Interested in learning more about the risks and rewards of using telemedicine in your office? This month, TMLT will be hosting an ethics CME on the topic. The seminars will take place on April 20 and 28 and will be streamed live.
You can register here. If you have any questions, call 800-580-8658, ext. 5050.
This piece was originally published in the September/October issue of the Tarrant County Physician. You can read find the full magazine here.
It happened twice in the same morning.
I saw two women for checkups that morning—their stories were so similar. Both older but not elderly, living alone, physically impaired needing a walker or motorized scooter, and always very crabby at their appointments. A litany of chronic non-specific complaints—fatigue, aching, headachey, etc. Honestly, I was not looking forward to their visits. They never seemed satisfied, and I never felt like I had helped them much. When I saw them both on the schedule that morning, I confess that I grimaced a bit.
But their telemedicine visits were just the opposite of their usual in-person visits. They both were happy, smiling, and relaxed. The conversations were easy and their questions were few. I anticipated much COVID-19 anxiety but found little; they were used to staying at home and hadn’t had to change their way of life much. They both just needed refills—I would have liked to have done a physical exam, but I really didn’t need to.
At the end of the morning, I wondered to myself what was different, and then it hit me. They didn’t have to physically come to see me, which so many of us take for granted but for them was likely a physically draining, frustrating, expensive, humiliating, and even painful experience. Wow. Was I humbled.
Telemedicine is a gift to some of our patients, such as parents stuck without childcare who have to bring multiple children along with them, people who lack reliable transportation, or elderly people who don’t like driving anymore but are embarrassed to ask for a ride. It can help someone two hours away who just needs a refill or a patient who can’t afford to miss work. I could go on and on; I’ve seen cases like every example I’ve given and I’m sure many of you have, too.
The coronavirus pandemic has added a new layer of urgency to the implementation of telemedicine. Physical distancing and shutdowns have made it extremely difficult, if not impossible, to see our patients safely face to face (especially when PPE is still hard to find). Telemedicine enables routine care to continue without the risk of exposure to the virus. It keeps medical offices safe and in business.
The AMA, along with many other organizations, has been developing telemedicine policy and recommendations for years. The AMA House of Delegates approved a report from the Council on Medical Services laying out principles for coverage and payment in June 2014.
An AMA survey in 2016 showed that 15 percent of physicians worked in a practice that utilized telemedicine in some way.1 But a far smaller percentage of actual patient encounters were done via telemedicine.
When COVID-19 struck and communities were shutting down all over the country, the telemedicine guidelines, reimbursement policies, and the work we had already done with CMS helped the organization be ready with their new guidelines for coverage and payment, which were initially released on March 17, 2020.
AMA had been working with the Physicians Foundation, the Texas Medical Association, the Florida Medical Association, and the Massachusetts Medical Society to create the Telehealth Initiative to provide a wide array of assistance for physicians to implement telemedicine in their practices.2 The launch of the program was not scheduled until later in the year but instead was moved up to March 19, 2020, just two days after the CMS announcement.
Virtually every medical society in the country now has guidance available for physicians on using telemedicine.
However, the current telemedicine coverage and payment program will only stay in effect as long as there is a national emergency, which has now been extended to the end of October 2020. Of course, we all know that COVID-19 will not be gone then, so AMA is working with state and specialty societies to lobby Congress for permanent solutions.
I believe that every specialty will develop its own guidelines for the appropriate use of telemedicine going forward, and every practice will utilize telemedicine to some degree.
The genie is out of the bottle. Let’s hope it stays that way. We deserve to be compensated fairly for services regardless of location, and our patients deserve the ease of access.
As you’re no doubt aware, telemedicine has made it possible for many physicians to continue seeing patients while reducing the risk of spread during the COVID-19 pandemic.
Temporary changes to state and federal rules, particularly regarding payment for services, have helped push up the new demand for and use of telemedicine.
Prior to the pandemic, health plans did not have to pay physicians the same rate for telemedicine visits as for in-person visits.
But what does each type of plan pay for visits?
The Texas Medical Association has compiled information for various types of plans. Remember that some plans’ policies are different for audio-only visits.
State-regulated plans. The Texas Department of Insurance’s (TDI) emergency rules requiring state-regulated health insurers and HMOs to pay an in-network health professional at least the same rate for a telemedicine or telehealth service as they would for the same service or procedure in-person took effect March 17. Those rules remain in effect for up to 120 days (mid-July). They can be extended for an additional 60 days if needed. (For more details, see TDIs FAQs.)
ERISA (self-funded) employer-sponsored plans. There is no requirement for these federally regulated plans to pay the in-person rate for telemedicine care. However, many ERISA employee health plans are administered by Texas insurers – as a Third-Party Administrator (TPA). Many of the plans’ administrators have encouraged these plans to pay for telemedicine services at the same level as TDI-regulated plans, and many have.
Texas Medicaid recently authorized telemedicine payment for well-child checks for children older than 24 months. The state also approved other telemedicine flexibilities, such as payment for audio-only telemedicine and telehealth visits. These waivers all expire May 31, but TMA anticipates the Texas Health and Human Services Commission (HHSC) will extend them at least for one more month. TMA and state societies representing primary care and obstetrical physicians have asked for a six-month extension, through November.
Reprinted from the July 1995 issue of the Tarrant County Physician. by Jay Haynes, MD, MSc
The Promise of Telemedicine: A Look into the Future was originally published in Tarrant County Physician in July of 1995. The author, Dr. Jay Haynes, reflects on the changes that have taken place in telemedicine in the past 25 years:
During the managed care days and Clinton Administration of the 1990s, before the Internet, we had visions of using technology and telemedicine to improve access to care and the dreams to use it to better serve the underserved. A quarter of a century later, the massive use of telemedicine has now abruptly become a stark reality that is likely to transform the future delivery of healthcare. The recent spike in utilization and acceleration of telemedicine and virtual care during the COVID-19 pandemic crisis is unprecedented. Its adoption by Texas Department of Insurance and CMS has led to approved reimbursement, loosened bureaucratic regulations, and broadened telemedicine and telehealth access across the nation.
In a recent poll by TMA, 74 percent of physicians in Texas began using telemedicine for the first time only after March 1, 2020. It is predicted that healthcare systems and physicians will continue to accelerate their capabilities and learn to adapt to evolving partnerships, technology, and communication to deliver care to their patients.
As we reflect on the past, we knew telemedicine was coming, we just couldn’t predict the exact “tipping point” in time when the technology would be embraced. Who could have guessed that it would be a catastrophic public health crisis caused by a horribly infectious viral contagion that riddled our world and its healthcare systems in early 2020 driving us to use technology in order to connect with our patients and practice remotely and safely?
Our handheld smart phone apps, platforms, and technology today are so much better than we would have predicted, and relatively, much less expensive than in 1995. The overhead cost of the modern-day virtual office visit and data storage is minimal compared to then.
The objectives, potential applications, and challenges that are identified in the original article have stayed relevant. The value perception of the healthcare consumer continues to be driven by enhanced quality, convenience, and service utilizing evolving technology, adaptive systems, and innovative healthcare payment models. One point remains especially valid—the true promise of telemedicine is still to serve the underserved.
And here is the original article from 1995:
In the last 100 years, our own social evolution has been driven by the quest for knowledge through enhanced communication. A century ago, great physicians and assistants would unite together in the disciplined arena of the operative amphitheater to observe and discuss the management of challenging cases. We are now able to reunite in the much broader “virtual electronic amphitheater” of telemedicine.
We have a responsibility as citizens, businesspeople, and leaders of healthcare to find innovative means of creating equity of access to healthcare, cost-containment, and uniform quality. The ultimate challenge of the future in healthcare will be to accomplish these social demands by uniting networks of healthcare providers and their facilities using tools such as interactive telemedicine systems.
The Frontier Ahead
“Telemedicine” is derived from the Greek “·tele,” meaning at a distance, and from the Latin “medri,” meaning healing. In 1971, K.T. Bird, the first pioneer to develop a complete prototype system in Boston, viewed telemedicine simply as “the practice of medicine without the usual physician-patient confrontation … via interactive audio-visual communications system.” He later reassured the medical profession that “telemedicine does not replace or regulate the physician; rather, it offers a new way to practice medicine.”
Current telemedicine systems utilize an interactive audiovisual system integrated with biomedical telemetry that allows a physician at a base station, specialty medical complex, or teaching hospital to consult with another practitioner, examine and treat their patient at multiple remote satellite locations, such as rural hospitals, ambulatory health centers, correctional institutions, facilities caring for the elderly, the home, ambulances, community hospital emergency departments, or international facilities.
Within the next 20 years every household in America will have access to a face-to-face consultation with a healthcare professional through interactive television. Diagnosis and management for many ailments and education about prevention will likely be rendered in the home by means of telemedicine. Patients will have one-on-one linkage to the best medical experts in the world. Psychologists and social workers may even be available for mediating family disputes.
Dr. Leland Kaiser has said, “The hospital of the future is the hospital without walls.” Every major competitor in the healthcare market of 2015 will be electronically, audio-visually linked to their patients’ community and home. Quality, convenience, and service will drive the value perception of the healthcare consumer of the next century.
Telemedicine is the ultimate and timely management solution to our nation’s problems of rural healthcare access, over-utilization of medical services, loss of economical productivity due to illness, cost-containment, and quality assurance. With well-designed networks, a harmonious and cooperative relationship among healthcare providers and consumers will ensue.
The New Healthcare Gridiron
The era of traditional institutional healthcare is in its final stages. The paradigm of hospital and physician centered care has transformed into patient and community driven care. Wide and local area networks of seamless information transfer are replacing the past architectural designs of brick and mortar. The leaders of medicine who can best orchestrate the information change for the betterment of our society will surpass the expectations of the healthcare market of the next century.
The current environment of abrupt change in the healthcare industry presents an extraordinary opportunity for biomedical technology leaders to create economic abundance and job opportunities. Research and development, manufacturing, distribution, and servicing of interactive telemedicine systems and communication networks worldwide will serve the moral obligation of improved access, enhanced quality of care, and appreciably decreased relative costs of our current healthcare system.
Healthcare services are becoming more energy efficient, available, and accessible to even the most remotely isolated patients. Medlife Corporation’s pilot project in an independent Rural Health Clinic in Groveton, Texas, employs a skilled physician assistant who successfully uses still-image telemedicine over regular telephone lines to consult with a physician in a tertiary health center 45 miles away. The telemedicine system acts as an adjuvant assistant, “High Tech with High Touch,” bringing more quality and efficiency to the patients and enhanced confidence and competence to the on-site provider. It has great ease of use and requires a minimal number of participants to facilitate its regular operation.
The Leap of Faith
Physician pioneers will acknowledge that telemedicine will broaden their scope of practice and range of services. Patients perceive quality in terms of the value and effectiveness of service on site. Netting providers within an integrated framework with the common tool of telemedical communication will enhance the following applications:
Initial urgent evaluation of patients, triage decisions, and pre-transfer arrangements;
Medical and surgical follow-up and medication checks;
Supervision and consultation for primary care encounters in sites where a physician is not available;
Routine consultations and second opinions based on history, physical findings, and available test data;
Transmission of diagnostic images;
Extended diagnostic work ups or short-term management of self-limited conditions;
Management of chronic diseases and conditions requiring a specialist not available locally;
Transmission of medical data; and
Public health, preventative medicine, and patient education.
Healthcare executive leadership’s decision to invest in a telemedicine system should be consistent with their institution’s mission and strategic goals, while satisfying the needs and concerns of its users. Potential objectives include:
To perpetuate a proactive leadership role in continuous quality healthcare improvement;
To enhance care and access to remote locations while preserving local autonomy;
To link rural professionals with their urban colleagues;
To decrease the burden and isolation of rural professionals;
To serve the public, decrease costs, and save time;
To support the infrastructure of a medical management information network;
To redevelop trust of rural patients in local healthcare providers and the system at large;
To decrease unnecessary transfers and overutilization;
To deliver Continued Medical Education and reduce travel costs; and
To access the global healthcare marketplace.
America has the highest quality healthcare in the world, but it has also been the costliest and has neglected those who had the misfortune of indigence. To be a universal competitor, we must implement a healthcare system that has excellent outcomes, constantly improves efficiency and quality, enhances access to the underserved, and reduces costs and time, ultimately increasing the satisfaction of the patients we serve.
Information of new developments and domestic and worldwide therapies are shared through telemedicine. Additionally, continued medical education is attained and tested through interstate or intercontinental didactic training. An incredible opportunity exists for health providers to be readily available and ON CALL to intercontinental business travelers who may become ill in foreign and third world countries. Telemedicine units placed in both domestic and foreign airports, as well as health institutions, would provide a value-added service which businesses and travelers would gladly purchase.
Hurdles to the Finish Line
Much of the waste in our current traditional healthcare system is in its fragmentation of specialization with overutilization and repetition of diagnostic testing. In addition, the “wind shield” time lost by provider traveling from hospital to clinic to hospital is unproductive. We must maintain continuity of care without subjecting the patient or provider to inefficient activities of travel, waiting, and redundant examinations. Telemedicine eliminates the loss of valuable time, measurable in dollars and expertise, as well as pain and prolonged suffering.
The prevailing concerns of telemedicine skeptics remain centered on issues regarding licensure, reimbursement and policy regulations, liability and confidentiality, system design, costs, and complexity of use. In our current system, a physician utilizing telemedicine to provide consultative services to patients in other states must hold a license in that state. The FTC also has the issue of whether this would be deemed interstate commerce. New laws and definitions must be introduced that would allow unrestricted interstate trade for telemedicine. A more practical solution would be to determine that the patient is “electronically transferred” to the physician’s state of licensure.
The Healthcare Financing Administration is analyzing outcome studies as it plans its strategy to pay for services. There is still great hesitancy on the part of many providers to enter the practice of telemedicine until the reimbursement and service valuation issue is resolved. Currently, HCFA is moving forward with a cross-cutting evaluation of telemedicine based on a series of three-year projects using waivers to reimburse for telemedicine consultations.
Political and congressional action is required to lighten regulations so that we may create vigorous telemedicine network systems with greater accessibility and freedom of choice. This year’s fiscal budget cuts included much of the federal funding for telemedicine research and development. Access issues may be resolved if American citizens and private industry unite with a strong voice in support of telemedicine and its benefits.
Malpractice liability is always a prevailing question of potential users. To date there have been no malpractice claims regarding telemedicine. Practically speaking, the visual enhancement of current telephone communications should improve information exchange and decrease liability. However, one can be sure that as medical centers with “deep pockets” become networked with remote sites, an “Agency” relationship becomes established and our legal brethren will pay close attention to the potential for wealth transfer in the event of an unexpected bad outcome. Theoretically, their argument would rest on the perception of an “incomplete” exam. The telemedicine systems of the future will incorporate clinical practice guidelines and ensure adherence to community standards of care.
We have not established the standard of care for telemedicine. Most medical-legal concerns may be alleviated by utilizing mediation agreements and detailed informed consent. Utilizing telemedicine as a management and triage tool should be encouraged, especially if the visual/audio links do not provide adequate information transfer or resolution qualify to meet “diagnostic” standards of interpretation. We must make reasonable efforts to ensure confidentiality in telemedicine consults. To avoid electronic intrusion and exposure, encrypting algorithms will provide security. Although not foolproof, measures such as these are better than the open access systems that currently prevails.
The vast majority of both patients and physicians who have experienced telemedicine find it to be strikingly effective and useful. Now, with the second generation of telemedicine proponents in the newly organized American Telemedicine Association, the reality of telemedicine has truly come of age.
However, as in the last generation, resistance to change by those who have benefited greatly from the status quo remains the major hurdle to overcome.
Acknowledging the obvious improvements of quality and access as we integrate into managed care markets of the next century, we must evaluate the history of telemedical cases and consultations and place cost into the equation before we fully accept the effectiveness of telemedicine. The expense and production demands of interactive, full motion, video conferencing currently cost a staggering $65,000 per site unit, with operating costs ranging from $2,000 to $5,000 per month.
However, similar outcomes may be attained with less expensive, desktop still-image telemedicine systems. On analysis by selected generalist physicians, over 85 percent of all telemedicine consultations since 1990 did not require “full motion” for an adequate consultation. In fact, much less expensive, interactive digital “still-image” desktop telemedicine systems accomplish similar end results with maintenance costs equal to regular telephones.
Telemedicine systems must meet the needs of the user. It should be as easy to operate as a telephone. For some specialists, full-motion video conferencing may indeed be a necessary added value. For the majority of others such as family practitioners, physician extenders in remote clinics, home healthcare nurses, ophthalmologists, dentists, orthopedists, and dermatologists, the added expense of compressed full motion seems impractical.
Public (political) perception and need in this time of budget cutting dictates a search for the most efficient quality means to an end. Indeed, more controlled studies and research will be necessary. The current reasonable cost of entry into the high resolution, still-image technology with its ease of use and minimal operating costs may outweigh any potential shortcomings as compared to the more elaborate systems.
The true promise of telemedicine is to serve the underserved. Telemedicine may facilitate quality healthcare to those who are homebound or remotely isolated. It also presents a golden opportunity to stimulate the economy while serving society’s needy.
Jay Haynes MD, MSc, is a Family Physician in Tarrant County and has been a member of the TCMS since 1987 and a past President of the Tarrant County Academy of Medicine. He serves as Senior Medical Director for Innovation and Integration for Acclaim Physician Group at JPS Health Network and also Associate Professor of Family Medicine at TCU and UNTHSC School of Medicine in Fort Worth.
Preston, M.D., Jane. “The Telemedicine Handbook” 1/A TA Newsletter.
Negroponte, Ph.D., Nicholas. Being Digital.
Sanders, M.D., Jay. ‘’Telemedicine, Challenges to Implementation” Congressional Subcommittee on Investigations and Oversight Committee on Science, Space and Technology on May 2, 1994
Tangalos, M.D., Eric. “Hearing on Telemedicine: An Information Highway to Save Lives.” Congressional Subcommittee on lnvestigations and Oversight Committee on Science, Space and Technology on May 2, 1994
Fear of coronavirus have caused a significant reduction in healthcare visits and both physicians and their patients are feeling the impact. Melanie Lagomichos, DO, shows Star-Telegram that one way to combat this is through the use of telemedicine.