We conduct many aspects of our lives through computer-based communications. We talk to the kids on the other side of the country using Skype. We do our holiday shopping without ever leaving the couch. We avoid the bank branch and still manage our finances. We expect that these service efficiencies should be at the center of our health care experiences as well. Now, after decades of low adoption, telehealth might finally be the next big thing in health care.
Medical uses of communication technologies date to the late 1950s; they were borne out of a desire to connect remote populations to a variety of health services. One of the more novel first applications of telemedicine is credited to Massachusetts General Hospital, which established a telecommunications link with Boston’s Logan Airport in 1963 to evaluate and consult with airport employees and ill travelers. Years later, the hospital added an interactive television microwave link that provided electrocardiograph, stethoscope, microscopy, voice and other capabilities.
In the decades that followed, telemedicine use grew to include demonstration projects, remote interpretation of images, care consultation for captive populations and support for rural patients. Though effective and well-received in the communities where its use was prevalent, interest in telemedicine waxed and waned.
Today, a confluence of factors is driving a renewed interest in telemedicine, including the demand for a consumer-driven health care system, a growing shortage of specialists and cost-containment strategies that shift financial risk from payers to providers and consumers.
Additionally, advancements in technology are enabling higher-definition video and more robust data to be transmitted more efficiently. Patients and providers have become quite adept at incorporating technologies such as smartphones, iPads and video chat apps like FaceTime into their daily lives.
Another Access Point to Care
The American Telemedicine Association defines telemedicine or telehealth as the exchange of medical information via electronic communications to improve a patient’s clinical health status.
Health care providers are embracing telemedicine because they see it as an efficient and cost-effective way to deliver high-quality care and improve patient satisfaction. From basic fitness tracking data shared with a primary care physician in support of health and wellness programs to virtual consults with specialists in time-critical care situations, today’s telehealth framework spans the continuum of care and can include services such as:
· Remote image interpretation (teleradiology, teledermatology)
· e-visits or televisits between providers and their patients
· Video visits for semi-urgent care
· Clinician-to-clinician consultations
· Critical care (virtual intensive care unit, telestroke)
· Remote monitoring of a patient with a chronic disease
These services vary in their use of communication technology and in the information technology systems that are deployed. For example, remote patient monitoring requires devices with sensors, and software that aggregates data for clinician review. Video visits must have applications that “find” available care providers, while clinician-to-clinician consultation requires electronic health record integration between health systems.
As the industry continues its collective march toward a more interoperable health care system, it further strengthens the foundation for more applications of telemedicine.
According to the American Hospital Association, 52 percent of hospitals used some form of telehealth in 2013, and another 10 percent were beginning to implement such services. Its growth potential is also notable. Business information provider IHS predicts that the U.S. telehealth market will grow from $240 million in revenue in 2013 to $1.9 billion in 2018 — an annual growth rate of more than 50 percent.
Making the Case for Online Care
In addition to the growing demand for access and convenience, the need for telehealth is driven by other factors such as:
· A significant increase in the U.S. population
· A shortage of licensed health care professionals
· Increasing incidence of chronic diseases
· The need for efficient care of the elderly, homebound and physically challenged patients
· A lack of specialists and health facilities in rural areas and in many urban areas
· Avoiding adverse events, injuries and illnesses that can occur within the health care system
These factors become increasingly important as new health care delivery and payment models evolve and providers are challenged to manage chronic diseases better, avoid readmissions, improve quality and remove low-acuity care from high-cost venues. As we know, for example, the long-term benefits of population health programs are predicated in large part on managing high-cost, chronically ill patient populations more effectively.
Furthermore, the rapid deployment of high-deductible health plans, which make consumers more conscious and accountable for their health care consumption and spend, has added to the pressure on providers to provide low-cost, convenient options.
Against this backdrop, consider one of the biggest health system challenges today: lack of 24/7 access to physician specialists. The supply of specialists is shrinking — a substantial percentage of specialists such as pulmonologists, cardiologists, orthopedic surgeons and psychiatrists are older than 55 — while medical school capacity remains flat.
When the right specialist is not available, everyone suffers. Accurate diagnosis and best practices often are missed. Patient outcomes are frequently poor. Care is prolonged, resulting in higher costs and, oftentimes, patients must be transferred at considerable cost and family disruption.
Even more troubling, studies show that upward of 20 percent of patient deaths or permanent injuries related to emergency department delays are attributed to lack of specialists’ availability.
Among its many value propositions, telemedicine provides an opportunity to combat the specialist shortage by enabling more efficient use of limited expert resources who can “see” patients in multiple locations without leaving their facility. Additionally, studies of speed-to-care rates have shown that specialists at a remote location can be “at the bedside” in an average of nine minutes. Compare that with an on-site provider, who can take up to 60 minutes.
Overcoming the Barriers
Telemedicine’s rebirth can be attributed to its usefulness as both a potential cost lever and an avenue to deliver expanded routine and specialty care.
However, those who are active in telemedicine can quickly discover a fairly complex playing field, muddled by the absence of consistent guidelines governing who can provide telehealth services, where they can be provided — and, most importantly, what’s covered and who pays.
Medicare, Medicaid and private payers all apply different definitions, may cover different services and have varying requirements for payment, making it a bit like the Wild West on the reimbursement front. Adding to the complexity, while a majority of states provide some form of Medicaid coverage for telehealth services, reimbursement is not standardized. On the Medicare side, coverage and payment for telehealth services still face restrictive statutes and regulatory limitations, though these problems are improving.
Disparate regulatory and reimbursement treatment of telehealth has been one of the main barriers to the expansion of services. However, updated payment policies of remote care management and coordination services on the public payer front are signaling a changing tide, eliminating restrictions and expanding the scope of covered services.
On the private payer side, telemedicine use has been bolstered by a growing number of states that are enacting parity laws, which require health insurers to treat telehealth services the same way they would in-person services.
In addition to reimbursement challenges, state policies limiting licensure have slowed the adoption of telehealth by U.S. providers. Once again, each state has unique laws regarding the scope of practice permissible through telehealth. Even more limiting, licensed providers who practice telehealth across state lines have needed a full, unrestricted license in the state in which the patient is located, which often has been too expensive.
To combat the limitations associated with licensure, a growing number of states now recognize a medical license issued by another state to treat patients via telehealth services. In fact, the creation of a multistate licensure compact model is expected to lead to the development of a national framework of telehealth providers. Additionally, though the particulars vary widely, most states maintain a consultation exception in their licensure requirements, enabling licensed physicians to consult with a licensed physician in another state.
Efforts are also underway to address other policy issues such as privacy and security, malpractice insurance, and fraud and abuse, which present their own legal and regulatory challenges.
For example, providers may need to revisit their security risk protocols and update their data privacy and security practices to combat any vulnerabilities associated with using telehealth technologies. Moreover, the AHA predicts that as utilization and coverage of telehealth services continues to ramp up, the potential for exposure to liability under various federal and state fraud and abuse laws will only grow.
A Good Prognosis
Like shopping or banking online, consumers now expect a no-hassle, Amazon-like experience when they’re interacting with their health care system. Telemedicine not only affords this opportunity, but also holds the potential to dramatically improve patient satisfaction and outcomes while providing an affordable alternative to traditional modes of care.
Telemedicine proponents espouse its value in making patient interactions more convenient, expanding geographic horizons particularly where needed medical specialists are few in number, and making care more accessible to those with mobility issues.
Although there are several complex and evolving issues related to its application, the barriers to widespread adoption of telemedicine are eroding under mounting pressure from all health care constituents. Licensure portability will further ease the barriers to accessing services, while regulatory and payment policy changes in support of telehealth are widely expected in the coming years. This alone will help to further cement telemedicine’s place in modern health care.
From the growing use of remote patient monitoring to virtual ICUs, telemedicine is well on its way to becoming a foundational technology for care delivery — as unremarkable as buying a book on the Web.
John Glaser, Ph.D., is a senior vice president with Cerner in Kansas City, Mo. He is also a regular contributor to H&HN Daily.