|Dear ACP Member,|
|I am writing to share with you the American College of Physicians’ plans to address the implications of the 2016 U.S. Presidential and Congressional elections. We are preparing for a new administration in Washington, D.C., and assessing the challenges and opportunities related to health care and our policy priorities that will come in this new environment.|
|The election has evoked strong reactions from ACP members, both within the U.S. and abroad. Like the public, ACP members have divergent views. What unites us is our abiding commitment to our profession, and to our patients. We affirm our continued commitment to equal access to care and non-discrimination against persons based on their gender, gender identity, race, ethnicity, religion, or sexual orientation, including support for our international ACP members and immigrants to the U.S. who are concerned about potential changes in U.S. immigration policies.|
|The College, as a matter of U.S. law and practice, is non-partisan. We engage in advocacy based on policies that have been adopted by our Board of Regents, through a deliberative, consensus-building process involving our policy committees, councils and elected Board of Governors and Regents, supported by a rigorous review of the evidence of how different policy options will affect patient care. We are obliged to pursue these policies no matter the results of any given election.|
|Accordingly, ACP will strive to engage in a constructive and bipartisan way with President-elect Trump and his administration, and with Congress, to achieve bipartisan progress on the College’s policy objectives. Our hope is to find common ground. If policies are proposed by the new administration or Congress that in our judgment would be detrimental to our profession and our patients, we won’t just seek to prevent them from being implemented, we’ll offer better alternatives. We remain steadfast in our mission to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine and supporting the critical role played by internists and other primary care physicians in providing high-value, team-based, patient and family-centered care, continuing the transition to value-based payment models, and reducing administrative burdens that interfere with the patient-physician relationship.|
|Let me share with you some of the areas where we think bipartisan progress may be possible:
|We are also aware of areas where ACP’s policy objectives do not appear to be aligned with those of the new administration and Congress and may be more challenging:
|Over the next few weeks, we will assess our advocacy priorities to determine how best to proceed given the election.|
|How can you help? Please email me with your thoughts on ACP advocacy priorities. Let your ACP chapter governors, U.S. and international, know if you have suggestions for them to take to the Board of Governors. And, if you are a U.S. member of the College, become a grassroots activist for internal medicine by joining our Advocates for Internal Medicine Network (AIMn). As a member of AIMn, you will get timely and concise updates on key developments in Congress, and what you can do to help us achieve our advocacy priorities in this new environment.|
|Nitin S. Damle, MD, MS, MACP
American College of Physicians
AN OPERATOR IS TRYING TO CONNECT YOUR CALL: A coalition of telemedicine advocates in Congress are working to attach Hawaii Sen. Brian Schatz‘s CONNECT for Health Act onto a year-end spending bill. The bill would expand telemedicine coverage in Medicare through alternative payment models, Medicare Advantage and for stroke care. Because the bill is backed by Senate Appropriations Chair Thad Cochran, supporters feel they have a better-than-average chance of getting it tied to a must-pass spending bill.
However, some members of Congress expect a “clean” continuing resolution. “There no way to say with certainty what may or may not be included in appropriations legislation considered during the lame duck,” a Senate Appropriations Committee spokesperson tells David.
From Morning eHealth and Arthur Allen of POLITICO
The AMA and AAFP are at odds with new legislation that affects interstate medical licensing. However, in Senate Bill 2943 which is a defense bill, a section on telehealth says the site of the provider rather than the patient determines the source for the consultation. In a letter to both the Senate and the Congressional Armed Services Committee , both organizations take issue with the point of service being the provider. Some excerpts from the AMA letter:
“We are therefore deeply concerned with the language in section 705(d) of the Senate version of the NDAA (S. 2943) that would alter the point of care from the location of the patient to the location of the provider. This provision would deprive TRICARE beneficiaries of essential protections by fundamentally subverting and undermining existing state-based patient safety protections that are currently in force, and remove an essential mechanism used by states to ensure medical care provided to patients in their state meets acceptable standards of care.”
Response: Why wouldn’t every state have the same protection in place? We don’t practice differently from California to New York. One driver’s license protects a person in an accident if they are from two different states. Rather than spending the money for the Compact why not spend it to promote better working reciprocal relationships among the states?
“Changing the applicable state laws from the location where the patient is located to the state where the health care provider is located for purposes of state licensure, medical liability, and reimbursement does not achieve the intended outcome. Namely, it would create confusion by altering well-established legal principles and open new conflicts of law questions, degrade important patient protections, and create confusion with regard to payment and coverage.”
Response: Why shouldn’t we have the same laws for all states? We train in one state and practice in another. We have malpractice that extends across state lines.
“Section 705(d) would dismantle accountability mechanisms needed to ensure patient protection because (1) state licensing boards, where the patient is located, would lack authority over practitioners licensed in another state and (2) state boards where the practitioner is licensed would have no authority to conduct investigations in a different state where the patient is located.”
Response: Again, a driver has automobile insurance which works in every state he or she drives. Isn’t it time that artificial borders be removed when it affects patient care. We all want to ensure patient safety but what has been done to make this universal. After 100 years, state medical boards need a 21st-century model.
“The medical profession has long advocated that state licensing boards and the Federation of State Medical Boards (FSMB) streamline and simplify the medical licensure process. And, to that end, a workable solution is rapidly advancing through the FSMB’s Interstate Medical Licensure Compact”.
Response: the FSMB started this process in 2014, and to date, only 18 states have approved this. In fact, the state of Ohio came out against accepting the Compact. So how do we know if the majority of states will sign on?
My concern is that the telemedicine practitioners and clinical service providers are not being heard. When it takes 4-6 months for a license and 3-4 months for credentialing, just how many patients are not receiving the benefits of telemedicine? There has always been a concern that state medical boards face a conflict of interest when they control who comes into their state to practice medicine. In 2016, it is time these boards catch up with expanding medical technology that enhances patient access to healthcare. I still favor an unencumbered reciprocal license (drivers license model) or a national license so we can resolve this barrier to telemedicine.
Ventura, CA, October 8, 2016 – C3O Telemedicine is pleased to announce the successful launch of if its latest telehealth program, a partnership for 24/7 stroke care with Meridian Neuroscience, now part of the Hackensack Meridian Health family, the most comprehensive and most integrated network in the state of New Jersey.
C3O’s Acute Neurology Telemedicine Program, designed to improve access to specialists for stroke patients and other neuro-critically ill patients, was successfully implemented at all Hackensack Meridian Health hospitals in Monmouth and Ocean counties. The hospitals are Riverview Medical Center, Ocean Medical Center, Bayshore Community Hospital, Southern Ocean Medical Center, and Jersey Shore University Medical Center, the only hospital in the region to be both a state-designated Comprehensive Stroke Center and a nationally accredited Primary Stroke Center.
Utilizing technology from InTouch Health, based out of Santa Barbara, the program allows C3O’s board-certified neurologists and neurointensivists to work closely with the emergency department teams at the network’s hospitals throughout the region and Jersey Shore’s neurosurgical interventionalists who are available 24/7 to provide access for mechanical retrieval of clots during an acute stroke.
Dr. Herb Rogove, president and CEO of C3O Telemedicine, and past board member of the American Telemedicine Association states, ”C3O is honored to have been selected as the first provider of telehealth for Hackensack Meridian Health hospitals in Monmouth and Ocean counties. We are already seeing patients and the onsite teams have been very enthusiastic and engaged in supporting the program. Meridian Neuroscience is an outstanding program that offers the most advanced treatment options when interventional procedures and surgeries may be needed. We are excited to partner with them in this new program and continue our company’s growth.”
“Telestroke is a significant advancement in how we provide health care and treatment for stroke patients,” says Alan Colicchio, M.D., medical director of Meridian Neuroscience. “Because strokes occur at all times of day, Telestroke ensures that a patient is assessed immediately rather than having to wait for a neurologist to arrive at the hospital. Since we started using it in the emergency department, we have been able to diagnosis and treat patients faster, helping to reduce the amount of recovery time a patient faces and decreasing the length of time they must remain in the hospital. It’s been met with rave reviews by patients, families, and care teams alike, and we have been extremely pleased with how seamlessly the tele-neurologists have blended with our medical staff. It’s been a great partnership so far.”
According to the National Stroke Association, stroke is the third leading cause of death in the United States, and stroke-related healthcare costs total $73.7 billion. Expediting the presence of a skilled neurologist to the bedside to assess the appropriateness of the lifesaving medication tPA can dramatically improve healthcare outcomes. Telemedicine technologies have been proven clinically and cost-effective methods for supplying the care these patients need.
C3O Telemedicine and its physicians have been providing tele-neurocritical care services to hospitals and health systems since 2008. http://c3otelemedicine.com/
About C3O Telemedicine
C3O Telemedicine is an innovative provider of virtual presence clinical coverage solutions to metropolitan and rural health facilities. As a physician owned and operated organization with renowned, board-certified specialists, C3O Telemedicine delivers flexible, easily implemented, and highly supported telemedicine services to its clients with exceptional clinical quality. C3O’s physicians and engaged physician-led management have developed programs at multiple facilities with demonstrated value through rapid response times, enhanced patient outcomes and immediate definitive care and discharges, with an accompanying improvement in hospital financial performance. http://c3otelemedicine.com/ .
About Hackensack Meridian Health
Hackensack Meridian Health is a leading not-for-profit health care organization that is the most comprehensive and truly integrated healthcare network in New Jersey, offering a complete range of medical services, innovative research, and life-enhancing care. There are 13 hospitals in Hackensack Meridian H, including two academic medical centers, two children’s hospitals and nine community hospitals, physician practices, more than 120 ambulatory care centers, surgery centers, home health services, long-term care and assisted living communities, ambulance services, lifesaving air medical transportation, fitness and wellness centers, rehabilitation centers, and urgent care and after-hours centers. Hackensack Meridian Health has 28,000 team members, more than 6,000 physicians and is a distinguished leader in medical philanthropy, committed to the health and well-being of the communities it serves.
The Network’s notable distinctions include having one of only five major academic medical centers in the nation to receive Healthgrades America’s 50 Best Hospitals Award for five or more consecutive years, the number one hospital in New Jersey as ranked by U.S. News and World Report, consistently achieving Magnet® recognition for nursing excellence from the American Nurses Credentialing Center, recipient of the John M. Eisenberg Award for Patient Safety and Quality from The Joint Commission and the National Quality Forum, a six-time winner of Fortune’s “100 Best Companies to Work For,” one of the “20 Best Workplaces in Health Care” in the nation, and the number one “Best Place to Work for Women.” Hackensack Meridian Health is a member of AllSpire Health Partners, a regional consortium of leading health systems, to focus on the sharing of best practices in clinical care and achieving efficiencies.
The hospitals of Hackensack Meridian Health include: academic medical centers – HackensackUMC in Hackensack, Jersey Shore University Medical Center in Neptune; children’s hospitals – Joseph M. Sanzari Children’s Hospital in Hackensack, K. Hovnanian Children’s Hospital in Neptune; community hospitals – Ocean Medical Center in Brick, Riverview Medical Center in Red Bank, HackensackUMC Mountainside in Montclair, Palisades Medical Center in North Bergen, Raritan Bay Medical Center in Perth Amboy, Southern Ocean Medical Center in Manahawkin, Bayshore Community Hospital in Holmdel, Raritan Bay Medical Center in Old Bridge, and HackensackUMC at Pascack Valley in Westwood.
To learn more, visit www.hackensackmeridianhealth.org.
Abstract from PubMed
We undertook a scoping review of the published literature to identify and summarise key findings on the telehealth interventions that influence waiting times or waiting lists for specialist outpatient services. In this report, searches were conducted to determine relevant articles. In this review articles were included if the telehealth intervention restructured or made the referral process more efficient. We excluded studies that directly increased capacity. Two categories of interventions are – electronic consultations and image-based triage. Electronic consultations are asynchronous, text-based provider-to-provider consultations. Electronic consultations have been reported to obviate the need for face-to-face appointments between the patient and the specialist in between 34-92% of cases. However, electronic consultations are appropriate in less than 10% of referrals for outpatient care. Image-based triage has been used successfully to reduce unnecessary or inappropriate referrals and was used most often in dermatology, ophthalmology, and otolaryngology (ENT). Reported reduction rates for face-to-face appointments by specialty were: dermatology 38-88%, ophthalmology 16-48% and ENT 89%. Image-based triage can be twice as efficient as non-image based triage in reducing additional appointments.
Telehealth interventions can be used to reduce waiting lists and improve the coordination of specialist services.
Dr. Kevin Sheth, one of the lead investigators in this trial and a member of the C3O Telemedicine’s clinical team has been researching avenues to reduce complications following an acute stroke. One major contributor to poor outcomes after a stroke is brain swelling and was found to be reduced by intravenous glyburide treatment according to phase 2 clinical trial. The information collected from the study is further used for other phases of clinical trial.
Accumulation of excess fluid in the brain may cause brain swelling. This usually occurs during stroke which is mainly due to a blockage in the blood supply to the brain. Swelling in the brain may increase pressure and pushes the brain out of the skull resulting in 50% of the mortality rate. Surgery procedures like hemicraniectomy ( removing a portion of the skull to reduce swelling) may not be possible with all patients and treatment using drugs may also be less effective.
According to previous animal studies, glyburide utilized in the treatment of diabetes was found to reduce brain swelling in stroke patients. The phase 2 clinical trial for glyburide was sponsored by Remedy Pharmaceuticals following a pilot study conducted by Kimberly and co-author Kevin Sheth, MD, Department of Neurology, Yale University School of Medicine, which reported that glyburide was found to be safe for stroke patients.
Glyburide Advantage in Malignant Edema and Stroke (GAMES-RP) trial was conducted in 18 hospitals across the United States. About 77 stroke patients were randomly assigned to continuous glyburide treatment or placebo for 72 hours.
The results were obtained from patients after 90 days, using a standardized stroke scale ranging from 0 to 4 indicating no symptoms to moderate and severe brain swelling. About 40% of the patients met the criteria and were able to survive without surgery.
Sheth said that the decision for performing surgery seems to be complicated and was noted only in cases where physicians decide based on the wishes of the patient or their family. And this was found to be the main reason for not reaching the endpoint of the clinical trial.
However, the results of the clinical trials were able to show a reduced degree of the midline shift in the brain by 40% after treatment with glyburide and was also able to reduce MM-9 biomarker which was associated with brain swelling in previous studies. These results will further be used in 2017 for phase 3 clinical trials.
Rogove Testifies at Congressional Hearing: Technology And Treatment: Telemedicine In The VA Healthcare System
Technology and Treatment: Telemedicine in the VA Healthcare System
Dr. Kevin Galpin M.D.
Acting Executive Director for Telehealth, Veterans Health Administration, on behalf of U.S. Department of Veterans Affairs
Dr. Scotte Hartronft M.D., MBA, FACP, FACHE
Chief of Staff, VA Greater Los Angeles Healthcare System, Veterans Health Administration, VA Desert Pacific Healthcare Network (VISN 22), on behalf of U.S. Department of Veterans Affairs
Dr. Herb Rogove DO, FCCM, FACP
President and Chief Executive Officer, C30 Telemedicine
Zachary D. Walker
The issue of interstate medical licensing has been alive and in ill health for over 20 years. Recently in an op-ed in the WSJ (http://on.wsj.com/2b3ekFX) the suggestion, once again, for one medical license to practice in all fifty states fits under the aegis of the federal government accepting the credo that telemedicine occurs where the physician is and NOT the patient. Under this logic, telemedicine practice is considered under the commerce clause of the Constitution. Patient protection under the state medical board is upheld, no additional costs are added to the healthcare bill, and telemedicine programs can be implemented after the hospital credentialing process (for hospital-based programs). Too logical, yes. Too reasonable, yes. Too Twenty-First century, yes. Will it occur, NO! The FSMB’s compact is just a smoke screen, and anyone with knowledge or serious interest in telemedicine should be indignant that after twenty years, our state medical boards need to catch up to our own Veterans Administration or even the European Union.
A group of fifteen physicians compared interpretation of chest x-rays using established 23 major findings from cardiology, radiology, and pulmonary-critical care via Google Glass screen, viewing on Google Glass and interpreting on a mobile device, and viewing the original chest x-ray on a desktop computer screen. A top score was maximum 23 points.
Google Glass: 14.1
Google Glass photo on mobile device: 18.5
Desktop computer: 21.3
Of the 15 physicians, 11 (73%) felt confident in detecting findings using photographs taken by Google Glass as viewed by mobile devices.
Remote chest x-ray interpretation using hands-free Google Glass is less accurate than description using a desktop computer or a mobile device. Further technical improvements Google Glass are needed before widespread application and acceptance.
What others say
Google Glass is revolutionizing the healthcare world. As in fields like higher education, third-party application developers and users are embracing Glass to deliver highly empowering, meaningful Glassware with amazing results. Mark Taglietti, head of ICT delivery services and vendor management at London University College Hospitals says, “Google Glass represents a step change in technical innovation, wearable technology, and the convergence of personal devices in the workplace. The healthcare applications of Glass are wide-ranging, insightful and impactful, from enabling hands-free real-time access to clinical and patient information, to the transmission of point of view audio and video for surgical research and educational purposes. Glass marks the beginning of a remarkable journey for technical innovation within healthcare, enabling providers to improve the delivery of care, as well as overall quality and patient experience.”
The nature of telemedicine is to connect doctors to patients on-demand. The range of telemedicine scenarios is vast. Glass can provide synchronous video conversations with physicians at remote locations. Remotely-conducted procedures can be recorded and embedded in patient records for future reference. With Glass, physicians at rural hospitals can consult with specialists located anywhere in the world in real-time to provide world-class service to their patients. Telemedicine also plays a significant role in streamlining care to hospice patients. Care providers can communicate with physicians remotely and proactively monitor patients whose EHRs can be transmitted in real-time. The seemingly high $1,500 price of Google Glass is significantly less than other types of hospital videoconferencing, which can run upwards of $40,000.
More work in developing the technology may result in radiology’s quick acceptance and adaptation.
Published by Dove Press 21 April 2016 Volume 2016:11(1) Pages 809—822
Thorbjørn L Gregersen,1 Allan Green,1 Ejvind Frausing,1 Thomas Ringbæk,1,2 Eva Brøndum,1 Charlotte Suppli Ulrik1,2
1Department of Pulmonary Medicine, Hvidovre Hospital, Hvidovre, 2Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
Objective: To summarize studies addressing the impact of telehealth on Quality of Life (QoL) in patients with COPD.
Design: Systematic review.
Methods: A series of systematic searches were carried out using multiple databases: from 2000 to 2015. A predefined search algorithm was utilized with the intention to capture all results related to COPD, QoL, and telehealth published since the year 2000.
Outcome measures: Primary outcome was QoL, assessed by validated measures.
Results: Out of the 18 studies fulfilling the criteria for inclusion in this review, three studies found statistically significant improvements in QoL for patients allocated to telemedical interventions. However, all of the other included studies found no statistically significant differences between control and telemedical intervention groups regarding QoL.
Conclusion: Telehealth does not make a strong case for itself when exclusively looking at QoL as an outcome since statistically significant improvements relative to control groups have been observed only in few of the available studies. Nonetheless, this does not only rule out the possibility that telehealth is superior to standard care concerning other outcomes but also seems to call for more research, not least in large-scale controlled trials.
Comments: While this important meta-analysis shows an insignificant improvement in the quality of life, once must keep in mind the number of advancements in technology since 2000. For example, some recent data from the application Propeller (formerly Asthmapolis) has shown more compliance with inhalers and potentially a decrease in hospital admissions. That in itself might be considered an improvement in the QoL. A rush to judgment after reviewing this study should be tempered by an update within the next few years. Don’t throw the bath water out so soon!