The Texas Medical Board on Friday, April 10th finally decided to severely restrict the practice of telemedicine. In a majority vote with one dissent, the Board upheld the previous decision that requires an established physical encounter prior to a telemedicine visit. Now text, email, chat, or telephone are considered inadequate for the establishment of a physician-patient relationship.
Who is on the Board? It appears the membership is diversified and accomplished in their respective professions. There are currently 19 members, 12 of which are physicians. The remaining members are three business executives, one real estate banker, one biochemist, and three attorneys.
What does this mean for telemedicine?
- A significant departure from where the rest of the country (and world) is going.
- The board’s presumption that telemedicine is not a regulated and safe healthcare delivery system.
- Challenges the medical literature, which establishes telemedicine as a highly acceptable and safe means to deliver healthcare.
- The presumption that the only specialty that has a shortage is psychiatry since mental health is the one true exception for the use of telemedicine.
What does this mean for Texans?
- Texas is the second largest state with 24.7% of its population in small towns and rural areas. That accounts for over 6 million people, which is the size of the state of Tennessee (2010 census).
- As a result of the new regulations, access to healthcare for over 6 million of these Texans is limited to traveling long distances to seek care.
- Because the level of poverty is high in these areas, not only the cost of travel but the cost of care in an ED versus the less expensive telemedicine consult is an added burden on an already stressful life.
- Finally, the citizens of Texas had no say in this decision. The freedom of choice has been significantly curtailed.
Texas has made a decision based upon 19 Texans. It appears the only way that telemedicine is acceptable by the board is in a clinic or hospital setting, which requires a qualified healthcare provider to “assist” in the consultation. If this means only a physician, then again a major barrier exists.
Despite how one analyzes the decision, it would be safe to say that everyone in the telemedicine community supports patient safety and quality of care as the principle of why telemedicine is an important and integral part of our healthcare delivery system. Support for strong regulation is essential and must be part of every states mandate, but the restriction of the practice of telemedicine without thoughtful deliberation deprives Texans of accessible and affordable medical care.
A telepediatric cardiac critical care program dealing with children with congenital cardiac problems has shown a significant decrease in length of stay for both the ICU and hospital. This prepublication abstract is at Telemedicine and eHealth.
This unique study whereby UPMC (Pittsburgh) partnered with the Cardiovascular Foundation of Columbia was able to provide post-operative critical care to pediatric patients in the ICU. These children required surgery as they had significant congenital cardiovascular diseases.
While there was no difference in mortality, a good sign that care was the same, the TeleICU component was able to reduce length of stay. In the ICU the LOS went from 17 to 10 days. For the hospital, the LOS went from 28 to 22 days. This is important as the telemedicine patients had a higher acuity.
According to estimates by ATA, the number of ICU patients in the U.S. that are remotely monitored for at least a portion of the day will reach 550,000 this year. This represents roughly 11 percent of all ICU patients in the U.S. The estimates were reached in consultation with leading providers and vendors involved in providing tele-ICU services. The use of telemedicine for intensive care involves highly skilled specialists including intensivists and critical care nurses that allow clinicians in one center to remotely monitor, consult, and care for ICU patients in multiple distant satellite centers. Estimates of the growth of these remote medical services range from 10 to 25 percent per year. The rapid increase in the use of telemedicine for critically ill patients is a result of a number of factors including shortages in specialty providers, increases in the number of ICU patients (due to the aging of population) and better acceptance of telemedicine by established health systems. Such use has been documented to improve efficiencies, clinical outcomes and financial results. The widespread use of tele-ICU services has had a significant and lasting impact on the way healthcare is delivered. This is a leading indicator that ATA’s vision, that telemedicine will be fully integrated into healthcare systems to improve quality, access, equity and affordability of healthcare throughout the world, is starting to be realized. Last year, ATA adopted Practice Guidelines for Tele-ICU Operations which have since been endorsed by several medical specialty societies. They are available for free on the ATA website.
Perceptions of tele-ICU users are not well studied. Thus, we undertook a study focused on assessing staff acceptance at multiple hospitals that had implemented a tele-ICU system.
Materials and Methods: We designed a survey instrument and held interviews that gathered perceptions on multiple facets of tele-ICU use and administered it to clinical and administrative staff at 28 hospitals that had implemented a tele-ICU system.
- Respondents were generally positive about all facets of the service.
- Analyses found no significant differences in comparisons between critical access and larger hospitals or between clinical and administrative/managerial respondents.
- Respondents at hospitals averaging more tele-ICU use and that had implemented it longer were significantly (p<0.05) more positive in their responses on multiple survey items than other respondents.
Conclusions: Tele-ICU was particularly valued when critical access hospitals retained critical care patients. Tele-ICU can aid rural hospitals, but multiple delivery models are warranted to meet disparate needs.
For the study, researchers sent a 30-question survey to health professionals across the U.S. who process medical licensure applications (Rogove, C3O Telemedicine study, 2/11).
More than half of respondents said they process more than 100 applications annually (C3O Telemedicine release, 2/25). Of those:
- 54% said the application process takes longer than 12 hours; and
- 17% said the process takes four hours to nine hours (FierceHealthIT, 2/26).
After the application process is complete, the amount of time it took to acquire licenses varied among states. For example, it took one to three months to obtain licenses in Indiana, Arizona and Virginia, while it took at least 10 months in California, Illinois and Texas (C3O Telemedicine release, 2/25).
Just 8.3% if respondents said all states were “reasonable in processing the applications,” according to the study.
The authors concluded that state medical license portability “continues … to remain elusive for a solution that will allow for the exponential and timely growth of telemedicine.”
They added, “If there were ever a time for the mission of state medical licensure boards to rally in support of shaping the future of health care delivery by finding a solution for removing a most significant barrier to telemedicine, the time is now” (FierceHealthIT, 2/26).
According to Jonathan Linkous of ATA in todays Inside ATA:
“It’s only February, but telehealth is clearly a priority to state lawmakers. One hundred telemedicine-related bills have been introduced to define telehealth and telemedicine, redefine licensed provider practice standards, remove artificial barriers or improve coverage and payment options. Some bills seek to improve the telemedicine policy landscape while others risk to severely limit health providers’ clinical decision making and patient choice. ATA members are monitoring state activity using the ATA legislative and regulatory trackers, and seizing the opportunity to educate lawmakers about the clinical application of telemedicine and the unintended consequences of over regulation. Join the ATA State Policy webinar this Thursday, Feb. 26, at 1 p.m. EST, to hear about legislative proposals and possibilities for engagement.”
According to Christopher Cheney of HealthMedai Leaders: “Since the model Compact legislation was finalized by state medical board representatives and released to the states for their consideration at the end of 2014, it has been introduced in 12 state legislatures and endorsed by 26 state medical and osteopathic boards. We expect both counts to continue to grow,” Humayun Chaudhry, DO, president and CEO of theFederation of State Medical Boards, said last week.
So far, the draft has been introduced at statehouses in Iowa, Maryland, Minnesota, Montana, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, West Virginia and Wyoming. The FSMB is tracking the legislation’s progress on the organization’s website.
The Compact also has the support of the American Medical Association, the Council of Medical Specialty Societies, the Society of Hospital Medicine, and many other national and state provider, hospital, and specialty organizations. Consumer and patient advocacy organizations like the South Dakota AARP chapter have also been very supportive of the Compact and its potential for improving access to care.”
Critics of the Compact
The FSMB has lashed out at critics of the Compact, among them Independent Physicians for Patient Independence (IP4PI) and the Association of American Physicians and Surgeons (AAPS). In a letter to the US Senate dated Jan. 26, AAPS called the Compact “little more than a pretext for transferring state sovereignty to out-of-state, private, wealthy organizations” and called for “an investigation of the FSMB to “[evaluate] the very reason for their existence on top of state licensure boards and specialty boards.”
Critical Mass of States Needed to Launch Compact
Several states will have to enact laws codifying the model legislation before the Compact can seat commissioners and launch.
“The model Compact sets a minimum of at least seven states to enact the legislation in order to enable functionality and the creation of an interstate commission. The commission would be charged with the administrative functions of the Compact and be led exclusively by members of participating state medical boards,” Chaudhry says.
Just fast tracked on Telemedicine and eHealth’s website is an important survey of professional license companies that deal with over 1,000 applicants a year to practice telemedicine in multiple states. Dr. Herb Rogove and co-authors sent surveys to participants who have experience with telemedicine as well as on site practices in multiple states throughout the continental United States and its territories. Here are the key elements of this article:
- Fifty four percent of the respondents felt it was a prolonged process because of variable requirements and deficiencies within the medical board office.
- Difficulties were centered around failure to respond to questions, lack of cooperation, inability to use FCVS, lack of a uniform process and consistency across all medical boards.
- Lost documentation occurred and 79% had to resubmit documents.
- The most reasonable states (reasonable defined as responsive, cooperative, willingness to expedite, and knowledge) were identified as Oregon, Wyoming, Pennsylvania, and Montana.
- The respondents felt the most difficult states to deal with were: California, Texas, Arkansas, and Massachusetts.
- The shortest time to obtain a medical licenses was felt by respondents to be Indiana, Arizona, and Virginia.
- The longest time to obtain a medical license was thought to be California, Illinois, and Texas.
- Variability of requirements, which is set by each state, was considered to be a major issue.
- Reciprocity for all states was a major suggestion by those who were surveyed.
This survey illustrated that medical license portability continues to be a major and time consuming barrier for expanding telemedicine’s rapid deployment to areas in need of physicians. Despite the recent compact by the Federation of State Medical Boards, the process may be streamlined but lacks the major impact of full reciprocity of all states.
John Brumbach reports: This year the Washington State Legislature is considering legislation that would ensure Telemedicine services are reimbursable for those enrolled in commercial, managed care and public employee benefit plans. Telemedicine, which consists of health care services provided via interactive video and video technology, has built strong bipartisan support in Olympia because of the potential to increase access to more diverse services in rural and other under served areas. These services include telepsychiatry, telepain management, teleradiology and many other specialties not commonly available in all areas. In addition, a study showed that covering telemedicine could save Medicaid $37 million in reduced primary and follow-up care costs. Despite this support, previous efforts have failed to make it through the legislature to the Governor’s desk.
The last effort to pass legislation began in 2013 and received strong support in the House, but died twice in the Senate during the 2013 and 2014 sessions, where there was no corresponding companion bill.
Reasons for telemedicine’s failure in the Senate appeared to center around concerns from health plans around a lack of flexibility for reimbursement levels, as well as social conservatives regarding the potential to ease access to chemical abortions.
Health plans have fully embraced this version of the bill, while it remains to be seen whether or not social conservative concerns will be addressed, or if those concerns will be enough to halt the progress of the bill.
HB 1403 is scheduled to be voted out of the House Health Care & Wellness committee on February 3rd.