learned and finally comments on the validity of the conclusions.

THE FACTS

The study used a random sample of 1,653 heart failure patients with a median age of 61 who were divided evenly into a test and control group. Over six months, the test group was asked to telephone a call center daily and follow automated prompts to a series of questions about their health status. At the end of the six months a comparative study was done on the rates of hospital readmission or death of the two groups. Using statistical analyses, it was determined that there were no appreciable differences between the groups. Based on these findings, the authors concluded: “Among patients recently hospitalized for heart failure, telemonitoring did not improve outcomes.”

Despite pre-study training, approximately 15 percent of the patients in the test group never started calling in for monitoring. By the end of the study 45 percent of the remaining test patients stopped making their monitoring calls. The comparative statistical analysis was based on the entire test group, including those that failed to participate in making the phone calls.

The authors of the study decided not to use automated data collection devices in the test patients’ homes nor were medication minder devices included. Although attempts were made to remind patients who failed to make their telephone calls, the study was based on the patients initiating the calls and self-reporting their information including weight gain or loss.

LESSONS

One of the most glaring outcomes (as well as one of the most glaring errors in the study design and data analysis) was the lack of patient participation in the test group. Of the 826 patients in the original test group, only 707 ever started making the monitoring calls and by the end of the study only 390 kept making the calls. Perhaps some types of monitoring devices in the home (or maybe just an annoying reminder beep) could have improved participation. Certainly greater efforts need to be made to engage patients in their healthcare, whether that is reducing weight, taking their medicine or using technology to monitor and report on their conditions.

An accompanying editorial in the NEJM focused on several concerns. For example, telephone monitoring services may not be asking the right questions of patients, suggesting that we need to reevaluate the appropriate ongoing physiological data that should be measured for heart failure. Also more timely staff follow-up with the test patients for corrective action may make a difference. Alternatively, smart software automatically generating diagnoses and treatment plans based on the data and supplementing health provider support, may lead to significantly improved outcomes.

COMMENT

In the Discussion portion of the article, the authors chose to take a swipe at vendors and use an incredibly broad generalization about all patient monitoring: “In an environment in which vendors promote their products to health systems that are under increasing pressure to reduce readmission rates, the knowledge that telemonitoring is ineffective suggests the need to consider alternative approaches to improving care.” Even worse, one of the authors chose to write an article on the study for Forbes.com with the headline: “Why Telemedicine is Overhyped.” This raises serious doubts about any intent to be fair and balanced.

Unfortunately, we don’t know whether the test group patients that participated in telemonitoring to the end of the six months showed any differences in their rate of re-hospitalization. It would have been helpful and relatively easy to show this data. It is troubling why this was not included.

The authors made a point of criticizing previous studies as using too small of a sample, but it does not appear that they ever conducted a literature search on the subject. Despite quoting several other studies, they failed to reference a landmark study of telemonitoring by the Veterans Administration, concluding positive results, that was based on a broad grouping of patients over a longer time span.

I am concerned that in the days to come we may witness misinformed discussions and articles about remote patient monitoring as a result of some unfortunate printed malware that slanders all of telemedicine. Let’s not throw the baby out with the bathwater, especially when the bathwater may just need adjusting.

In Memoriam, Bob Waters

The telemedicine community suffered a loss this week with the passing of Robert J. Waters, JD, the founder of the Center for Telehealth and eHealth Law and a long-time leader in telemedicine. He was diagnosed with brain cancer some time ago and died peacefully on Wednesday at home with his family.

His dedication to the field and his contributions to moving telemedicine forward were enormous. When ATA was founded in 1993, Bob was one on the first people I talked to in Washington, DC about telemedicine. His knowledge and expertise of legal and legislative matters related to telemedicine never ceased to amaze me. Bob established the Center shortly after the creation of ATA and has served as a major resource for health care providers, for leaders in Washington and for ATA regarding the many legal and regulatory issues confronting the expansion of telemedicine.

Bob served for four years as a member of the board of the American Telemedicine Association. In 2005, he received the ATA’s Leadership Award for the Advancement of Telemedicine and he was among those named as an ATA Fellow in the inaugural class in 2009. Bob played an instrumental role in the development of the Interstate Nurse Licensure Compact and received the National Council of State Boards of Nursing Exceptional Achievement Award for this work in 2004.

Bob’s passing is a great loss to telemedicine, a loss to ATA and a loss to his many friends and family. I will miss his passion, his deep intellectual insight and his ability to help make the world a better place.

In lieu of flowers, the family suggests that memorial gifts be made to: The Preston Robert Tisch Brain Tumor Center at Duke (c/o Ellen P. Stainback, Box 3624 DUMC, Durham, NC 27710); The Iowa State University Foundation – Robert J. Waters Memorial Fund (2505 University Blvd., Ames, Iowa 50010); or St. Peter's Episcopal Church (4250 N. Glebe Road, Arlington, VA 22207).

For those wishing to send Bob’s family a note or card, please send those to Bob’s wife: Patty Beneke, 1604 Crestwood Lane, McLean, VA 22101. Bob's family and Drinker Biddle would like to invite all his coworkers, colleagues, and friends to a memorial reception to celebrate his life on Tuesday, November 16, 2010 from 4:00 - 6:00 pm with details regarding location to follow.

FDA is Not the Bogeyman

There has been a lot of talk and, frankly, a lot of uninformed fear about possible forthcoming regulations from the U.S. Food and Drug Administration (FDA). As FDA explores its role in the changing world of health technology there has been a lot of talk about how the agency may require certification of every cell phone or every laptop that may be used in some way for provide medical assistance. Fears that FDA regulation may cause innovation in healthcare technology to come to a standstill are just plain silly. Medical devices that are used in providing healthcare to an individual are, and should be, regulated.

Over the past couple of years a lot of entrepreneurs have looked at the growth of healthcare costs, now above a trillion dollars a year, and decided to try and get a piece of the action. Many have decided to jump into the telemedicine market. An especially attractive part of telemedicine is mHealth with low entry requirements to create a new application for a digital phone. This Spring ATA sponsored a webcast with mobihealthnews where they reported on a recent survey that identified over 6,000 applications for health and wellness for digital phones. My guess is that the number is probably over 7,000 by now.

This is a welcome development and a great sign of progress but the new entrants need to understand the realities of healthcare and medicine. It is naive to assume that medical devices will not be regulated. It is not the same as creating a new video game.

I don’t believe increased scrutiny by FDA of health applications will appreciably slow development of the quality devices and applications that will really impact the delivery of health care. In fact, regulatory approval will help gain public and clinical acceptance of these new innovations as FDA approval implies a stamp of approval. However, it will slow down those with innovations that may not be appropriate.

Telemedicine - Where Both Sides Agree

In an era of partisan wrangling over healthcare reform there is one topic which enjoys widespread support across the spectrum of politics: telemedicine. Nowhere is that more evident than at an ATA meeting to be held next Monday September 26 where the current CMS Administrator, Don Berwick and Mark McClellan, the CMS Administrator under former President George Bush will discuss how telemedicine plays an important role in the future of health care delivery. The meeting will occur during the 2010 Summit of the American Telemedicine Association in Baltimore Maryland.

Both Berwick and McClellan have talked frequently since Berwick’s appointment and both individuals support realigning quality and accountability in healthcare delivery. Of course, devotees of telemedicine are waiting for when the rubber hits the road - when real changes will take place in the payment system to support the use of such applications as remote patient monitoring, remote clinical consultations and other forms of health care provided with the use of telecommunications.

Such change is coming fast. CMS will soon announce the formation of the new Center for Medicare Innovation and rules governing Accountable Care Organizations as well as hospital re-admittance policies, both of which will support the use of telemedicine, are now being drafted.

ATA has developed several specific proposed changes in healthcare policies, which do not require legislation and only small changes in current administrative regulations. These will be unveiled next week.

After waiting so long, the future is now coming fast. Stay tuned.

ATA 2010 Summit – What a Difference a Year Makes

Last spring, the ATA staff proposed that this year’s Mid Year meeting include a Summit to showcase national leaders from government, the largest insurers, leading medical centers and other sectors that are embracing telemedicine and the changes they are spearheading to expand its use. As I look over the list of speakers who have readily agreed to participate in the Summit, I realize that there is no better sign of the change that has taken place for telemedicine.

The list includes the top or number two leaders from many organizations that would not consider the use of telemedicine one or two years ago. Today, not only are they coming to speak and meet our members but they are all talking about major new initiatives that will expand the use of telemedicine and resolve long-standing barriers. Take a look at the agenda for the Summit as well as the Pediatric Symposium and see for yourself how much things are different. I hope to see you there.

It is an incredible feeling to live through such change. Who knew that we would have to wait 20 years for things to change overnight?

Barking Up A New Tree

Changes in the way healthcare services are paid from fee-for-service to single payment mechanisms create vast new opportunities for telemedicine but shift the decision makers that govern adoption and market expansion.

Since the start of ATA, the Holy Grail for many has been the expansion of existing fee-for-service insurance programs to cover telemedicine. In a perfect world, programs such as Medicare would reimburse for the following:

• All clinical telemedicine services, as defined by CPT and HCPC codes;
• Telemedicine from any location of the patient - rural or urban;
• Telemedicine originating from any type of facility;
• Telemedicine services provided by any type of appropriate health professional; and
• Remote health services provided by any method of delivery: live or store-and-forward.

Time consuming, piece by piece efforts to expand telemedicine over the past fifteen years have focused on fee-for-service coverage, trying to convince payers, acting as gatekeepers in such a system, rather than the providers and healthcare administrators. Annual petitions to the Centers for Medicare and Medicaid Services to expand covered clinical service codes have resulted in adding about 15 services as eligible for reimbursement. Federal and state legislatures have added eligible facilities and types of providers.

Despite these efforts, overall, fee-for-service coverage for telemedicine remains a problem. Large holes in coverage remain. For example, fee-for-service programs altogether ignore paying for remote monitoring except for a few cardiac monitoring services. consumers in urban areas, about 70 percent of the U.S. population, are not eligible for most remote health services. Providers using interactive telemedicine are forced to follow complex billing and coding procedures to ensure the procedures are reimbursed.

All of this is changing. The growing trend to single payments that cover individual lives, certain medical conditions and episodes of care allows providers flexibility to use telemedicine services whenever and wherever they make sense. These alternative payment mechanisms are expected to mushroom in the next three years. Two examples:

Medicaid - In 2008, 71 percent of the 47 million Medicaid enrollees were in a managed care plan. This is over 33 million insured, up from 17 million ten years ago. This is expected to grow quickly as Medicaid starts to cover about half of the additional 30 million uninsured under health reform. Within three years there could be as many as 60 million Americans covered under Medicaid managed care programs. Of course, these plans cover lower income patients and have less incentive to use some high tech solutions. However, because cost containment is a critical factor, lower cost telemedicine solutions such as remote monitoring for chronic care populations will remain a very attractive alternative.

Medicare – While the overwhelming majority of current payments under Medicare remains traditional fee-for-service this is changing. The traditional managed care side of Medicare, Medicare Advantage, serves less than 15 percent of enrollees. However, health reform is accelerating the use of a wide-range of other, pseudo-managed care approaches including bundling of payments, shared savings, Accountable Care Organizations and Medical Homes that will transform the fee-for-service side of the program. These single, capitated payment approaches allow providers to make the decisions on the way services are provided.

This trend may spark another growth spurt in telemedicine. Under these new payment systems, decisions regarding the use of telemedicine are delegated to local and regional managed care organizations, regional accountable care organizations and healthcare systems managing bundled services. In recent years, single-payer health systems such as the Veterans Administration and countries with socialized healthcare have increasingly relied on telemedicine. The single payment approaches offer far greater incentives for using telemedicine. This is especially true for remote monitoring services.

However, whether the decisions are made by payers in a fee-for-service system or providers under single payment initiatives, the use of telemedicine will continue to be based on its efficacy and its impact on costs and access. A remote ICU initiative, outsourced imaging service, or mHealth application will still have to be proven as a trusted, worthy component in the delivery of healthcare.

What may be different with the growing number of integrated, regional, single payment mechanisms is that the use of telemedicine services will not be stand-alone programs or applications and decisions on their use will be made by providers, not payers.

It’s mHealth but will it be a Revolution?

The funny thing about “mHealth” is that it has taken on such a cult-like status among investors, industry and the media. Certainly the potential for the use of mHealth in the delivery of healthcare is huge and it may have an impact on other parts of healthcare such as chronic care management, emergency response services and the role and responsibilities of the consumer in their own health.

The market for mHealth is still in its infancy. There is still confusion about all that is encompassed in the term. It may include a mobile device or a service using mobile technology. The devices include an array of products and services that use mobile, wireless technology: cellular phones, wide-area, local-area and personal networks. These use different parts of the radio spectrum, different standards and protocols and different levels of signal strength or power. Generally the term mHealth does not include the use of satellite technology.

Some parts of mHealth are devices and services focused on direct consumer purchases and use. For example, the vast majority of the 6,000+ health-and-wellness smart phone applications are designed for use by consumers. However, when measured by dollar volume, these applications are probably smaller than other mobile devices and services aimed at the use in the traditional healthcare system.

The wide-spread media attraction in the mHealth market is because it’s new and it’s fun. It is still a bit of a Wild West atmosphere with new ideas and crazy applications coming up every day. Some include incredibly smart and exciting approaches to solving age old health care problems; others appear to be solutions in search of a problem. The investment money is flying out the door. Although there is a positive growth in sales, almost all of the mHealth companies or divisions have not yet made a profit. It reminds me a bit of the dot com (sometimes called the dot bomb) market of the 1990s. Certainly at this point mHealth is close to the top of the “hype cycle” (as described by Gartner, Inc). There are new associations and think tanks devoted to the subject, academic and commercial conferences galore. We are approaching the cycle's "Peak of Expectations."

For those on the sidelines it makes great fun. For developers and investors it is much more serious. It is a bit like a game of musical chairs. Most of the mHealth ventures are hoping to be bought up or merged into another, larger venture. At some point the music, or the outside funding, is going to stop (as we enter the Trough of Disillusionment) and those ventures not bought out or turning a profit will be in trouble.

But here is an important point – mHealth is not a stand-alone market. It is part of a mature, two trillion dollar healthcare business. To be successful, mHealth devices and services have to understand how the healthcare market operates; how it is funded and regulated; and, most important, how buying decisions are made. Developing a way to use a mobile device to measure blood glucose and send the data to another location may be interesting but is not nearly enough.

Further, relying on consumer expenditures for mHealth is probably not the answer for most such ventures. Out of pocket expenditures for healthcare in 2008 were a little below 12 percent, following a steady decline of over fifty years. This still represents a lot of money but it describes a public expectation that insurance, private or public, will pay for almost all of health care. Efforts to have consumers get more “skin in the game” will have only limited success when consumers are not even paying for their own drugs or eyeglasses anymore. Even the use of Flexible Spending Accounts will be restricted or eliminated as health reform is implemented.

Therefore, to recognize the benefits and opportunities offered by mHealth applications for healthcare delivery, they need to be incorporated into traditional healthcare financing and services. Surprisingly, despite the huge increase in health expenditures, the place where health dollars are spent has stayed relatively the same. Hospital care continues to be roughly one third of expenditures, physician services at about 20 percent and prescription drugs about 10 percent. Home health constitutes about 2 percent of national expenditures. What is changing is the source of these funds and who controls the spending. Accompanying the decline of direct consumer expenditures is the growth of public funding. On the horizon are more comprehensive regional healthcare networks with a broad authority to provide integrated, comprehensive care. This will dramatically accelerate with health reform.

The point of all of this is that the success of the mHealth revolution in the United States is directly linked with developments occurring in broader health reform and how mHealth applications may be an option for use in such developments as Accountable Care and Independence at Home initiatives. Such change is coming fast, really fast. In three to five years we may see an incredible change in the way various organizations are involved in health care delivery. It will be interesting to see how much mHealth is picked up and integrated into these changes.

Finally, assuming mHealth becomes recognized as an important component of mainstream health delivery, regulatory oversight is sure to increase. The Food and Drug Administration has played it light so far but the agency's role in reviewing and approving mHealth devices may grow. Similarly the Federal Trade Commission, Federal Communications Commission and all of their counterparts in other countries will also soon take notice and start similar regulatory oversight activities.

Telemedicine and State Licensure

State licensure of health care has become an important national concern. The National Broadband Plan, released by the Federal Communications Commission in March 2010 states: “State-by-state licensing requirements limit practitioners’ ability to treat patients across state lines. This hinders access to care, especially for residents of states that do not have needed expertise in-state.”

Fundamental to the controversies swirling around the state-based licensure of physicians are three issues:

1. Assurance of quality of care.
2. Protection of state’s rights
3. Protection of trade from outside competition

The discussion has entirely focused on assuring quality of care. However, the other two issues have been motivating factors in many, if not most, cases and are the primary reasons why national licensure approaches will probably not be adopted anytime soon.

Let’s look at the issues one at a time.

Assurance of quality

The doomsday scenario is that a physician from out of state that is not adequately trained or is not in good standing would provide inadequate care for a patient. Of course, inherent in this is the assumption that some states are lax in their policing of physicians or that becoming a doctor in some states is easier than in others.

In order to practice clinical medicine in an unsupervised setting (i.e. outside postgraduate training programs), all physicians (international graduates and domestic graduates in USA) must be licensed by the medical licensing board of the state where they plan to practice. All 50 states require passing all four tests of the United States Medical Licensing Exam® (USMLE) sequence for any physician to obtain a license to practice medicine (or for osteopaths, the Comprehensive Osteopathic Medical Licensing Examination (COMLEX)). The test is the same in every state. The differences in requirements for a medical license between the states are fewer and fewer each year. The only substantive differences are in the number of years required for postgraduate training (1 or 2 years and generally 3 years for graduates of non-U.S. medical schools) and the number of attempts and time limit for completing the examination.

Checking on whether a physician is licensed in any one state is relatively easy. For example, the Federation of State Medical Boards maintains a data base of licensed physicians throughout the United States. Similarly, each state medical board maintains a list of physicians licensed in their state and as well as any legal notice or order in the state regarding that physician.

It is significant to note that this is similar to national and state databases maintained for individual driver’s licenses. Each database is accessible by law enforcement from any state through reciprocity arrangements.

The issue of assuring quality is important in every state. Any state or local licensing authority or any medical center credentialing center can quickly check up on any doctor who is licensed in any other state.

State’s Rights

Getting closer to the heart of the matter is the reluctance of any state to cede its power to license and collect licensing fees. This makes it extremely difficult to move to any federal preemption of state law.

Money is a part of the state’s rights debate. Initial licensing fees range from $200 to $1,000 per state. With almost a million doctors licensed to practice medicine in the United States the amount of state revenues raised through licensing fees is substantial.

Trade Protection

This is the often unspoken heart of the issue in medical licensure. Physicians and specialty groups have supported strong licensure laws in an effort to block out of state physicians from providing services in their own state in competition for patients and health services. Trade protectionism - the imposition of duties or quotas on imports in order to protect domestic industry against foreign competition – is the result.

Over the years, a number of proposals have been made to negate state-based licensing of physicians and adopt a national licensure policy. In 1995, ATA worked in partnership with then Representative (now Senator) Ron Wyden (D-OR) to craft a proposed amendment to the Communications Act of 1995 that would have prohibited state licensure restrictions of interstate commerce. The American Medical Association feared that it would open the door to a national licensure policy. Under strong lobbying pressure, the Wyden amendment was ultimately withdrawn.

Academically, there have been several calls to end state licensing. A 1983 study of state-based and physician-dominated medical licensing bodies in the United States found that “Excessive restriction on entry into the profession has occurred; difficulty in developing innovations in the distribution of medical care have resulted; and severe limitations on the activities of nonmedical health practitioners who pose a competitive threat to the physician have taken place” (Medical Licensure, Social Costs and Social Benefits, Elton Rayack, Law and Human Behavior, Vol, No 213, 1983). Economist Milton Friedman goes so far as to state “It is clear that licensure is the key to the medical profession's ability to restrict the number of physicians who practice medicine. It is also the key to its ability to restrict technological and organizational changes in the way medicine is conducted.” (Medical licensure, Milton Friedman January 1994, Friedman, M., Capitalism and freedom. Chicago: University of Chicago Press, 1962).

Current ATA Policy

While there is a public interest in maintaining physician licensure as part of assuring quality of care, there is currently little political will to completely overturn state authority to license all physicians. However, the increasing demands for healthcare in America and the potential of telemedicine to provide safe, cost-effective access to healthcare calls for a plan of action. There are two approaches that ATA suggests.

Federal Programs - ATA supports the current federal policy of national preemption of state licensing laws for physicians providing federally funded health services. There are several groups of federally funded physicians who are already exempt from obtaining a license in every state in which they see patients. Military, veteran and Indian health doctors, while required to have a license from at least one state, are exempt from needing additional licenses for providing care for a patient located in another state, whether the physician travels to that state in-person or via telemedicine.

There has been talk by some parties that the same policy should be extended to physicians providing services to Medicare patients. Such a policy was suggested on page 206 of the National Broadband Plan where it states: “If states fail to develop reasonable e-care licensing policies over the next 18 months, Congress should consider intervening to ensure that Medicare and Medicaid beneficiaries are not denied the benefits of e-care.”

Intestate Collaboration - ATA also supports policy at the federal, state, and local levels creating collaborative agreements between the states allowing medical licensure portability. Specifically, ATA supports an interstate licensure process, involving reciprocal recognition, which provides adequate state supervision and licensure of physicians and other health professionals but does not continue an undue restriction on the ability of every consumer to access qualified health professionals regardless of their location.

Such a licensure arrangement is loosely based on similar arrangements that were made years ago for drivers’ licenses, recognizing the derived benefits of interstate commerce as well as the existence of national, interconnected networks of roads and highways. Reciprocal agreements for licensure also support the national priority of developing interconnected broadband telecommunications networks and using the resulting infrastructure to improve the lives of all citizens.

ATA suggests that such a process should have the following characteristics:

• Establishes a national multi-state clearinghouse where out-of-state physicians can register with other states and where the national clearinghouse provides assurances of the physicians training and competence as determined by the physician’s home state and provides the single conduit for physicians to pay applicable state licensing fees;
• Does not interfere with an institution’s credentialing and privileging process;
• Clarifies that certain health care services that do not qualify as medical practice, such as clinician-to-clinician discussions and providing health information, are not affected by state licensure laws;
• Avoids counterproductive and anti-consumer restraints on interstate commerce;
• Ensures that all patients have access to health care expertise necessary to protect and promote their health regardless of the location of the patient or provider;
• Does not restrict the use of telemedicine as a valuable service delivery strategy that can play a critical role in overcoming time and distance barriers that often limit access to quality health care;
• Does not restrict virtual travel by patients to seek medical advice outside a state, similar to situations in which patients physically travels to see a practitioner in-person in another state;
• Enables a duly licensed physician and health professional in one state to seek medical consulting medical expertise (collaborative diagnosis or second opinion) from a physician and health professional licensed in another state;
• Allows in-person encounters and virtual (telemedicine) encounters between physician and health professionals and patients who are both located within state borders to remain the purview of the state; and
• Maintains the responsibility of medical care for the patient remains with the requesting physician and health professional (i.e., care never transfers to the out-of-state physician and health professional in the telemedicine model) and that the requesting physician and health professional is the attending physician and health professional.

The Cost of Red Tape

Recently, the Centers for Medicare and Medicaid Services (CMS) came out with an interpretation of how a hospital should provide quality assurance for physicians providing health care via telemedicine to a patient in the hospital. The issue swirls around privileging, the process used by health facilities, after verification of credentials, to grant a physician the authority to provide a specific scope of patient care services, largely based on past performance, capabilities and skills. The new interpretation represents a dramatic change from the current approach in use across the country and could create a dire situation for telemedicine networks, teleradiology companies and other programs providing remote health services. It would affect all hospital-based telemedicine services across the country, including non-Medicare related services.

However, there is a chance that we might avoid this train wreck before it happens. Recent meetings with CMS officials, other leaders in the Administration and members of Congress have increased the awareness of the issue. Suggestions were offered. The seriousness was made clear. But time is running out.

The new interpretation from inside CMS would require each local hospital to individually privilege every physician providing telemedicine services to patients in the hospital. This is contrary to the procedure currently used by the Joint Commission on behalf of CMS whereby the local hospital can have a written, blanket agreement that accepts both the credentialing and privileging of the distant organization where the physicians are physically located. This has been an efficient and effective approach that relies on the quality assurance controls of the larger referral facilities where there is usually far greater expertise and close oversight of the physician’s activities.

To understand the potential catastrophic costs of such a new requirement, let’s take a conservative look at the potential cost for a single telemedicine network that, over the course of a year, uses 40 doctors to provide telemedicine services to 60 sites.

To cover the costs of privileging, there is generally an up-front application fee by the local hospital for their initial determination of privileging and a fee to maintain a physician’s privileging status every two years. A typical cost for this service would be $300 for the initial application and $150 for the renewal. All 40 doctors would have to be individually privileged at each site in the network since there is no way to predict what doctor would be needed at which local site. This works out to be a minimum of $12,000 for each site for the initial privileging fees with an additional $6,000 per site every two years for the renewals.

For the sample telemedicine network it would result in a minimum additional cost of $720,000 in initial fees plus $360,000 every two years to meet the new CMS interpetation. This just covers the fees and does not include the associated FTE cost of having 3-5 physicians meet to review and take action for each privileging determination.


For all of telemedicine nationally, the cost of this new interpretation by CMS would be astounding, certainly millions of dollars. There are 200 telemedicine networks connecting to over 3,000 sites across the United States. Plus, approximately 3,000 hospitals also contract out for teleradiology services, which, over a year’s time are provided by 20-30 radiologists per site.

Recent conversations and meetings with CMS leaders, officials in the White House and Members of Congress have resulted in an agreement that this issue must be addressed as soon as possible. The deadline for implementing this new interpretation is July 15, 2010.

Stay tuned...

Adoption of Telemedicine Accelerating

A series of news announcements and reports over the past few days provides an interesting look at the breadth and scope of telemedicine being by health professionals and consumers, worldwide.

• Almost 6,000 health-related mobile phone applications are now available for consumers and health practitioners over mobile phones according to a report released on March 1 by MobiHealthNews. Over three fourths of the applications are designed for and marketed directly to the public, the remainder are for use by health professionals. The CEO of Sprint Communications declared at a health technology conference on March 1st that wireless communications will take U.S. health care “out of the '70s.”
  
  



• On March 2nd the Virginia State Legislature unanimously approved a bill mandating that all private health insurers in the state pay for telemedicine services. Virginia becomes the twelfth state to adopt similar legislation with several more states currently considering such a move. All 50 state Medicaid programs already reimburse for remote medical imaging and over half of these state programs also pay for additional telemedicine services.
  
  



• A report just released by Manhattan Research revealed that 39% of physicians now email, secure message, or instant message their patients – a 14% increase since 2006. Dermatologists and medical oncologists are the physician specialist groups most likely to communicate with patients online.
  
  



• In recent testimony before Congress, the Veterans Administration has requested a significant increase in spending for telehealth services. The agency hopes to increase the use of home telehealth from 35,000 homes to 50,000 homes by the end of next year. A recent study of the VA’s experience found patients enrolled in home telehealth programs experienced a 25 percent reduction in the average number of days spent in the hospital and a 19 percent reduction in hospitalizations.
  
  



• A market report released recently by In-Medica, a European-based research firm forecasts that the number of worldwide gateways used in telehealth applications will increase to over one million in 2014 and to around 3.6 million in 2018.

Telemedicine and the Underserved Community

This week I had the pleasure of sharing a podium with Dr. Garth Graham, the Deputy Assistant Secretary for Minority Health in the Department of Health and Human Services. We spoke at the annual meeting of the Health Information Management Systems Society in a session titled: “Underserved Communities and the Health Information Technology Landscape – the Necessity for Partnership.”

Dr. Graham pointed out the critical healthcare issues facing underserved and minority communities and the work of the National Partnership for Action to End Health Disparities. More information is available on this initiative at http://minorityhealth.hhs.gov/.

I spoke about the potential role of telehealth in addressing some of these issues. This came out of previous discussions with the Office of Minority Health and a special meeting they sponsored on this issue several weeks ago.

It seems to me that three facts frame the issue:

1. Minority populations suffer from a number of chronic diseases at a disproportionate rate. A few examples:

• African Americans are about twice as likely to have diabetes.
• Hispanic Americans have a higher prevalence of diabetes.
• African Americans have 4.5 times more asthma-related emergency room visits.
• African American men are 30% more likely to die from heart disease.

2. For a variety of reasons, minorities have more difficulties accessing quality health care. Notable reasons include: cost; accessibility to the work place or home; travel time and language.

3. This lack of regular access to health provider is an important factor leading to greater use of emergency room visits for non-emergency conditions. The average use of emergency room visits is more than double for minorities. The average visit to an emergency room costs about $1,000 in 2007 so paying for avoidable emergency room visits has reached crisis proportions for health insurance payers, American tax payers and for those who must pay out of pocket for their health care.

So, how can telehealth help? Study after study has concluded that remote monitoring can spot health problems sooner, reduce hospitalization and use of emergency rooms, improve life quality and save money.

• A meta analysis of research studies related to the use of remote monitoring for congestive heart failure concluded that the use of remote monitoring resulted in a 27%–40% reduction in overall admissions.
• The study authored by VA national telehealth staff members, looked at health outcomes from 17,025 VA home telehealth patients. The results show that when home telehealth was used, there was a 25% reduction in the average number of days hospitalized and a 19% reduction in the number of hospitalizations for patients. The data also shows that for some patients, the cost of telehealth services in their homes averaged $1,600 a year which is lower than in-home clinician care costs.
• A study of 281 congestive heart failure patients who received telehomecare found that they experienced a 60 percent reduction in hospital admissions, a 66 percent decline in emergency room visits and a 59 percent reduction in pharmacy utilization. In contrast, the control group experienced increases in all of these areas.

Using telehealth to overcome such disparities requires a change of thinking for many U.S. policy makers.

One of these changes is recognizing that telemedicine is not just a rural solution. Historically, government grants and program targets have only supported telemedicine services for those living in rural and remote areas. Such a policy may have been appropriate when telemedicine was first established. However, times have changed. Medical devices have become cheaper, better and smaller. So too have telecommunications services. The growth of cell phones and small health monitoring devices have matched the growth in older and chronically ill populations.

Another is recognizing and paying for remote health monitoring. While recognized as an important component in the delivery of health services for veterans and other covered populations, Medicare still has resisted any effort to encourage and pay for remote monitoring as part of covered home health services.

Of course telehealth will not solve all of the problems related to the underserved. But it is a critical tool. The evidence is in, the need is well documented and the conclusion is self evident. Using telehealth to help meet the needs of all underserved populations should be a priority for the U.S. as well as all governments.

Lessons from the Snow

The past five days in Washington, DC have been a test for those who live in the nation’s capitol. Twenty inches of snow last weekend have been followed by an additional 15 inches of snow and ice this week. Roads were clogged. Snow overwhelmed the region’s snow removal equipment. Mass transit virtually stopped. For days schools, local businesses and even the federal government closed.

Many residents were trapped in their homes, far from the nearest store or major roadway and further still from doctors' offices and health professionals who themselves were unable to reach their office. More than one parent was faced with a child who suddenly came down with a fever and no way to get to a doctor to see if it was something more serious. More than one chronically ill patient became just a bit more worried that the visiting nurse was now out of reach.

But what was a temporary inconvenience for a week is a permanent problem for thousands of people who are homebound or live in neighborhoods without adequate mass transit.

Some say that telemedicine, the provision of health services using telecommunications, is only for the most rural and remote communities. For 40 years almost all federal funds for telemedicine have been targeted only for rural areas. Congress and the federal Center for Medicare and Medicaid Services have allowed reimbursement for remote health care to rural hospitals and clinics but nothing for the 77 percent of Americans living in urban areas. Even further, nothing is available to support remote monitoring for anyone at home, leaving the homebound and chronically ill to depend on a visiting nurse or to trek to the nearest health professional.

New technologies allow access to health professionals via home computers and cell phones. Sending vital signs, getting answers and even reassurance from a health professional can now be only a call away. But none of this will be available unless insurers pay for such services for their covered populations, no matter where or when they are needed.

Isolation is not always measured in miles and healthcare is not only needed in the hospital.

My Favorite Myths About Telemedicine

Last year I asked the ATA staff to come up with a list of the top myths about telemedicine. With years of fielding questions from the public, from ATA members and the press I figure they were in a good position to come up with some of the leading examples.

Yes, I admit that these are pet peeves of mine as well, so this is partly a cathartic exercise and a good way to start the new year. Anyway, here are a few of the most popular myths, in no particular order, and a brief explanation why the statement is a myth:

Telemedicine is a new, emerging field. This has been repeated in a number of articles and blogs by newcomers to telemedicine who haven’t heard of it before and, thus, believe it must be new. In fact, telemedicine has been around in various forms for about fifty years. Know it or not millions of Americans directly benefit from telemedicine every year. Be it from an MRI viewed by a radiologist using teleradiology, a pacemaker checked on via telephone or a specialist remotely checking on a patient in intensive care telemedicine is becoming pervasive. Yes, there are many parts of telemedicine that are emerging just like there are a lot of new applications related to the telecommunications industry that are emerging.

Telemedicine is only about providing health care to remote, rural areas. Certainly the early, government-funded demonstrations of remote health services targeted remote areas. Most of the 200 or so telemedicine networks in the United States were formed in order to connect tertiary care facilities in urban cores with rural clinics. While there remains a great need to provide health care to residents located outside of metropolitan areas, many telemedicine applications are being used in urban areas. Linking suburban and inner city hospitals in a network providing intensive care services and other specialty care is a fast growing phenomenon. Outsourcing radiology and other imaging services is used by hospitals throughout the nation regardless of their location. Remote monitoring, mHealth applications and telemedicine for emergency response are being deployed in every metropolitan area.

Telemedicine is all about video conferencing and, therefore, requires broadband. There are many critical needs and uses of video conferencing in telemedicine. But a live image is not always needed. Two of the most common applications in telemedicine: remote monitoring and teleradiology rely primarily on sending still images and data and don’t require live video. Medical images may need high speed lines but typically not two way and not at the same speed as high-quality video. Furthermore, the required quality of the video image also varies. Sometimes, a simple video image from a video-phone may be enough depending on the use. Broadband is important but not for every telemedicine application.

Telemedicine can be a significant threat to patient privacy. Enough already with the privacy fears. Just like in the use of networks for banking, the use of telemedicine can provide a secure, efficient way to transmit medical information without compromising privacy. With the use of data encryption, information flowing over telecommunications lines can be just as private, or even more private, that paper-based records kept in doctors’ offices and hospitals.

Telemedicine needs far more research before it can be used or reimbursed. Oh, how this one burns so many in telemedicine! Over 40 years of research has yielded a wealth of data about the cost effectiveness and efficacy of many telemedicine applications. PubMed a bibliographic database of medical research that is maintained by the National Library of Medicine includes over 10,000 citations of published works related to telemedicine or telehealth. Over 2,000 evaluative studies related to telemedicine have been published in two journals devoted to telemedicine alone. There are areas where more research can be helpful but this massive body of evidence has proven the effectiveness, safety, cost effectiveness and patient acceptance of many applications of telemedicine years ago.

Telemedicine, telehealth, eHealth, mHealth and telecare are all different. Huge amounts of time have been spent arguing about the differences in meanings about these various terms. At ATA, we take a very broad definition of telemedicine, encompassing a continuum of applications from cell phone based-wellness products to remote, robotic surgery. ATA defines telemedicine as the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care.

Telemedicine is a subset of health information technology (HIT). OK, I saved one of the best for last. There are many reasons why telemedicine and HIT are critically important and should work together. However, each operates in a different world with different objectives. Generally, HIT describes the design, development, creation, use and maintenance of information systems for the healthcare industry. Some would claim that HIT is a broad term encompassing everything touching on electronic data in health care. However, in reality there are significant current differences in the world of HIT and telemedicine. HIT is primarily focused on the electronic medical record and associated management and clinical information systems that improve the efficiency of administrative systems and back-end support for patient services. Telemedicine, on the other hand, is the use of applications to directly provide health care services. Within a hospital, HIT is mostly driven and managed by the CIO (Chief Information Officer). Telemedicine in a hospital is mostly driven and managed by the medical staff but a large part of telemedicine is not even hospital based but part of an independent monitoring service, an outsources specialty service or a stand-alone service. Telemedicine is also entirely focused on providing health services outside of the walls of a health institution, whereas HIT is primarily focused on hospital systems and, sometimes, linking hospital systems across a region. There are notable exceptions where the HIT world and telemedicine world are one in the same and there are huge opportunities for collaboration but it is a big mistake to assume that telemedicine and HIT are one in the same. They are not.