This Month in Telemedicine

Each month, the American Telemedicine Association broadcasts This Month in Telemedicine, a webcast discussing news and topics in the telemedicine field. February’s webcast featured ATA’s Jonathan Linkous, Chief Executive Officer, and Gary Capistrant, Senior Director of Public Policy, discussing the growth of telemedicine and policy issues.

A deluge of demand, a raft of pending legislation, and licensing challenges—these are a only a few of the issues facing telemedicine.

Activity:
Telemedicine is undergoing an “explosion of activity,” says Linkous. The ATA estimates 10 million patients in the U.S. and Canada are now using telemedicine (the majority for radiology). Two trends he’s seeing: the involvement of patient groups, who are showing interesting and researching how telemedicine could be employed by their members, and the growth of “big med” across the country.

The ATA is anticipating the demand will only grow—possibly reaching 50 million patients in the next couple of years. The question is whether providers, telemedicine networks, and vendors will be able to meet the growing need for telemedicine services. Linkous calls this, “A serious issue we need to focus on.”

New Developments:
“We’re moving away from the fee-for-service model,” says Linkous. “We’re moving to managed care, accountable care, medical homes.” This is good news for telemedicine, he says.

New developments in telemedicine include specialty service providers—a group that’s appeared in the past couple of years. To help track this growth, ATA created a new service provider forum of private companies that provide direct services to patients.

Also, a few major companies are offering online consultations, including American Well and TelaDoc. And insurance plans are also expressing interest in the potential of telemedicine. Several major plans now reimburse patients for online consultations, but only in a few states so far. Some are offering the service as an add-on to traditional care for an additional fee. However, while patients can get prescriptions online, they won’t for controlled substances, in compliance with federal law. “You will not see that done,” says Linkous.

Issues:
With health care reform becoming a reality, a large number of people are expected to be added to Medicaid, and states don’t know how they’re going to accommodate the increase in Medicaid demand. The ATA sees telemedicine as an answer to that problem.

A big issue with telemedicine is licensing. Each state has its own licensing board. About 22% of doctors have licenses in more than one state, and the ATA estimates this costs $300 million per annum, paid to states for 2nd, 3rd, and 4th licenses. They’re looking to the model established by the Department of Defense and approved by Congress last year—their doctors only need to be licensed in one state. Several states have proposals to follow the D.O.D.’s lead, but that’s a cause for consternation for the medical boards, who are looking at a major loss of income if this licensing model is actually established nationwide.

For health systems and private companies that are telemedicine focused, health care provider licensing is a subject they’re following closely. “There are concerns that an agreement requiring approval by each state could mean years of delay,” says Linkous.

California Congressman Mike Thomas introduced a bill (The Telehealth Promotion Act) with the aim of increasing federal acceptance of telemedicine, which would include Medicaid, the V.A. medical system, and other federal health programs. The licensing model proposed with this bill is one where health care providers need only be licensed in their own state, and the patient’s location would be deemed irrelevant.

Policy & Legislation:
“We’ve never had so many bills introduced at state level,” says Gary Capistrant. There are 13 states plus D.C. that have legislation pending to mandate private insurance coverage of telemedicine services (15 states already have this as law). 11 states are expanding Medicaid coverage to ensure parity with in-person health care. He suggested the Thompson Bill might be segmented to smooth the commitment process.

States:
As of March 1st, 2013, California, Texas, and Vermont are the only states that have legislation for both private and Medicaid coverage; 14 other states have a legislated mandate for private coverage, and only Pennsylvania and Nebraska have it for Medicaid. But 24 states have proposals on the table for either are both. You can see the full list here. To help track state telemedicine information and changes, the ATA has set up atawiki.org—click on Current Events, or type in a state in the search box for the latest info.

 

The Yahoo! Fall-Out

Ever since Marissa Mayer, CEO of Yahoo! issued her memo calling back remote workers into the office and effectively ending telecommuting within the organization, countless stories and commentaries have been written. These responses have spanned from total disagreement to downright endorsement of the new employment practice.

The interesting thing about the announcement is that it appears to have started to influence other organizations to act the same. Just this week, Best Buy announced that they too would be ending their work from home program. This is particularly noteworthy because Best Buy’s initiative (announced in 2006 and called the Results Only Work Environment (ROWE)) was seen as a trendsetting program and applauded by many HR advocates.

In the case of Best Buy, the change in policy is not as stringent. Managers still have discretion to allow telecommuting but the employees can no longer make that decision. The question now is two-fold: will more companies follow suit and is this the right decision for a company to make?

Mayer noted, “To become the absolute best place to work, communication and collaboration will be important, so we need to be working side-by-side.”

To really understand if this is the “right” decision; let’s take a look at the different types of collaboration that occurs within an organization on a daily basis:

Spontaneous Collaboration:
This method of collaboration occurs when team members run into each other in the hallway and strike up a conversation or perhaps in the cafeteria grabbing a cup of coffee. There is nothing formal about it and it can happen in an instant.

Deliberate Collaboration:
With deliberate collaboration, teams may schedule a time for everyone to get into a conference room and hash out an important idea or project. This might be accompanied by white boarding or some other form of facilitated brainstorming.

Formal Collaboration:
Formal collaboration involves a scheduled meeting with a formal presentation structure. This could be a business review or strategy overview. The major difference between deliberate collaboration and formal collaboration is the presence of a formalized agenda with specific content to be presented.

When reviewing the three collaboration types noted above, what do you lose when your workforce is remote? Spontaneous collaboration is the victim here, at least to an extent. When workers are remote, they are not running into each other randomly and striking up conversations.

All is not lost, however, as many organizations who have implemented collaboration technologies, such as video conferencing, have installed “water cooler” systems that allow remote employees to connect in at will and see what’s going on. While this may not be as spontaneous as being there, it gets remote workers pretty close.

When looking at deliberate and formal collaboration, much of what occurs in these meetings can be recreated with remote workers. Formal collaboration sessions can easily connect in remote team members to view the formal presentation or even present themselves. Technology now makes it possible to easily present, no matter where you are. With deliberate collaboration, remote participants can view white boarding sessions and be involved in the brain storming process. Again this is possible thanks to the latest developments in cloud and collaboration technologies.

Whether the Yahoo! decision was the right call remains to be seen, but other organizations should examine the different types of collaboration that occur within their facilities and see what is most pervasive. Ultimately, it may be about both a technology solution and a people solution.

As cloud services pick up speed in the private sector, questions about security, cost savings, implementation and best-practice models have emerged in concert with its rapid growth and adoption. But are institutions of higher learning following suit? Cambridge, MA-based Forrester Consulting turned their focus on 12 universities in the U.S., the U.K., Australia, India, and New Zealand, surveying CIOs and IT directors for their July 2012 report “Cloud Bursts Into Higher Education.”

They found out how and why these schools are employing the cloud; plus they give some suggestions as to where the partnership between higher education and the cloud is headed.

So, how is Higher Ed approaching cloud services?

The Forrester study found that universities are adopting cloud services to boost productivity, and speed, budget, and scalability were the top three features university interviewees valued most about cloud services. But the study uncovered an interesting dynamic: professors and department staff are leading the way with cloud services at their universities, implementing cloud applications as needed, and circumventing the IT department. One side benefit of this autonomy is that IT departments can then focus their resources on other, critical IT tasks.

Echoing concerns coming from the private sector, universities are concerned about security. In fact, the report states “security is the No. 1 roadblock to cloud service adoption.” For schools, the two primary concerns are keeping research (intellectual property) and private student information confidential and secure.

The most common cloud adoption right now is the private cloud, with many of these schools keeping private information, like emails and research, on their private cloud, and “student-related information” on the schools’ servers. The report does note, however, that hybrid clouds are in use, and expected to increase. Additionally, as academic institutions partner up to offer expanded learning experiences, often online, expect to see a growth in the use of community clouds for sharing research and course materials.

Lastly, schools are looking to the cloud for cost savings; however, as cloud usage goes up so do costs. While several interviewees claimed significant cost savings with adoption of various cloud models, in one example the “expanded use of the services over three to seven years raised the cost of SaaS to nearly even with the cost of a perpetual license and on-premises deployment.” In other words, as academic staff and students become more familiar and comfortable with using cloud services, related costs increase, thereby erasing some of the gains.

Related Articles:
Learning the Cloud Way – Part II

With the technology used in telepsychiatry becoming more reliable, inexpensive, and ubiquitous, there has been a corresponding increase in mental health professionals who are turning to remote treatments. In fact, psychiatry has been at the forefront of telemedicine use.

The general consensus thus far is that telepsychiatry is particularly useful for rural populations, children, the military, and those in institutions like prisons. In other words, telepsychiatry reaches people who otherwise wouldn’t have access to mental health services. (There is a severe shortage of child and adolescent psychiatrists). Telepsychiatry can also lessen some of the barriers often cited to obtaining mental health treatment, including cultural, shame, cost, and distance.

Many states, often in conjunction with state university medical and public health departments, have recently initiated telepsychiatry programs. The South Carolina Department of Mental Health established a program in 2007 to provide telepsychiatry in state hospital emergency departments. Also in 2007, University of Alabama’s College of Community of Health Sciences joined the Alabama Department of Mental Health (and others) to launch a telepsychiatry program, focusing on rural populations. New York State’s Office of Mental Health runs the New York Consultation and Telepsychiatry Program (NYCaT) aimed at children, and last fall West Virginia University’s WVU Healthcare received a government grant that will cover four years of telepsychiatry programs for an addiction treatment clinic. The Centers for American Indian and Alaska Native Health at the Colorado School of Public Health also run a telehealth program that includes mental health services.

That’s just a handful of examples, but they demonstrate the range of applications and growth of telepsychiatry. While the interest and investment is there, acceptance is by no means guaranteed. Here are five potential obstacles to telepsychiatry adoption.

Cost: States vary greatly in their definitions, approach, and regulation to telehealth (or telemedicine) according to a recent report from the Center for Connected Health Policy, State Telehealth Laws and Reimbursement Policies. While the majority of states reimburse telehealth through Medicaid; some do not, including Connecticut, Iowa, Massachusetts, New Hampshire, New Jersey, and Rhode Island, plus the District of Columbia. Amongst those that do reimburse, there is a wide range of what and who is reimbursed, and when.

Privacy: “Increased video-conferencing over public networks also creates the potential for unauthorized access to protected health information.” This is from a recent article in Current Psychiatry. The authors’ recommendations: use VPNs and encryption; train health professions in data storage and telemedicine ethics.

Legal: A provider must be licensed in every state they provide care. So a health care provider in one state that is conducting a telepsychiatry session with a client in another means they must be licensed in both states. There are 9 states, however, where the medical boards have instituted special telehealth certifications. As telemedicine becomes more common, look for this issue to become a hot topic.

Habits: Old habits die hard, and not every mental health care provider sees the value of telepsychiatry, or wants to invest the resources in training and adopting new modes of treatment. A study by the California HealthCare Foundation, which focused on telepsychiatry adoption in 7 emergency departments, found that in every case, there were initial problems getting support from involved parties, including doctors, nurses, and psychiatrists. From the study: “Some of the spoke sites felt that they had neither the time nor the energy to devote to telemedicine efforts.”

Lack of training or incorrect training: “Training is critical,” writes Mark Vanderwerf in his chapter Ten Critical Steps for a Successful Telemedicine Program. He recommends “layered” training, that is, training presented in progressive stages, and it should be formal to increase its perceived value. For the first level, he suggests course materials, a syllabus, registration, and testing, and even a certificate awarded to those who pass the course. The second layer includes on-site evaluations, and the third includes support and “refresher sessions.”

Boeing’s much anticipated 787 Dreamliner encountered a laundry list of problems which eventually led to the grounding of many of the planes. There are several different theories as to what went wrong and Boeing could have done better. Many have to do with the decision to embrace outsourcing and overall lack of supply chain management.

In a recent Forbes article, Jonathan Salem Baskin is quoted “It didn’t help that the outsourcing plan included skipping the detailed blueprints the company would have normally prepared, and allowing vendors to come up with their own. Delivered components arrived with instructions and notes written in Chinese, Italian, and other languages.”

With the plethora of video conferencing and visual collaboration technologies available it’s surprising that Boeing had this many issues coordinating and communicating with their remote teams. While we can’t know for sure exactly what went wrong or what Boeing did or did not do; we can offer some suggestions as to how organizations can utilize collaboration solutions to their fullest extend and help ensure a seamless supply chain.

A UC solution is a must to connect internal team members assigned to the project. These solutions can even allow approved external team members, such as suppliers, to connect easily. Features such as instant messaging (IM), screen and document sharing, and video conferencing are key components to keeping the lines of communication open. For example, if a supplier has a quick question about the design, he can quickly IM a team member asking the question or if the person is available for a quick chat. Quick video conferences or even formal meetings with video and document sharing can help ensure consistency and reliability among suppliers.

For more crucial aspects of the manufacturing process, such as discussing blueprints and inspecting components, an immersive visual collaboration solution that includes Datapresence (ability to see multiple sources of data) is necessary. Simply showing a single document while the video participants are minimized on screen will not provide the collaboration experience necessary for such critical aspects of the manufacturing process.

Solutions like Oblong or Cyviz combine video conferencing with the ability to share multiple steams of data in real time creating a true collaboration environment. Team members would be able to see detailed designs and prototypes of the outsourced components in addition to the supplier’s team. Both teams would then be able to communicate, give and receive feedback, and discuss any potential issues. By repeating this process with all suppliers, the organization can help ensure consistency among components. They can also connect and facilitate collaboration between the supplier of Component A which connects into Component B from a separate supplier.

Supply chain management is one of the most complicated aspects of any organization as it relies heavily on communication and coordination between two or more parties. By underestimating the importance of communication, an organization can run into problems similar to the ones Boeing faced. On the other hand, by providing both internal and external (supplier) team members with the tools and opportunity to effectively communicate and collaborate and organization can successfully manage all aspects of its supply chain.