The Cost of Red Tape

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

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

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

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

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

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


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

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

Stay tuned...

Adoption of Telemedicine Accelerating

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

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



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



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



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



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

Telemedicine and the Underserved Community

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

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

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

It seems to me that three facts frame the issue:

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

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

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

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

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

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

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

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

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

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

Lessons from the Snow

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

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

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

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

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

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

My Favorite Myths About Telemedicine

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

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

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

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

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

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

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

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

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

Beyond the Legislation

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

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

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

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

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

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

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

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

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

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

Standards of Care - Key to Telemedicine’s Growth

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

Payer Acceptance

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

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

Avoiding Legal Negligence

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

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

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

Regional and Worldwide Partnerships in the Delivery of Health Care

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

Telemedicine Ballyhoo

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

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

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

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

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

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

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

Ford Produces an Electronic Health Record for Cars

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

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

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

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

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

Here is the bottom line:

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

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

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

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

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

Shaman-Based Triage for Telemedicine

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

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

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