April’s This Month in Telemedicine by the American Telemedicine Association, hosted as always by Jonathan Linkous, Chief Executive Officer, and Gary Capistrant, Senior Director of Public Policy discussed state and federal updates, collaborations, and quality assurance.

State Licensure Remains a Hot Topic
Gary Capistrant went over the basic situation of licensure, including a proposal that would let Medicare recipients to (virtually) cross state lines for care but would impose a requirement that the patient and doctor have a previous relationship, i.e. an initial consultation in person has to occur. While some states do allow that a legitimate patient-doctor relationship can be established via video, this proposal does not recognize that and could be a “step backward” for telemedicine, plus require states to enforce a prior relationship where they hadn’t done so before.

“In terms of our principles on licensure, we want to be regulated the same as in-person services, not held to a higher standard or a lower standard,” said Capistrant. The ATA has set up a petition. Also, some states are deciding that telemedicine needs regulating but are doing so by treating it as a separate health service, even though telemedicine was already active under the current medical regulations.

State Activity
Three states have enacted full parity with private insurance: Mississippi, plus Medicaid and state employee benefits; Montana, including parity with private; and New Mexico. Connecticut and Missouri passed parity bills in Senate, which are now moving to their respective Houses. New York recently introduced a parity bill, and Ohio will soon follow suit.

ATA is finalizing state best practices guidelines for home telemedicine and remote monitoring, and in the works: school-based care, telemental health, and more.

Federal Action
A workgroup was recently announced, a joint effort between the FDA, FCC, and Office of National Coordinator. A report is due in January 2014 examining the overlap of some issues that are overseen by the various agencies, including consumer health devices, electronic health records, and clinical decision support.

“It’s a little bit of a mess right now in terms of the regulation and one of the reasons they have this is group is because there’s a little bit of uncertainty amongst the different agencies over who’s taking the lead on what,” explains Linkous.

Quality Assurance
A big area of activity for ATA is quality assurance, which, although it’s flown under the radar somewhat, is getting plenty of attention now. ATA’s next board meeting will see the approval of the organization’s practice guidelines for online video-based telemental health. “A very important role for ATA is to weigh in and try to get some meaning and some semblance of order to what’s happening,” says Linkous.

ATA’s board has also approved the move towards ATA becoming an accrediting body with the end goal of becoming a reliable information source for consumers. They’re also involved with some trade associations to improve consumer awareness. Linkous: “It’s important that consumers know that if you’re not getting access to telemedicine, you could and you should and you need to ask your doctor about it.”

Next year, look for a cohesive effort by patient and consumer groups to expand telemedicine, including physician communications, consultations, lab results, etc., which should all be accessible online by patients.

The Q&A: A Selection of Questions Asked & Answered

Q: Define telemedicine, telemedicine, etc.

A: I think we should come up with a contest to see who can come up with the most names that relate to telmedicine. E-consults, e-health, telemedicine, telecare, e-care, telepractice, remote care. About 6 or 7 years ago we had a board meeting in Chicago and we talked about changing the name of the ATA. We talked about what we should change it to…we spent about 3 hours of the board meeting [discussing this] so at the end, we just threw our hands up in the air and left it as it is.

We define telemedicine very broadly as providing healthcare to patients or consumers using telecommunications.

Q: How can companies assist ATA in the process of getting legislation passed?

A: ATA has a Circle Membership and Industry Council and we have corporate members representing anything from large, multi-national, multi-billion dollar companies to a small ma and pa [businesses], but all of them have a stake in this. And if there’s a large corporation that has a Washington office with a staff of people who are full-time policy people, yes, please let them get in touch with us. We’d love to talk with them about what they do. Or if you’re an organization that has a consultant online who does work in Washington, or if you’re a small company in another state and you have an area representative…it’s important that you get very active…There’s always things to do at the state level.

Annual Meeting
ATA’s annual meeting will be held next week in Austin, Texas, from May 5 to 7. For a free exhibit hall pass, click here to register and enter  the code VIPcomp13.

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.

 

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.”

Telemedicine continues to be one of the most exciting advancements in the delivery of healthcare today. The benefits are significant and legislation throughout the United States is being passed to provide parity between a telemedicine visit and a live, in-person doctor visit. At a high level, telemedicine is about extending the reach of healthcare and providing care to those who may not have access to specialists and other needed experts.

Within telemedicine there are a number of very specific applications that are finding their place in hospitals throughout the country and the world. Telestroke is the application of telemedicine technology for the diagnosis and treatment of stroke victims.

According to the Centers for Disease Control and Prevention more than 795,000 people in the United States have strokes and 130,000 of those stroke victims lose their lives. One of the greatest allies to a stroke victim is time. The sooner a patient is able to be seen and diagnosed by a doctor, the higher likelihood of a positive outcome. Many of the treatment options available today are highly effective but require a rapid diagnosis.

Of the many treatments out there, two are particularly time sensitive. Thrombolytic drugs dissolve the clots that block the flow of blood to the brain. These drugs need to be given as quickly as possible. Another option is tPA which is an enzyme that can help dissolve blot clots as well. It is found naturally in the body and if given within three hours of stroke symptom onset, it has a high success rate ofpreventing the stroke from occurring. This, however, is highly dependent upon the recognition of early stroke signs and symptoms.

The application of telemedicine to stroke, or telestroke, is usually deployed in a hub and spoke model. Hospitals with stroke/neurology services serve as the hub and allow connections from outlying or rural hospitals, known as spokes. Many of these rural hospitals simply do not have access to neurology and stroke specialists so these hubs can assist with timely diagnosis and treatment.

The technology of telemedicine allows neurologists to remotely examine patients when they are admitted to an emergency room or the hospitals. These doctors can review CT scans and other diagnostic tests quickly and make real-time decisions on initial treatment.

Beyond the obvious benefits to the patient, there are several other key advantages to telestroke including:

  • Reduced Costs: For hospitals who have established a comprehensive stroke care center, the investment is significant. This prevents smaller hospitals from implementing these critical programs. With a telestroke program in place, patient care is not sacrificed when budgets are not available.
  • Fewer Transfers: When facilities are lacking the specialists needed to care for strokes, it can become necessary to transfer those patients to larger, more distant facilities who offer a stroke center. The cost of these transfers is incredibly high, both for the patient and the medical facility. With remote specialists on hand, patients can stay in one facility, get the care they need, reduce the risk of their condition worsening, and ultimately save the system money.
  • Training: When local doctors get exposed to stroke specialists they are able to get real-world training on key stroke indicators and how to rapidly respond to them. This type of training can make the difference between a full recovery and a life of stroke complications.

The application of video conferencing and telemedicine technology to healthcare is truly exciting. As facilities continue to bring this technology on board, patients will be the ultimate beneficiaries. The highest level of healthcare diagnosis and treatment should not be reserved for those who live in proximity to major medical centers. Telemedicine technology has the potential to reduce or eliminate both geographic and financial barriers that can prevent access to high quality healthcare for everyone.

Football reigns supreme in our nation; whether it’s the NFL, NCAA, High School or even little league. In many towns, Friday night games are the center of a town’s social activity; and anyone involved with the winning touchdown is considered a hero. It’s no wonder kids are gearing up to play almost as soon as they can walk.  In fact, my nephew has been playing since he was four years old!

Unfortunately, repeated hits to the head from high contact sports have spurred a concussion epidemic that spans from football, to hockey, to even wrestling. Multiple concussions can cause brain damage that leaves lasting effects. In an article, former professional wrestler Christopher Nowinski states “I can’t exercise without getting a headache and without feeling sick.”

With kids playing sports at earlier ages, it is even more important to properly diagnose concussions to prevent brain damage from cumulative injuries. As a result, Davidson County in North Carolina has introduced a new telemedicine program linking high school athletes who may have a concussion to specialists at the Lexington Medical Center for diagnosis.

A remotely operated telepresence robot allows doctors to look for symptoms and give brain and balance tests to determine whether or not an athlete has sustained a concussion. While diagnosing a concussion over video may seem lacking, Dr. Daryl Rosenbaum, Director of Wake Forest Baptist’s Sports Medicine Fellowship Program, said the contrary in a recent article.

“There’s not a lot of hands-on evaluation needed with concussions. Typically, you are making two big decisions: return to play or not to play, and go to the emergency room or go home.” – Dr. Daryl Rosenbaum

Telemedicine clinics can be especially valuable for rural areas where access to health care specialists typically requires a lengthy drive to the nearest metropolitan area. Instead of depending on local doctors or sports trainers, these athletes can have instant access to a concussion specialist who is trained to spot signs that might otherwise be missed.

Watch the video below for a quick demonstration!