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6/16/2014
09:07 AM
Alison Diana
Alison Diana
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Sorry, AMA: You're Wrong About Telehealth

By recommending that doctors be licensed in a patient's state, the American Medical Association places another hurdle in the path of telehealth adoption.

Engage Patients: 16 Creative Healthcare Strategies
Engage Patients: 16 Creative Healthcare Strategies
(Click image for larger view and slideshow.)

In forcing telehealth usage to mirror the pattern of traditional healthcare, the American Medical Association limits the power and scope of this transformative capability. This week the AMA released a telemedicine policy that calls for in-person consultations in some cases and recommends that physicians providing a telehealth consult be licensed in the state where the patient receives treatment.

The organization said these in-person visits could occur via "real-time audio and video technology," which appears solely to negate the possibility of email, text, or instant-messaging consultations between patients and physicians. However, the AMA's recommendation that doctors should be licensed within a patient's state could stifle the many benefits telehealth delivers.

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The AMA wrote:

    The Council believes that key tenets in the delivery of in-person services hold true for the delivery of telemedicine services. Notably, physicians and other health practitioners delivering telemedicine services must abide by state licensure laws and requirements as well as state medical practice laws including, for example, laws concerning consent involving minors, prescribing, reproductive rights, end-of-life, and scope. In addition, prior to the delivery of any telemedicine service, physicians need to verify that their medical liability insurance policy covers telemedicine services, including telemedicine services provided across state lines if applicable. It is essential that patients have access to the licensure and board certification qualifications of the health care practitioners who are providing the care in advance of their visit.

Few would argue practices or individual physicians should open themselves to liability by engaging in telehealth. But requiring doctors to become licensed across state lines will reduce the number of physicians willing and able to participate in this practice. The healthcare community must find ways to remove these hurdles, not create new roadblocks to telehealth adoption across state lines and healthcare organizations' walls.

Consider some ways telehealth is used today:

  • Both insured and uninsured patients turn to tools like American Well and TelaDoc for 24/7 access to care from home, work, or travel, thereby avoiding clinics and emergency rooms for non-emergency care.
  • The chronically ill regularly -- and remotely -- check in with caregivers, eliminating time-consuming and painful travel, and freeing up office visits for other patients.
  • Hospital caregivers consult with experts in their fields from around the country (or even world) on unusual cases.
  • Apps and add-on devices, such as InstaMD's Multi-Use Headset plus any stethoscope, expand the use of telehealth, since patients now can check their vitals and remotely share results with practices.

Healthcare is becoming more transparent. Patients, increasingly known as consumers, have more control over health. Premiums are increasing, and overall awareness, in an age of population health and patient engagement, is on the uptick.

(Image: American Well)
(Image: American Well)

In addition, the flexibility of telehealth empowers physicians who might otherwise have left the field to continue practicing medicine. Dr. Nicole Boxer, for example, shut down her general practice after starting a family. But working as a full-time telehealth physician for American Well allows her to treat patients from any location, as long as she has her lab coat and an Internet connection, she told InformationWeek. With doctor shortages -- especially among general practitioners -- predicted to reach 45,000 by 2020, telehealth provides physicians with a new pathway to treat patients, either through full-time or part-time employment with telehealth providers or as a complementary role to their full-time medical position.

Murkiness surrounds telehealth laws. In May, the Federation of State Medical Boards (FSMB) adopted guidelines and provided a roadmap for this approach. The American Telemedicine Association delivered its recommendations for TeleICU operations. With multiple organizations providing their well-meaning suggestions, states following their own rules, and insurers taking various strategies, telehealth adoption is hampered by fear, uncertainty, and doubt. Telehealth providers cannot expand into some regions due to uncertainty. Some physicians won't consult remotely because they're afraid of malpractice or disruption. There is also doubt about when clear-cut guidance will arrive.

The mantra of delivering better care more affordably guides everyone within the healthcare spectrum. Telehealth delivers on both needs -- but not if we force new, disruptive solutions into old patterns.

Download Healthcare IT In The Obamacare Era, the InformationWeek Healthcare digital issue on changes driven by regulation. Modern technology created the opportunity to restructure the healthcare industry around accountable care organizations, but ACOs also put new demands on IT.

Alison Diana has written about technology and business for more than 20 years. She was editor, contributors, at Internet Evolution; editor-in-chief of 21st Century IT; and managing editor, sections, at CRN. She has also written for eWeek, Baseline Magazine, Redmond Channel ... View Full Bio
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Alison_Diana
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Alison_Diana,
User Rank: Author
6/23/2014 | 5:34:35 PM
Re: Where are the Doctors?
Your points are good @GAProgrammer -- and living where you do, you certainly have the experience of dealing with two states simultaneously. It just seems extremely shortsighted to prevent a Minnesota doctor who's a world-renowned specialist in, say, brain cancer not to be allowed to consult or speak to a patient in California. Or make a rural patient travel 75 miles to the nearest doctor if she has a migraine if her state doesn't have any telehealth providers on-call at the time of her headache to call in a prescription for Imitrex or Zomig. The insurance industry can and should figure out the malpractice changes required. That's an insurance, not a medical or technology, problem. 

And I don't even think of this as gee-whiz tech -- although that is always a risk, you're right. I've been writing about telemedicine, off and on, for probably about 15-20 years so I get more frustrated by some of the regulatory blockades than animated by the tech. Apart from mobile adoption, prices dropping, and video improving, most of the capabilities haven't changed all that much. Sure, speed's improved but if you're talking about telehealth via phone or desktop/laptop, a lot is still the same as it was when I first covered the topic waaaay back when!
GAProgrammer
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GAProgrammer,
User Rank: Ninja
6/23/2014 | 4:01:09 PM
Re: Where are the Doctors?
I disagree with the headline, but agree with some of your points.

We should always strive to use technology in new ways to enable people and ideas. However, that "dreamer's" perspective MUST be tempered by reality. In reality, telemedicine is no different than in-person care - they are merely separated by distance. Therefore, the licensing issue still applies. If you could instantly teleport the doctor from Kansas to Alabama, would you feel the same? Don't let "cool tech" blind you to the real issues here. The doctor's are still practicing medicine in that state, and therefore, are subject to the laws and procedures of each state. This is why we have doctors that are licensed to begin with - to make sure that we have real doctors with the appropriate knowledge and proof of that knowldge.

Not to mention, if a doctor commits malpractice and he is on the other side of the country, now I have to fight a legal battle in two states, possibly requiring the patient to spend thousands of dollars to show for court cases.

I am usually against overregulation and overreach of state and federal government, but I am 100% with the AMA on this one for one simple fact - they ARE practicing medicine in another state and should be licensed as such. I actually live in a town that borders two states. Insurance companies, doctors, lawyers, all these professionals get licensed in both areas because they want to serve both areas, even when the business is all conducted by phone (no different really than a teleconference). It's just the cost of doing business. Teledocs should have to play by the same rules.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/18/2014 | 9:26:46 AM
Re: Where are the Doctors?
Doctors' time is spread thin and, actually, it's one reason some think telemedicine could help. The doctor I cited in the story closed her practice after she and her husband had a child. When she wanted to return to work, she didn't want to open a new practice because of the long hours, so when she heard about becoming a full-time employee of American Well -- a situation that allowed her to practice medicine, see patients from anywhere, and have all the benefits of a f/t position -- she was very excited. She was an MD and familiar with tech, plus had a good bedside manner, enabling her to get the job, apparently. 

In other words, just as there are different personalities and ambitions across other fields, there are the same demands and drivers in medicine. In an interview for a separate story, an American Well exec told me the company has some retired doctors who don't want to work full-time, but enjoy putting in two or three days per week, helping patients. So telehealth actually expands the base of doctors by allowing physicians to work a day (or more) instead of retiring or stopping working. Also, while some areas of the country have only a few or no doctors or specialists, other regions -- such as cities like NYC, LA, etc. -- have many, many specialists. Through telemedicine, these specialists and doctors can see patients far away, who would not otherwise have been able to visit a doctor for many weeks or maybe months.

That's the main reason, @LeeB, I disagree so strongly with the AMA on its stance about being licensed within the patient's state.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/18/2014 | 9:20:18 AM
Re: "...ways telehealth is used today"
One big reason telehealth adoption is being held up, IMHO, is because of the payment model and insurance: How do you figure out the fee for a video and/or audio consultation, where the patient's done the 'paperwork,' vs. a traditional in-office visit? And how do you get doctors to buy into this? As you say, too, how do you protect the system from fraud. There's already fraud in the in-office system; couldn't the virtual system encourage a surge of fraudulent claims?

We're seeing several cases where insurers are reaping the benefits of this approach. People are going to get sick and see a doctor, whether or not telehealth is an option. Some payers provide free or reduced-cost telehealth as an option; while only a certain percentage of employees use this, it's one of those benefits that saves time and money for users and doesn't cost employers money unless it's used. As to fraud/waste, businesses can use the same tools used to monitor fraud/waste in the nonvirtual world.
LeeB120
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LeeB120,
User Rank: Strategist
6/16/2014 | 9:46:50 PM
Where are the Doctors?
I can see another reason this might not work so well in most places.  There simply isn't enough doctors to do this.  You rarely get more than 5 minutes face time with a doctor on a regular scheduled or emergency visit now because they are already stretched thin for time. 
alegh
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alegh,
User Rank: Apprentice
6/16/2014 | 8:30:36 PM
"...ways telehealth is used today"
OK...I looked at the link offered as an example of telehealth today.  It's an Indiegogo fundraiser that's been running for a month, with 3 days until close.  Buyers: 4.  Total funds raised: $546 out of 60K target.

That may be the current state of telehealth.  No-one's buying.

I can't even get my FSA to cover OTC ibuprofen without a written prescription and filing the paperwork with my payroll company.  For less than ten bucks of pills.  And I still get a paper check mailed to my house for reimbursements.  (The OTC meds scam was a popular way to cash in on flex-spend credit cards.  Buy the OTC on the card.  Wait a while, then return for cash or credit.)

We have not yet realized the realities of electronic data.  We don't know how to detect and fight fraud, so we create rules to revert back to paperwork and human processing.

How will we detect and fight fraud with telehealth?  By requiring face time, and licensing checks...and more recordkeeping.  Not at all efficient.  And the geniuses who want audio and video recordings?  That's part of a medical record now.  Any idea how those records compress compared to text-based chat and email?  That will keep the storage vendors happy.

It's a barrier to slow things down until payors can figure out how to maintain or increase profitability in a pseudo-risk-averse way.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/16/2014 | 5:23:50 PM
Re: Why stop at state borders?
I had not heard those stories, @Gary. They sound like a case of telehealth gone wild. Of course, telehealth -- like just about everything -- can be used in ways that seem to stretch creduility or good sense. You'd hope (and, quite frankly, expect) that payers treat patients in the same manner they'd expect their family members to be treated.  Telehealth is a terrific tool that's not right for every situation. But when it IS the right tool, both patients and providers appear to prefer it since patients can better use their time and so can physicians. 
Alison_Diana
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Alison_Diana,
User Rank: Author
6/16/2014 | 5:20:32 PM
Re: Why stop at state borders?
Not sure if you're being serious or have your tongue firmly planted in cheek (there are definite downsides to the typed word, although we do offer a video option!), but it's tough enough getting telehealth adoption widespread in the US; trying to take on worldwide adoption -- or allowing US patients to access treatment from elsewhere in the world -- sounds near to impossible, at least right now. I think there'd be issues from the patient's side, too. As a patient, you don't know necessarily whether your doctor was top or bottom of his/her class, but at least you have an idea of how good the school of medicine is, overall. When talking about a medical school in another country, you have no idea at all.
Gary_EL
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Gary_EL,
User Rank: Ninja
6/16/2014 | 4:14:51 PM
Re: Why stop at state borders?
Doctors operate under different laws in different states. Imagine a woman in Massachusetts consulting with an obstetrician in one of those states that have VERY restrictive abortion laws! I haven't heard about it for a while now, but not too long ago, there was a movement to require that people with certain types of conditions take the lowest cost provider - even if that lower cost provider was in - INDIA. The providers and hospitals involved were so inexpensive that insurance company saved money even when they paid the cost of air travel. NO THANKS. I'll be more than happy to take courses taught by Indian professors, but I'm not interested in being a patient of an Indian doctor - unless, of course, he or she is licensed in Massachusetts and practices Here.
Number 6
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Number 6,
User Rank: Moderator
6/16/2014 | 2:10:24 PM
Why stop at state borders?
Why require a license across national borders? We've already offshored manufacturing, customer support, software development, finance & accounting... why not medicine? The lawyers that make the laws won't lose anything-they've made sure that their own profession won't go offshore. If a physician can make a diagnosis and write a prescription from the next state, and surgeons can do telepresence surgery from 10 feet away, why not 10,000 miles? The FDA can already approve offshore prescription drug manufacturing. Why not a similar licensing for offshore doctors to ensure quality? We don't have a monopoly on the best doctors. Remember the first heart transplant was performed in South Africa. We'd have access to doctors that have the best skills needed regardless of where they were at and it would drive down healthcare costs. After all, isn't that the argument for offshoring IT? (insert SarcMark here)
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