Dr. Emanuel believes telemedicine is a critical component of ACA

According to MedCity News:

Dr. Ezekiel Emanuel, a healthcare economist and bioethicist at University of Pennsylvania and an Affordable Care Act architect presented a pretty dramatic vision of how the hospital landscape and healthcare delivery will change in response to healthcare reform. He also shared some insights into the law’s design at New York eHealth’s Digital Health Conference this week.

20 percent fewer hospitals Emanuel estimated that 1,000 acute care hospitals will close and be converted into outpatient facilities and physician offices. Top tier hospitals will focus on complex procedures such as fetal surgery and organ transplants.The emphasis will be on patients recovering from home and using telemedicine and home visits for follow-up care.

Leaner hospitals He also pointed out that hospitals needed to take a hard look at operational improvement to make them more efficient and less costly to run.

Telemedicine as a critical component He pointed out that telemedicine will be critical to achieving goals of ACA because it will expand the ability of physicians to treat more people beyond traditional office hours. It will also help address the physician shortfall.

Behind the scenes of ACA Emanuel shared some insights on developing ACA. He said that he wanted a 10 percent readmission penalty on Medicare reimbursement for hospitals instead of the agreed upon 1 percent to 3 percent because it would have made more of a difference to hospitals.

VIP care for patients with chronic conditions and mentally ill The big goal is to reduce healthcare costs for the people who tend to use it the most by devoting more resources to helping people with multiple chronic conditions manage their condition.

Digital Health To control healthcare costs, one element will involve mining claims data and electronic medical records to micromanage doctors to ensure that they are adhering to best practice guidelines and not over ordering tests.

Emanuel dismissed the defense that doctors were frequently driven by fear of malpractice suits to over order tests rather than medical judgement. A report last month found that two states with malpractice reform saw no change in the number of medical tests being ordered.



Posted by: C3O Telemedicine News

Posted on: November 19th, 2014

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According to Politico

The boards that license physicians in Tennessee and North Carolina meet this week to continue redrafting rules for how doctors can and can’t treat patients through telemedicine. The Tennessee Board of Medical Examiners convenes this morning in Nashville. The board drafted rules this spring that drew harsh criticism from telemedicine providers, and has been reworking them to better satisfy advocates. The North Carolina Medical Board meets Wednesday and is expected to finalize rules it issued for public comment in September. We’ll be following both.



Posted by: C3O Telemedicine News

Posted on: November 17th, 2014

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Telemedicine screening for diabetic retinopathy (DR) finds condition in one in five patients

A telemedicine program to screen for diabetic retinopathy (a leading cause of blindness) at urban clinics and a pharmacy predominantly serving racial/ethnic minority and uninsured patients with diabetes found the condition in about 1 in 5 people screened, according to a study published online by JAMA Ophthalmology.

About 29 million people have diabetes in the United States and  (DR) is the leading cause of new blindness in working-age adults. Preventing and treating DR includes tight blood sugar and  along with routine dilated comprehensive eye exams. The rate of eye examinations is low among racial and ethnic minority populations. Studies suggest DR screening results that use nonmydriatic cameras for retinal imaging through telemedicine meet the standard criterion of dilated photos. These screenings, because they do not involve dilation, can be less burdensome for patients with diabetes who may face barriers in transportation and cost in seeking comprehensive dilated , according to background information detailed in the study.

Cynthia Owsley, Ph.D., of the University of Alabama at Birmingham, and her fellow co-authors examined the use of a noninvasive DR screening with a nonmydriatic camera and telemedicine review at three urban clinics in Birmingham, Miami and Winston-Salem, N.C., and a pharmacy in Philadelphia.

The Innovative Network for Sight (INSIGHT) study included 1,894 people (average age 53 to 55 years) who were screened across the sites; 21.7 percent of the individuals were found to have DR in at least one eye, according to the study results. Background DR was the most common type of DR and it was present in 94.1 percent of all participants with DR. About half (44.2 percent) of the sample of people screened had eye findings other than DR and 30.7 percent of these other findings were cataract.

“The rate of self-reported dilated eye care use in the past year was low for the overall sample (32.2 percent), suggesting that DR screening in these settings could fulfill a critical role for patients with diabetes not routinely accessing annual dilated  care,” the authors note.

More information: JAMA Ophthalmol. Published online November 13, 2014. DOI: 10.1001/.jamaopthalmol.2014.4652


Posted by: C3O Telemedicine News

Posted on: November 13th, 2014

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Utilization of telemedicine in the U.S. Military in a deployed setting.

A recently released study in Mil Med. 2014 Nov;179(11):1347-53. doi: 10.7205/MILMED-D-14-00115.

Hwang JS1, Lappan CM2, Sperling LC3, Meyerle JH3

This article is a  retrospective evaluation of the Department of Defense teledermatology consultation program from 2004 to 2012 was performed, focusing on clinical application and outcome measures such as consult volume, response time, and medical evacuation status. There were 658 teledermatology cases reviewed to assess how the program was utilized by health care providers from 2011 to 2012. As high as 98% of the teledermatology consults were answered within 24 hours, and 23% of consults within 1 hour. The most common final diagnoses included eczematous dermatitis, contact dermatitis, and evaluation for nonmelanoma skin cancer. The most common medications recommended included topical corticosteroids, oral antibiotics, antihistamines, and emollients. Biopsy was most commonly recommended for further evaluation. Following teleconsultation, 46 dermatologic evacuations were “avoided” as the patient was not evacuated based on the consultants’ recommendation. Consultants’ recommendations to the referring provider “facilitated” 41 evacuations.

Telemedicine in the U.S. military has provided valuable dermatology support to providers in remote locations by delivering appropriate and timely consultation for military service members and coalition partners. In addition to avoiding unnecessary medical evacuations, the program facilitated appropriate evacuations that may otherwise have been delayed.

Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.


Posted by: C3O Telemedicine News

Posted on: November 9th, 2014

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From New rules around when and how doctors can prescribe medication through telemedicine take effect in Florida today. The changes adopted by the Florida Board of Medicine say “prescribing medications based solely on an electronic medical questionnaire constitutes the failure to practice medicine.” While the prescribing of controlled substances are generally banned, doctors can still issue such medication to hospitalized patients. This is the third time this year the state has enacted changes to its telemedicine regulations. Also, the state clarifies that its telemedicine policies don’t apply in emergency situations. In March, the state allowed for a valid physician-patient relationship to be established though telemedicine. They recognize valid relationships can be established with physician assistants as well as physicians. View the rule and changes here:


Posted by: C3O Telemedicine News

Posted on: October 27th, 2014

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A long-touted health-care revolution may at last be about to arrive

Stuck in the waiting room from The Economist

THE idea of telemedicine—health care provided using telecommunications equipment—has a lengthy history. Radio News, an American magazine, devoted its cover to a patient at home consulting a doctor in his surgery via a television link as long ago as 1924. When NASA began monitoring astronauts in space in the 1960s, fantasy became reality. It has been touted as health care’s future ever since.

But even smartphones and tablets have failed to usher in the telemedicine revolution: most health care still happens face to face. Now, enthusiasts think the wait is nearly over. Governments have been slow to embrace an approach that could improve coverage and outcomes, as well as saving money. But they are under increasing pressure from ageing populations and a surge in chronic diseases, just as public budgets are being squeezed.

At an industry conference in Rome on October 7-8th, participants discussed the problems that must be solved if telemedicine’s day is to come. They include redesigning laws and payment systems set up for face-to-face care, and finding ways to keep patients’ data secure and private.

In America, the world’s largest health-care market, states license doctors. Jurisdiction depends on the patient’s location, not the doctor’s—so doctors must be licensed in all states where they have patients, and meet care standards that René Quashie, a health-care lawyer, says are “complicated, incoherent and sometimes contradictory”.

The situation in the European Union is simpler: countries may not pass laws that would stop doctors practising telemedicine, and doctors need only be licensed in one country to practise in all. But member states do not agree on whether to pay for care that is administered remotely; some, including Germany, rarely pay for it at all.

In America only 21 states mandate that telemedicine be compensated at the same rate as face-to-face care. At the federal level, the Veterans Administration has embraced telemedicine whereas Medicare, the public-health programme for the elderly, largely ignores it. But private employers and insurers are increasingly paying for telemedicine, encouraged by a shift to paying doctors for packages of care rather than per service. This has “opened the door” to remote care, says Jonathan Linkous of the American Telemedicine Association.

Telemedicine is more than a Skype chat between doctor and patient, says Michael Young, who works on remote care for the University of North Carolina. The technology can look similar but the need for security and privacy is greater. Earlier this year the FBI warned American health-care providers that their cyber-security systems were not up to snuff. Electronic versions of sensitive documents such as X-rays or doctors’ notes must be as secure as paper ones. That is hard when they are flying through the ether. In August one of America’s biggest hospital groups said Chinese hackers had stolen data on 4.5m patients.

Some small countries are in the vanguard. Israel’s health-care system is fully digitised: all doctors use electronic medical records, and patients have access to their data. Doctors can write repeat prescriptions and refer patients to specialists over the internet. The health ministry noticed an uptick in telemedicine in 2010 and introduced relatively lax guidelines in 2012.

China is spending billions on health-care reform, with a focus on telemedicine. But keen interest is no guarantee of success in any country. “If you have a chaotic system and add technology, you get a chaotic system with technology,” says Peteris Zilgalvis, a health official at the European Commission. Telemedicine may even increase costs if it is added to old routines rather than replacing them. There is little evidence of its cost-effectiveness, says Marc Lange of the European Health Telematics Association, because studies simply lump it on top of standard care.

Lights, camera, interaction

Some doctors have been reluctant to embrace telemedicine, says Nils Kolstrup, a Norwegian doctor, fearing it may lessen their authority by making it easier for patients to seek advice elsewhere. Patients, too, may feel they are being fobbed off with second-best, and governments worry that it could stimulate frivolous demand.

So countries where provision is currently limited or non-existent may be quickest to move. Rwanda, for example, is short of oncologists, so American specialists consult on difficult cases. Doctors at the Cleveland Clinic look at tumours from several African countries. But if telemedicine is to take off, big, rich countries must embrace it—not least because that is where the money is.



Posted by: C3O Telemedicine News

Posted on: October 9th, 2014

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ATA’s Jon Linkous and the “Telemedicine Advantage”

By  of US News & World Report:

You could say telemedicine keeps patients at a distance – but Jonathan Linkous prefers to say it keeps them close. During “The Telemedicine Advantage,” part of the U.S. News Hospital of Tomorrow forum, Linkous, chief executive officer of the American Telemedicine Association, described the myriad ways telemedicine is extending the reach of health care, particularly for people in rural areas who don’t have easy access to high-quality care.

More than half of U.S. hospitals use telemedicine to engage with patients remotely – from monitoring vital signs to full-fledged consultations at a distance. Just the flash of a webcam, for example, allows critically ill patients, perhaps in an eICU, access to a world-class team of physicians who could be anywhere from miles to states away.

Patients’ doctor visits of the future will, in many cases, involve facing a screen – and “in some emergency rooms in San Francisco, you can walk into a kiosk, answer a set of questions and your course of care will be decided by an algorithm in a computer,” said moderator Steven Sternberg, U.S. News’ deputy health rankings editor. “There’s a lot of ferment in the field,” and real obstacles along with benefits. Among the highlights of the discussion, which explored both:

  • Linkous said telemedicine has been around 20 to 30 years “depending how you define it.” Perhaps the greatest example: radiologists, who don’t need to be in the same hospital or even city as a patient to examine digital images. Telemedicine is in place in 100 to 200 networks around the country, and close to 1 million patients will receive consultations online via webcam this year. “And that’s just the small tip of the iceberg,” Linkous said. He added that remote monitoring – for stroke patients, for example – has “huge potential” and can lead to a lower cost of care, coupled with higher quality. “It’s somewhat controversial, but the truth is, consumers want it,” Linkous said. There’s evidence in studies, he added, which suggest that patients overwhelmingly accept telemedicine, and recognize that it’s a step to receiving better care.
  • Steven A. Fuhrman, eICU medical director at Sentara Healthcare – the first remote critical care facility in the nation – said that when his clinic launched in 2000, caring remotely for a critically ill patient was “met with big question marks on people’s faces.” But it’s led to more efficient decision making and has allowed staff to become more efficient in dealing with complex cases. It also promotes proactive care. So why was the ICU one of the first places to have a population-management approach to telehealth? Because it’s such a data-rich environment – and monitoring sends data to centralized location, where it can be interpreted. If you can’t picture an eICU, “We’re not a security camera-based operation,” Fuhrman said, adding that there aren’t hundreds of screens plastered across the hospital’s walls. While physician care revolves around video access, and the ICU staff is not present in the ICU where the patient is, there is bedside staff who helps facilitate care.
  • Robert L. Satcher Jr., an assistant professor of orthopaedic oncology at The University of Texas MD Anderson Cancer Center, said cancer will become the most common cause of death in the coming decades. And because of insufficient primary physicians and specialists to meet the demand for cancer care, especially in rural areas, MD Anderson says telemedicine will play an increasing role. “Many patients live a long way from Houston and are looking for ways to receive care without traveling to Houston,” Satcher said. “The demand for teleoncology is from both patients and physicians.” He added that patients are typically satisfied with the “convenient” experience. Videoconferencing can lead to effective communication between physician and patient, he said, but it remains to be seen how that communication compares to a face-to-face meeting. Meanwhile, telemedicine has appeared at MD Anderson in a number of ways, from telementoring to telesurgery – a limited number of surgical procedures have involved robotic systems. Still, there are concerns, including the high cost of robotic systems, billing issues, safety and infrastructure (for example, a delay in the transfer of information from one site to another). While telemedicine is “not an ell-encompassing panacea,” Satcher said, he described its tremendous potential in meeting patient and clinician needs and enhancing cancer care to underserved regions.


Posted by: C3O Telemedicine News

Posted on: October 7th, 2014

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Reduction of readmissions for CHF by telemedicine

The Journal  Population Health Management reported that Telemonitoring provides a potentially useful tool for disease and case management of those patients who are likely to benefit from frequent and regular monitoring by health care providers. Since 2008, Geisinger Health Plan (GHP) has implemented a telemonitoring program that specifically targets those members with heart failure. This study assesses the impact of this telemonitoring program by examining claims data of those GHP Medicare Advantage plan members who were enrolled in the program, measuring its impact in terms of all-cause hospital admission rates, readmission rates, and total cost of care. The results indicate significant re-ductions in probability of all-cause admission (odds ratio [OR] 0.77; P < 0.01), 30-day and 90-day readmission (OR 0.56, 0.62; P < 0.05), and cost of care (11.3%; P < 0.05). The estimated return on investment was $3.30 on the dollar. These findings imply that telemonitoring can be an effective add-on tool for managing elderly patients with heart failure.


Posted by: C3O Telemedicine News

Posted on: October 6th, 2014

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Telemedicine policy revisions of North Carolina Medical board

According to Church and Richardson of the JDSurpa Business Advisor:

The Policy Committee of the North Carolina Medical Board (“NCMB”) issued proposed revisions to its “Telemedicine” and “Contact with Patients before Prescribing” position statements on September 23, 2014. In short, the proposed revisions:

  • Clarify that there is one standard of care for providers based on their specialty, and telemedicine providers are subject to the same standard of care as non‑telemedicine providers;
  • Revise the standard regarding when telemedicine providers need not conduct an in‑person examination, such that the licensee need not conduct an in‑person examination if he or she “employs technology and peripherals sufficient to provide an examination that is equal or superior to an in‑person examination”;
  • Clarify that it is the telemedicine provider’s responsibility to verify the identity and location of the patient;
  • Specifically state that prescribing controlled substances for pain treatment via telemedicine is disfavored; and
  • Specifically add the potential for a more general ability for telemedicine providers to prescribe for a patient when not personally examining the patient by including language that prescriptions may be made “where the threshold information to make any accurate diagnosis has been obtained.”

The proposed changes are in follow up to an NCMB‑hosted roundtable discussion on August 20, 2014, to gather feedback from stakeholders—including private practitioners, academic medical centers, government officials, and insurers—regarding its current telemedicine position statement. The comment period is open until November 5, 2014.

Proposed Telemedicine Revisions

The NCMB has proposed revisions to the following subsections of the current position statement:

Standard of Care. The proposed revisions reemphasize that current standards of medical practice in North Carolina, as well as professional accountability and consequences for failing to meet such standards, apply equally to the traditional practice of medicine and the practice of medicine via telemedicine. This includes current standards regarding practice improvement and outcome monitoring.

In‑Person Evaluations Not Required When Examination is “Equal or Superior to an In‑Person Examination.” The NCMB has proposed to remove language that required an examination via telemedicine provide “the same information…as if the exam had been performed face to face,” and instead suggests that an physical examination would not be required if he or she “employs technology and peripherals sufficient to provide an examination that is equal or superior to an inperson examination.” This change raises a number of questions as to how this standard may be satisfied. In this regard, it is noteworthy that that the revisions to the position statement did not remove a statement that telemedicine may require another licensed professional to be available to provide physical findings in order to complete an appropriate assessment, again suggesting that information typically obtained via a physical examination may still be required.

Accordingly, while it could be interpreted that practitioners have more flexibility to determine treatment via telemedicine, it also provides a high standard for telemedicine providers to meet without specifying how such a standard would be satisfied.

Patient and Practitioner Identification. The revisions also propose to no longer require that a practitioner practicing telemedicine have “some means of verifying” patient identity, but rather simply require that a practitioner should both verify the identity and location of a potential patient and provide the patient his or her own name, location and professional credentials.

Prescribing. The proposed position statement contains a new “Prescribing” section, which requires practitioners to practice telemedicine in accordance with the NCMB’s prescribing policy (discussed further below) and specifically cautions practitioners that prescribing controlled substances via telemedicine for the treatment of pain is “disfavored.”

Medical Records. Proposed additions serve as a reminder that the current standards of care regarding communication and the transfer of medical records to a primary care provider or facility also apply to practitioners practicing telemedicine.

Contact with Patients before Prescribing

As in the telemedicine position statement, the NCMB statement on prescribing has traditionally emphasized the standard of care as the guiding principal with respect to prescribing medications. While the NCMB continues to state that prescribing under certain circumstances is inappropriate, the proposed changes include an acknowledgement that prescribing drugs to patients is permissible if an evaluation is performed “to the extent necessary for an accurate diagnosis.” In addition, the proposed changes would explicitly state that telemedicine is included in the list of examples of circumstances in which prescribing without an inperson, physical examination may be appropriate. Specifically, the proposed revisions allow “an appropriate prescription in a telemedicine encounter where the threshold information to make an accurate diagnosis has been obtained.” Again, this raises questions as to how such a standard might be met.


The NCMB appears to be opening the door for telemedicine providers to potentially be able to meet the standard of care without an in person examination (but rather, through the appropriate use of technology); however, at the same time, it is reaffirming that the standard of care is not different. Ultimately, this appears to place the responsibility squarely on practitioners to distinguish those situations in which treatment of a patient via telemedicine is appropriate based on a patient’s clinical presentation (and how such telemedicine occurs) and when it is not.

The short, yet significant, revisions to the prescribing position statement contemplate that prescribing for a patient with whom the practitioner has never had a facetoface visit may be permitted if the practitioner determines that sufficient information has been obtained. However, it leaves open the question as to what constitutes obtaining sufficient information.

Moreover, the NCMB specifically stated that prescribing controlled substances via telemedicine is disfavored. In addition, NCMB has not changed its position with regards to prescribing based solely on an Internet questionnaire or a telephone conversation, which the proposed statement still states is inappropriate.

In sum, the proposed revisions to both position statements potentially provide practictioners additional flexibility, but the premise remains unchanged: the use of telemedicine to treat and diagnose illness and prescribe to patients is appropriate in cases in which a practitioner determines that he or she can meet the standard of care and appropriately care for a patient from a distance, except when it involves controlled substances.

While flexibility will be welcomed by practitioners, clarity is equally important. Hopefully, following the comment period, the NCMB will attempt to draw more brightline standards.


The proposed revisions to the telemedicine and prescribing position statements can be viewed hereand here.

The NCMB is soliciting comments regarding the proposed revisions to both position statements. Comments may be emailed to Please indicate “telemedicine” in the subject line. Comments are due by the end of business on November 5, 2015.



Posted by: C3O Telemedicine News

Posted on: October 6th, 2014

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Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life


While not under the sign of telemedicine, the Institute of Medicine just released a report on preferences at the End of Life.


Posted by: C3O Telemedicine News

Posted on: September 17th, 2014

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