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Seven Market Trends

2012-01-04T15:33:00.002-05:00

The telemedicine market is expansive, multifaceted and growing. I have selected seven topics for brief comments and predictions as we start 2012:

1. Shifting away from reimbursement and from CMS decision-making

It’s been the Holy Grail for telemedicine in America. But the rapid growth of managed care, Accountable Care Organizations and medical homes are changing the way telemedicine services are paid, away from the fee for service model. One quarter of all Americans, 73 million patients, are now covered under a managed care health insurance program. With such shifts the focus of decision-making is gradually turning to local and regional healthcare decision makers.

2. Telemedicine as a standard of care

Medical images, x-rays and the like, have been viewed in digital form for forty years. Teleradiology is now so common that many hospitals don’t use the term – outsourcing radiology, at least for after-hours, is just the way things are now done in healthcare. It has become so common that providing 24/7 services by a radiologist, relying on teleradiology where needed, may be the first part of telemedicine to become a true standard of care. Such standards are included in state, federal and Joint Commission requirements and serve a basis for court decisions on legal liability that hold hospitals accountable. It would not surprise me to see a legal suit decided on this basis, it has already been raised in a few cases.

3. Emergence of independent remote clinical enterprises

Outsourcing the interpretation of radiological images is now used by most hospitals in the U.S. Independent diagnostic testing facilities have been around since 1998. Now, a relatively new and related market is the use of private firms of medical specialists to provide remote clinical consultations. A series of vendors have sprung up to do just that for stroke care, mental health, hospitalist and intensivist services, and dermatology. Some may be considered competitors to hospital-based telemedicine programs serving smaller clinics while others may be contractors to the hospital. Look for mergers and expansions of such enterprises as the market starts to take off.

4. The rise of virtual medical centers

In October 2011, Mercy Hospitals announced that it would build a $90 million virtual care center near its headquarters in Chesterfield, MO. The specialists will be located at one site and serve patients in outlying centers across the four states in which Mercy operates: Missouri, Kansas, Arkansas and Oklahoma. On a smaller scale, intensivists at Inova Health System in Virginia are based out of a corporate office building and provide remote ICU services to 122 ICU beds throughout northern Virginia. Other health systems are looking closely at these developments and, if successful, will start on their own versions of virtual centers.

5. mHealth

mHealth is still a sizzling subject and is an important addition to the mix of technologies changing the way healthcare is delivered along with other innovations such as social networking, “Big Data” and personalized medicine. In June 2010 I wrote that we were at the top of the hype cycle for mHealth. I was premature. Wild promises, naivety about the way healthcare is paid for and delivered, and investors throwing money at some, well, “interesting” devices and services have continued. Mobile health apps are multiplying exponentially. No doubt there will be some upcoming market adjustments, but wireless technologies will continue to help redefine what we mean by telemedicine.

6. Programs vs. networks for multi-site telemedicine operations

Federal grants have helped to establish about 200 telemedicine programs linking multiple health centers throughout the country. Almost all have been based out of one large medical center, operating a hub-and-spoke program that allows the medical center to provide remote clinical and educational services to connected spokes. Such a design can expand a center’s competitive footprint and increase referrals. An alternative approach connecting multiple centers, clinics and offices based on a true network design is starting to gain favor. Such a network is typically financed by paid memberships from participating sites and grants rather than clinical services fees. Services can be delivered from any site on the network to any other site. An early model is the Arizona Telemedicine Program. The Ontario Telehealth Network is a classic model of his approach.

7. Multi-nationalization

Once confined largely to international charities to under developed nations and a few remote image-reading centers, telemedicine is poised to become a major source of international trade. Global investments in high-speed networks and emerging practice guidelines are providing the infrastructure. Issues such as licensure, payment mechanisms, trade protectionism and cultural biases are but a few of the barriers in the way. However, the potential revenue from such services could have a significant effect on worldwide trade balances.

© 2012 Jonathan D. Linkous

Standing at the Threshold of 2012

2011-12-30T14:32:00.002-05:00

It’s been a great year. 2011 left many old timers in telemedicine enjoying the newfound enthusiasm about telemedicine, telehealth and all the other related expressions (mHealth, e-health, etc.) that describe this field. Bells were pealing. Hypers were hyping. Prognosticators were predicting. We were overwhelmed with an ocean of hullabaloo about the wonders of telecommunications technology and health care. We were awash with inventors, entrepreneurs, investors and captains of other industries leaping into the frenzy like groups of whirling dervishes all vying to profess the most superlative expectation. Truly it is wonderful to see.

Woo hoo!

Back on earth the day-to-day reality for telemedicine remains on delivering care, modifying clinical processes, changing public policy and, oh yes, making a profit. Nevertheless, I believe we stand in December 2011 at a significantly different place than last December. The change is not so much in the hype or even the numbers (although they are significant) but that we have witnessed a fundamental shift in the landscape, leaving this field poised for enormous change during the twelve to twenty four months ahead.

Special thanks is deserved to three groups that have made all of this possible. First, ATA’s Board of Directors reflects the dramatic shift in attention toward telemedicine with a unique mix of clinicians that provide health care through telemedicine joined by several captains of industry, private payers, government agencies and non-profit groups from the United States and other countries. Under the leadership of Dr. Bernard Harris the Board has provided guidance and unwavering support for ATA as we sail ahead. Second, my thanks to the hundreds of volunteer leaders and thousands of members of ATA whose enthusiasm, hard work and insights have contributed both to ATA’s success and the tremendous progress for telemedicine this year. Finally, the ATA staff, a small band of incredibly talented, dedicated and very hard working group of professionals. Few in the Association business can believe that a staff of only eleven full time employees manages all of ATA. Thanks to the use of a number of great contractors and innovative use of technology, the staff has been able to make ATA one of the fastest growing Associations in the country and an effective, widely recognized leader in health care throughout the world.

From the start, a key value of this Association has been to focus on transformation and not building castles. But it still amazes me that, from a small group of idealists and true believers that gathered together in 1993, ATA is on the verge of helping to transform the world of healthcare.

Moving Our Eggs Out Of One Basket

2011-12-06T01:22:00.002-05:00

According to Gary Capistrant, ATA’s resident expert on all things related to health policy, at least 73 million Americans, almost one quarter of the population, are now covered under some form of managed care. Such plans eschew the fee-for-service approach in favor of a fixed sum to provide health services with flexibility in what and how such services are provided. Importantly, federal restrictions on the use of telemedicine don’t apply to such managed care plans.

Managed care comes in many flavors. Medicare Advantage is offered mostly as a private managed care insurance plan and covers about 25 percent of all Medicare patients. About two thirds of state-run Medicaid patients are now enrolled in Medicaid managed care programs. Health reform, leading to 32 million more Medicaid enrollees will skyrocket that number in the next five years. On the private side, employer and private plans are all shifting away from traditional fee for service models and embracing various forms of bundling payments, incentives for cost reduction and coordination of care.

How important is this? Cigna, a traditional fee-for-service insurer is spending $3.8 billion to buy HealthSpring, which has 340,000 customers in its Medicare Advantage program in 11 states. Private insurers around the nation are rushing to turn their portfolio of covered lived from fee-for-service to managed care and, to further control costs, are becoming owners and managers of their own medical facilities and health services. It will be interesting to see if this leads to such dilemmas as United Health doctors pressing for privileges at a hospital owned by Aetna.

The rush toward alternative payment models is already shifting decision-making on services from the payer to the provider. To prepare, we need to shift traditional lobbying for a new CPT code or national payment policy toward efforts to convince health systems and even local providers on the benefits of using telemedicine.

Telemedicine Patents and Trademarks

2011-11-21T15:27:00.001-05:00

Over the last three months, several ATA members have been contacted by lawyers representing a third party that was recently awarded a business-process patent regarding the use of telemedicine by the U.S. Patent and Trademark Office. The patent reportedly covers a physician simultaneously evaluating two or more remotely-located patients using a video-conferencing system. The following information is being provided because of the current member interest in this subject.

Patents for telemedicine are not uncommon and will likely grow as the industry matures. Typically, letters sent out regarding a patent claim reference the claim, suggest that the recipient may be in violation of the patent, and some offer to issue a license for the recipient’s continued use of the product or process. There is usually a fee or royalty associated with the license.

Patents are issued by the government in exchange for public disclosure of the underlying invention in order to protect the original inventor’s rights. In many cases, a patent is entirely legitimate and involves an appropriate claim of infringement. In other cases, questions have been raised about the validity and applicability of the patent.

When dealing with patents and trademark “cease and desist” or infringement letters, you may want to seek a legal opinion to determine the legitimacy and applicability of the patent. For instance, the patent may be invalid because it was issued for a product or process that had been in existence for many years prior to the claim (known as “prior art”). There are also cases of “patent trolling,” where an individual or group seeks to gain financial benefit from a patent with no intention to use it. You will want to consult with legal counsel as to how to respond to such demands.

More information on patents is available on the following websites

Copyright vs. Trademark vs. Patent
http://www.lawmart.com/searches/difference.htm

General information concerning patents
http://en.wikipedia.org/wiki/Patent
http://www.uspto.gov/patents/resources/general_info_concerning_patents.jsp

Patent Trolls
http://en.wikipedia.org/wiki/Patent_troll

Reed Franklin - a Colleague and a Friend

2011-09-08T13:15:00.005-04:00

I am truly sorry to report that Reed Franklin, ATA's former Director of Public Policy, passed away earlier this week. He died of natural causes at his home in Arlington, Virginia.

Reed was an important part of ATA while on our staff from 2007 to 2009. His professionalism and quality of leadership raised the visibility of this organization within the nation's capitol. He was well known among Washington health-policy insiders and used his connections, his knowledge of the political process and expertise in government affairs to move our agenda forward. As a result, telemedicine gained significant support in Congress and among federal agencies.

In 2009 Reed decided to move over to the American Health Care Association (AHCA) where he served as the Director of Government Relations. However, he often returned to visit ATA. Demonstrating how Washington is often filled with insiders, his successor at ATA, Gary Capistrant, had also worked for AHCA earlier in his career.

More important to me, Reed was a friend. The son of a minister from rural Virginia, he stayed true to his roots, often telling about how he grew up as part of a community just like that featured on the Waltons television show. His good nature and his integrity came from these roots. A wine connoisseur, Reed served as our resident expert in such matters. His dry humor and mischevious smile added a spark to every staff gathering.

Ironically, Reed and I were planning to sneak away from our jobs this very afternoon to catch a Washington Nationals baseball game. I am glad to have known him.

White House Announcements, Regulations and Telemedicine

2011-08-26T11:31:00.002-04:00

We are getting on the fast track.

President Obama recently announced a series of decisions to streamline the federal bureaucracy by eliminating hundreds of regulatory requirements across two dozen agencies, the changes could save $10 billion over five years. Included in the announcement was the May 5, 2011 decision to eliminate duplicative credentialing and privileging for telemedicine. CMS estimates that this will result in roughly $13.6 million in net savings.

The Administration and Congress are also considering a number of other regulatory changes related to telehealth that will further reduce costs and expand the availability and quality of care. Some of these were generated internally inside the Administration, others came as suggestions from ATA. Here are several examples:

The President has personally declared that he wants to a policy that allows patients to have face to face video chats with their doctor.

The Federal Communications Commission is streamlining a bureaucratically-clogged program to greatly expand rural health care networks.

The Administration and Congress are looking at ways to eliminate red tape and allow patients to access doctors and specialists in other states without having to go through the delays, complications and costs of getting duplicate state medical licenses.

CMS is considering changing regulations to allow Accountable Care Organizations to provide telemedicine services, reducing their costs and improving care.

Stay tuned...

Patents and Telemedicine

2011-08-23T14:31:00.002-04:00

I have been writing about how telemedicine is finally going mainstream. That is good news. However, sometimes when you get to be popular you also get noticed by, well, others.

One area I worry about is Patent Trolling. According to Wikipedia, the term Patent Troll “is a pejorative term used for a person or company that enforces its patents against one or more alleged infringers in a manner considered (by the party using the term) unduly aggressive or opportunistic, often with no intention to manufacture or market the patented invention.” http://en.wikipedia.org/wiki/Patent_troll.

I provide this information because, over the past fifty years, telemedicine has grown enough to become a potential target of firms that have somehow gained a patent and seek to enforce it by sending out large numbers of certified letters demanding a license. As a technology-based industry, there are many patents that have been filed about various aspects of telemedicine. My advice to vendors and providers alike is to be always vigilent.

Of course, I am not pointing fingers at anyone. However, a few of you may be nodding your heads right now...

Six Misperceptions

2011-08-17T14:28:00.002-04:00

Healthcare is a $2 trillion market in the United States and growing at a fast pace. For entrepreneurs, that figure is so alluring it is impossible to ignore. Companies, institutions and individuals from everywhere are looking to see how to get a piece of the healthcare market. It’s the gold rush of the 21st century and health technology is where a lot of companies are staking a claim. And now the attention is turning to telemedicine. The variety of new entrants is vast: vendors selling devices or software; sellers of remote health services; consultants and individuals simply wanting to get into the telemedicine job market. Every week there is a new conference, a newsletter or journal and even a new association targeting some aspect of telemedicine.

Based on the feedback from new entrepreneurs coming through the ATA offices it is apparent that there are a number of misperceptions about the telemedicine market. Here are six of them, learned over the past 18 years.

It’s not the technology, it’s the service. Dial up phones were a great invention. So was the VCR. They are both gone but telecommunications services and watching movies are bigger than ever. New and amazing devices and applications are coming on the market every day. But devices are tools that allow services to be provided at a distance. The focus, the purpose and the finances are on the service.

Despite what you hear, Medicare reimbursement is not the Holy Grail for telemedicine. It’s important, but… Medicare fee-for-service covers about 36 million Americans, 12 percent of the total U.S. population. 88 percent of Americans are covered elsewhere and 81 percent of healthcare spending comes from other sources. There are no federal restrictions on using telemedicine for billions of health dollars spent on managed care, bundled services and on alternative plans by private payers.

Healthcare institutions and physicians are partners, not the enemy. Transforming does not require replacing. So many new entrepreneurs in telemedicine start out with a negative, competitive attitude to traditional healthcare. We have not reached the point when someone with heart disease is going to trust their care to a computer alone. The role of doctors and hospitals is changing but they will continue to be the backbone of medicine.

Device regulation is not bad – it’s good; in fact it could rapidly accelerate adoption. FDA rules for wired and wireless telemedicine devices and their certification by an official government agency is a stamp of approval, providing reassurance for cautious buyers.

A great idea is born every minute but few of them are successful. I have heard of hundreds of stories about how a new technology, application or remote health service results in lower rates of hospitalization, improves compliance, etc. only to see it disappear a year later. Marketing, partnerships, revenue pathways and knowledge of healthcare business practices are essential, for starters.

Consumers don’t buy healthcare themselves. For fifty years the percent of spending on healthcare by consumers has dropped (not including insurance or co-pays). It is now about ten percent. Consumers are getting much more knowledgeable and engaged in selecting among available procedures and treatments but they don’t pay directly for healthcare products and services. The only exceptions are one-time beauty treatments and fitness fads.

I will no longer say “turning the corner” when it comes to telemedicine

2011-08-07T18:31:00.006-04:00

For years we talked about reaching the point when telemedicine services became self-sustaining outside of temporary grants, going from promise to reality. We have long passed the point of telemedicine being a new application. After eighteen years the corner is turned and I promise to put that phrase away. This is what I mean about the reality of telemedicine:

There are areas where remote health services have made a measurable difference in healthcare. At least half of the 5,000 U.S. hospitals are using teleradiology or other forms of remote imaging and the leading firm in this space, Virtual Radiologic, provided over 7 million reads last year. The Ontario Telehealth Network manages over 100,000 live physician-patient video consults a year for a variety of specialty and primary care services. The MedTrix Group provides 10-12 thousand video-based pediatric consults per month for the largest HMO plan in the Israel. The U.S. Veterans Administration is using remote health monitoring for 55,000 veterans.
Revenue generated from telemedicine has resulted in profits for independent service providers and is a self-sustaining business within some healthcare delivery systems. For example, Epocrates, an online and mhealth drug interaction application is used by 1.3 million health professionals including 45% of U.S. physicians and reported a first quarter profit for 2011 of $3.7 million.
Medical systems are integrating remote health care into the normal delivery of care. A recent survey of Washington, DC hospitals found that every hospital in the metropolitan area was using one or more telemedicine application as part of their normal delivery of health care for area residents. For example, to reduce time to catheterization , EKGs are transmitted from the ambulance to cardiologist’s cell phones at the George Washington University Hospital prior to arrival at the emergency room.

I tire of talk about needing to "prove the case." The argument that telemedicine is too new and needs more research falls away when looking at a list of a few other medical innovations that emerged around the same time or later than telemedicine (1960s-70s) and are now fully in use and reimbursed by most payer organizations including Medicare:
• Arthroscopic surgery
• CAT Scans
• Cochlear implant surgery
• Controlled drug delivery technology
• Deep-brain electrical stimulation
• Implantable cardioverter defibrillator (ICD)
• Laser surgery on human corneas
• Magnetic resonance imaging
• Permanent artificial heart implants
• Soft contact lenses

American States Lag European Nations in Licensure Portability

2011-03-23T14:27:00.001-04:00

Allowing physicians the right of free circulation as providers of medical services within the 25-nation European Union is part of a founding EU principle for freedom of circulation of goods, persons and services. The EU lays out minimum training requirements for general practice and specialist physicians and provides for mutual recognition of physicians’ qualifications. It also enforces measures to ensure that the licensing provisions of individual Member states permit the free movement of doctors both to establish themselves and to practice their profession in all Member states. This is currently covered under the EU directive 2005/36/EC.

The 25 independent countries in Europe long ago figured it out. But the fifty states in America are still struggling with how to allow physicians to practice, and citizens to access healthcare across state boundaries. With the help of the Federation of State Medical Boards we are looking to put together a patchwork solution, but that still may be years away.

Shame on us.

On Snooze Alarms

2011-03-14T15:58:00.005-04:00

A clever and well worn trick to resist change and protect the status quo by funding and regulating organizations is the use of demonstration or pilot projects. When faced with a constituency pressing for change, the official response is often to thank the group making the request and suggest that a demonstration project be established along with an evaluation of the outcomes. The decision whether to move forward is then postponed until after the final evaluation is completed. Such ideas may provide important resources for academic centers and researchers but are also commonly used to put off a decision.

All too often, the result of such studies are that more research is needed.

For ten years I was a proud government employee here in Washington, DC, and one of my favorite humorists at the time was the late James Boren, founder of the International Association of Professional Bureaucrats (INATAPROBU). The purpose of this tongue-in-cheek organization, according to Boren, was to "optimize the status quo by fostering adjustive adherence to procedural abstractions and rhetorical clearances.” It also promoted “feasibility studies, reviews, surveys of plans, surveys of feasibility studies and surveys of reviews.” The advice he gave us working in government was: “When in danger ponder. When in trouble delegate. And when in doubt mumble.”

It was funny because, for many of us, it used to hit so close to home.

Such “snooze alarm policies” have been effectively used for fifteen years as a way of resisting the use of telemedicine. Decisions on full reimbursement for almost every form of telemedicine have not occurred because “we just need more data” or that the research was not adequately designed or didn’t have a large enough sample size and a proper control group. Listening to such talk, one could come away wondering if telemedicine is just another far-out experimental idea.

Interesting. Especially when a search on Google Scholar for the terms “telemedicine” OR “telehealth” results in 98,000 references. Adding the term “outcome,” results in 28,500 references. Even PubMed lists almost 13,000 studies on the subject. Some of these date back over two decades.

No one in telemedicine is asking for blanket endorsement of each and every telemedicine application. Undoubtedly there are valid and important questions that need to be asked and answered about certain applications. However, there are also many areas in telemedicine that have been well researched, studied and proven to be useful for expanding access, improving care AND reducing costs.

Drastic health reform and innovations are needed in almost every country and by every insurer and employer. Donald Berwick, Administrator of the Centers for Medicare and Medicaid Management said “There has never been a better time to be an innovator in health care.”

We don’t need another snooze alarm; we need to wake-up and embrace the opportunities now before us.

A New Proposal for Telecommunications Support & Rethinking "Home Telehealth"

2011-02-10T15:35:00.003-05:00

In December 2009 ATA provided comments to the Federal Communications Commission regarding a proposed national plan for broadband. The proposed plan called for broadband deployment to focus on rural communities. For healthcare, the thinking was to focus on access to rural health institutions and to the homes of rural residents. However, the use of wire as the primary technology for providing telecommunications access has been surpassed by the use of wireless and almost a quarter of all Americans rely entirely on wireless phones for their telephone service. The tether to "place" has been broken. That is why ATA suggested that “instead of home-based telemedicine, a more appropriate term is remote person-based care or personal telehealth.” We recommended that the broadband plan should be changed to include “a national goal of 100% coverage of broadband wireless services.” In conversations with FCC staff we encouraged the plan to shift from coverage of rural communities to coverage of people, regardless of their location.

So I am encouraged by an announcement today by President Obama of a new national broadband goal of 98% wireless broadband coverage for all Americans. As part of this, the FCC’s issued a Notice of Proposed Rulemaking (available at http://hraunfoss.fcc.gov/edocs_public/attachmatch/FCC-11-13A1.pdf) to restructure its universal service program to provide greater support for wireless broadband.

This shift in thinking also challenges ATA and our members with the use of the term “home telehealth.” Such a phrase implies maintaining equipment only in the home and limiting remote monitoring to wireline services. In fact, the surge in mobile health applications and the use of wireless technology for all types of remote monitoring devices suggests a new paradigm for chronic care services. I would also caution against entirely shifting to the term “mHealth” as that, too, focuses on a technology and not the service.

We need to come up with a new term to better describe the use of telemedicine to support the needs of patients outside of traditional institutions. I am open to suggestions.

Thank you Mr. President

2011-01-26T14:20:00.005-05:00

An inside game in Washington held every year by hundreds of the top lobbyists, consultants and association executives is to get some mention about their area of interest in the President’s State of the Union address. Last night, President Obama spoke of the importance of telemedicine as part of his proposal to deploy broadband, internet access and high-speed wireless coverage. In describing the benefits of such efforts the President stated: “It's about a firefighter who can download the design of a burning building onto a handheld device; a student who can take classes with a digital textbook; or a patient who can have face-to-face video chats with her doctor.”

As ATA past President Thelma McClosky Armstrong said in an email today: “We sure have come a long way.”

But mention in the State of the Union address is only a beginning. We need to make sure this idea is made real with specific policy changes. Also, allowing patients to make face-to-face video chats with a doctor takes a lot more than deploying broadband or other technology. Reimbursement, regulation and other policies will need to be addressed. ATA has identified six specific changes that the Administration can make immediately to improve the delivery of healthcare using telemedicine. They are available on the ATA website.

Over the past three months, we have been working with the White House and federal agencies to get these six fixes adopted. Our fingers are crossed on the outcome. Between health reform, broadband deployment plans and the President's speeches, the time for widespread use of telemedicine may be here soon.

More Evidence of Remote Monitoring Cost Savings

2011-01-20T17:12:00.011-05:00

The results of new research, published in the January 2011 issue of Health Affairs (1), provide some interesting results that reinforce the importance of one aspect of remote monitoring: medication adherence. Compared to other studies, this one uses a more robust methodology, a larger sample size, demonstrates a strong link between adherence and reduced costs and directly refers to the benefits of remote monitoring. The study used data from 135,000 individuals with one or more of four chronic conditions, congestive heart failure, hypertension, diabetes and dyslipidemia. The article's conclusions provide an interesting perspective:

…“Our results indicate that despite higher pharmacy spending, medication adherence by patients with chronic vascular disease provides substantial medical savings, as a result of reductions in hospitalization and emergency department use. Benefit-cost ratios range from 2:1 for adults under age sixty-five with dyslipidemia to more than 13:1 for older patients with hypertension.

Given these findings, plan sponsors, government payers, and patients should consider participating in programs that improve medication adherence, as long as intervention costs do not exceed the estimated health care savings. Value-based insurance design, electronic monitoring devices, and pharmacist-led counseling are among the least costly alternatives. No matter what the intervention, actively encouraging medication adherence for chronic disease should be a top priority.”

The authors also stated that that the cost of an adherence intervention is directly related to the mode of delivery. Other studies that have assessed an intervention strategy involving heavy direct intervention by health professionals have not indicated results as strong as the ones reported here. The authors agreed with the results of an earlier study (2) that concluded: “Alternatives that require fewer resources—such as electronic monitoring devices and pharmacist-led patient counseling—have shown promise in improving patients’ medication adherence at less expense.”

(1)Roebuck MC, Liberman JN, Gemmill-Toyama M, Brennan TA. Medication adherence leads to lowerhealth care use and costs despite increased drug spending. Health Aff (Millwood). 2011;30(1
(2)Cutrona SL, Choudhry NK, Fischer MA, Servi A, Liberman JN, Brennan TA, et al. Modes of delivery for interventions to improve cardiovascular medication adherence: a systematic review. Am J Manag Care. 2010;16(12):929–42.

Telemedicine 2010 & 2011 Part 2 - TECHNOLOGY

2011-01-05T23:25:00.007-05:00

Telemedicine has never been bereft of electronic wizardry and 2010 included a host of exciting developments with clever new devices that see, analyze, and intervene with any number of medical maladies, all at steadily reduced prices. Here are a few thoughts on two leading technologies: mHealth and video.

mHealth, clearly the hottest topic in telemedicine technology for 2010, has become a trendy term used for a perplexing array of activities. Its expansive definition now includes low cost cellular-based services for developing countries, consumer health-and-wellness digital phone products and wireless applications for the hospital and clinician. The number of downloadable cell-phone health apps exploded with over 10,000 such products now available, created by hundreds of new entrants to health care seeking a part of the trillion dollar healthcare market.

Rosy forecasts abound. But, market watchers have reported that the mHealth industry is evolving into a more concentrated market. Further, the sheer pace of innovation has resulted in some consumers taking a wait-and-see approach before making a purchase. Last June I wrote about how mHealth is close to the top of the hype cycle (It’s mHealth but will it be a Revolution?). We may be due for an industry shakeout soon, termed by Gartner as the “trough of disillusionment,” which will pave the way for broader adoption. In 2011, mergers and acquisitions in mHealth are sure to be news.

Although many business plans appear to rely on consumer and third party buyers, it is important to note that 90 percent of direct healthcare purchases are made by individual doctors and health administrators. Most successful mHealth technologies, like the rest of telemedicine, will be those that integrate and mainstream with traditional healthcare. MobiHealth News recently profiled nine hospitals dabbling with mHealth applications (http://mobihealthnews.com/special-edition-9-mobile-health-hospitals). Many more are starting to look. A few applications are starting to get wide-spread adoption by individual providers. For example, Epocrates, providing drug information and interactions over a digital phone, is now used by over a million health professionals. Of particular interest will be the interplay between the next-to-nothing cost of some mHealth applications and the remote monitoring industry.

Video conferencing technologies were also a buzz in 2010. On the high end, telepresence applications became closer to mainstream with many large institutions. Also in 2010, high definition video became the de facto standard for videoconferencing. A lingering concern that may be addressed next year is interoperability between both high-end and medium level videoconferencing technologies. Customers are looking for it and it appears vendors are moving toward it.

On the other end of the spectrum, webcams powered by free or almost free software is now in use by tens of millions of consumers worldwide and has started to pick up steam for medical services such as telemental health. Last year a series of discussions about privacy and HIPPA compliance for such devices and applications created confusion in the market (for the record, there is no official HIPPA certification for technology; it’s how you use it not what you use). The new videoconferencing application for 4G and Wi-Fi cell phones may be a potential game changer for some telehealth services starting next year. A series of two-way video calls from my cell phone while I was in China to the ATA offices in Washington, DC this December still astounds me.

Also of Note –There has been a series of amazing innovations in robotics, micro technology and automated clinical decision making, which may also start to have a broad impact on health delivery in 2011.

Telemedicine - 2010 & 2011 - Part 1 Public Policy

2011-01-03T16:55:00.005-05:00

Here is the first of three pieces on where we have been in 2010 and where we are going next year for telemedicine. My comments throughout reflect the gobalization of the field. The focus here is on two critical public policy issues that have received worldwide attention: healthcare and broadband:

Since 2004, healthcare spending has been the single largest part of the national government’s budget in the U.S. as well as most industrialized countries. Thus, reform efforts attracted huge attention throughout the world. For telemedicine, 2010 appears to have been a watershed year - the point when many in charge of government healthcare programs finally started to seriously consider the benefits of such technology. Speeches in 2010 by the head of Medicare in the U.S. and Ministers of Health in Australia, China, England and Russia all included serious declarations on the importance of telemedicine. Its role in reducing hospital readmissions and the costs of chronic care have been highlighted as well as its ability to improve services for remote areas and even for special circumstances such as postoperative care. But the gulf between pronouncements and action is still there, with spending on telemedicine and integration of telemedicine into health systems in its infancy.
2011 will be the critical year when we find out whether leaders in Washington and other world capitols will follow-through with specific actions. Despite the positive press, telemedicine has been caught between lingering fears over the costs of medical technology and the enormous attention directed to electronic records. For next year, the most important factors affecting the deployment of remote health services will be an increased emphasis on both provider and regional decision making, continued outcomes from comparative effectiveness studies and practice guidelines. The outlook is brighter than ever but still not certain.

Plans to aggressively expand broadband access were unveiled by several countries in 2010. In the United States, the Federal Communications Commission announced in September its National Broadband Plan: Connecting America (http://www.broadband.gov/). The plan includes federal policies, financial incentives and other activities to “ensure every American has “access to broadband capability.” In December, 2010 China announced that its next Five Year Plan would include a nationwide broadband backbone for the exclusive use of healthcare. Also in 2010, Australia started to roll out its National Broadband Network and broadband policy was a major issue in that country’s national elections.
We will wait and see in 2011 what effect how the governments’ plans will actually have on accelerating broadband deployment. Our attention will be on 1) how much and where government dollars will be spent to support broadband deployment and 2) how much of the available broadband infrastructure will really be used for healthcare.

Global Opportunities for Telemedicine

2010-12-09T09:29:00.002-05:00

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

2010-11-19T12:18:00.004-05:00

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

2010-10-29T15:58:00.002-04:00

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

2010-10-05T11:09:00.000-04:00

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

2010-09-23T13:34:00.003-04:00

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

2010-08-26T20:06:00.003-04:00

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

2010-07-10T22:10:00.003-04:00

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?

2010-06-25T11:49:00.005-04:00

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

2010-04-19T11:00:00.004-04:00

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:

Assurance of quality of care.
Protection of state’s rights
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

2010-03-10T18:22:00.007-05:00

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

2010-03-04T10:10:00.007-05:00

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

2010-03-03T15:22:00.006-05:00

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

2010-02-10T10:01:00.003-05:00

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

2010-01-02T15:02:00.003-05:00

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.

Beyond the Legislation

2009-12-28T11:48:00.001-05:00

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

2009-11-30T11:58:00.002-05:00

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

2009-11-16T10:36:00.003-05:00

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

2009-10-13T19:40:00.019-04:00

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:

We now have access to better, faster and more consumer-firendly information including automated diagnostics for our car than for ourselves.
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.
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

2009-10-11T11:05:00.013-04:00

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

2009-10-11T11:02:00.008-04:00

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:

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.
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?

2009-10-05T18:44:00.002-04:00

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

2009-10-05T18:43:00.005-04:00

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

2009-09-22T10:21:00.003-04:00

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

2009-09-17T14:54:00.003-04:00

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

2009-09-16T14:27:00.002-04:00

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?

2009-08-24T14:59:00.006-04:00

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:

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.
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.
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.
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.

2009-08-18T10:19:00.001-04:00

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

2009-08-11T20:40:00.006-04:00

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.