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Just Released: Telemedicine Practice Guidelines for Live, On Demand Primary and Urgent Care


ATA just released the newly approved Practice Guidelines for Live, On Demand Primary and Urgent Care. These guidelines cover the provision of direct-to-patient, primary and urgent care services delivered by licensed healthcare providers using online, real-time videoconferencing and audio technologies. Technologies include mobile devices such smart phones, laptops or tablets where regulatory conditions permit.

These guidelines were developed by a diverse group of industry leaders and individuals including members of the Practice Guidelines Committee, Guidelines Work Group and ATA Staff.  Extensive reviews and comments concerning the guidelines were received from medical societies, health systems, provider groups, healthcare companies, medical boards and government agencies.  Access the Live, On Demand Primary and Urgent Care guidelines here: http://www.americantelemed.org/resources/telemedicine-practice-guidelines/telemedicine-practice-guidelines/practice-guidelines-for-live-on-demand-primary-and-urgent-care

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C3O Telemedicine News

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December 16th, 2014

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A major step for quality in telemedicine: ATA announces accreditation process


Today, ATA launched an accreditation program

for online, direct-to-consumer healthcare consultations. The program will accredit U.S. healthcare entities providing real-time, online consultations directly to the patient that meet specific standards.

The Accreditation Program will:

  • help to assure online healthcare consumers they are making good choices when it comes to online healthcare,
  • provide benchmarks for organizations building an online practice,
  • and provide reassurance for payers that the virtual services they are reimbursing follow federal and state laws and regulations, assure patient privacy, are transparent in pricing and operations, use qualified, licensed providers, and follow appropriate clinical practices and guidelines.

From Dec.15, 2014 through Feb. 28, 2015, registration for the Accreditation Program will be open to ATA Institutional Members, Sustaining President’s Circle and President’s Circle members exclusively.

Further information about the program is available here

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C3O Telemedicine News

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December 15th, 2014

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Paying for Telemedicine


Published Onlineajmc: December 12, 2014
Robert S. Rudin, PhD; David Auerbach, PhD; Mikhail Zaydman, BS; and Ateev Mehrotra, MD
Telemedicine has the potential to reduce healthcare costs, increase access to healthcare, and improve health outcomes.1,2 However, despite these prospective advantages, telemedicine has been adopted in only limited circumstances, such as for reading radiology reports and remote phone or video visits for minor health issues.3 To promote adoption, some have advocated for telemedicine services to be reimbursed by health plans and many states have issued “parity laws” that force payers to reimburse some forms of telemedicine services at a level equal to in-person care. In this perspective, we explore why health plans are reluctant to cover most telemedicine services as part of current payment arrangements and explain why newer payment models offer greater potential for its expanded and more effective use.

Telemedicine is the delivery of health-related services via telecommunication technologies, such as phones and the Internet. Although some services involve direct interaction between providers and patients.1 Others involve passively collecting patients’ data from their homes and sending the information to healthcare professionals for monitoring.

A central barrier to the adoption of telemedicine is fee-for-service (FFS), the predominant payment method in the United States. In FFS, providers submit a claim to be reimbursed for each clinical service they perform. Providers are not paid for any service not included in the payer’s fee schedule. In many cases, virtual “visits” via phone or the Internet may be as effective in delivering care as in-person visits and require fewer resources to provide.4 However, most healthcare providers who adopt virtual visits will be financially penalized because many types of visits are not reimbursed or are reimbursed at lesser amounts. The few forms of telemedicine that have been widely adopted, such as remote reading of radiology reports, are exceptions. In those cases, the technology does not jeopardize FFS revenue for the provider adopting the technology.

Proponents argue that payers should add telemedicine as a reimbursable service. Some states have enacted parity laws and Congress is considering legislation to expand FFS reimbursement of telemedicine by Medicare. However, arguments in favor of this approach meet resistance from providers and payers alike. Providers are concerned that offering telemedicine (which, other than services covered under a parity law, is usually considered lower intensity compared with in-person visits and therefore reimbursed at a lower rate) will eat up much of their income because it will reduce the need for in-person visits. Payers have the opposite concern: although telemedicine reimbursement may increase use of actual service, inappropriate use will increase costs.1 This concern regarding inappropriate use is consistent with other coverage decisions. For example, when payers expanded coverage of implantable cardiac defibrillators in the 1990s and 2000s, inappropriate use of the devices grew dramatically.5,6 Telemedicine may be particularly prone to overuse because of its key advantages—convenience and increased access.

Emerging Payment Models

Non-FFS payment models offer alternative ways to pay for telemedicine. Under capitation, the strongest form of these new models, providers receive a fixed payment to provide care for each individual. Thus, any reduction in care costs that results from using a lower-cost technology, such as telemedicine, would accrue entirely to the provider organization.

Because pure capitation involves substantial risks for providers, it is not a common payment arrangement. However, emerging models, such as Accountable Care Organizations (ACOs), involve a form of “global payment” in which providers’ payments partially depend on the total health costs that their patients incur. In ACOs, providers must also meet quality-of-care standards, thereby favoring technologies that both improve quality of patient care and reduce costs.

Evidence from health maintenance organizations (HMOs) in the 1980s and 1990s suggests that the new payment models can stimulate adoption of cost-effective technology. HMOs are similar to newer payment models in that they also typically hold providers accountable for the costs of caring for their patients. One study of HMOs found that hospitals in areas with higher concentrations of HMO patients were more likely to use low-intensity heart attack treatment technologies (eg, medical management techniques) and less likely to use high-cost technologies (eg, cardiac catheterization, angioplasty, or bypass surgery), which evidence suggests are overused.7,8 The HMO experience suggests that new payment models will likely stimulate the adoption of telemedicine, which has advanced considerably in technical capability since the 1990s, and early evidence suggests that this is the case.9,10

By placing incentives for reduced cost and improved quality in the hands of provider organizations rather than insurers, new payment approaches should help foster the efficient use of telemedicine. Under FFS, payers are often faced with blanket coverage/no coverage decisions for all providers in their network, regardless of whether FFS is being used in an appropriate or inappropriate clinical situation.11 Under new payment models, adoption decisions are made by the providers, who have the flexibility to experiment with telemedicine and use the technology in a way that maximizes clinical outcomes and minimizes costs.  We provide 2 examples of how this may happen: videoconferencing for outpatient visits, and home telemonitoring.

Videoconferencing for Outpatient Visits

Real-time video communication between patient and provider allows for many of the same benefits as an inperson visit, without requiring the patient or provider to travel. This form of telemedicine has been evaluated in research studies for decades, and several studies have shown positive effects on patient outcomes even when low-bandwidth, telephone-based Internet connections reduced the quality of the video image.12 Videoconferencing in the form of visits for new acute problems is often covered by health plans, but use of videoconferencing is uncommon, particularly for chronic illness care, where it may have the most benefit. However, provider systems that have non-FFS payment models are already making extensive use of videoconferencing. In the Veterans Health Administration (VHA), videoconferencing is used routinely to deliver mental health services.13 Kaiser, a capitated system that is providing 2.5 million “phone visits”each year, is testing videoconferencing for more general use,14 and has made more than 350 after-hours video visits to patients who claim they would have otherwise gone to the emergency department.

As more providers adopt new payment models, they will likely also begin to use videoconferencing. As an early example, the Alternative Quality Contract from Blue Cross Blue Shield uses global payments, and providers under that contract have begun piloting a telemedicine platform that enables videoconferencing visits.9 Because of global payments, the pilot practices will be motivated to prevent overuse, perhaps by triaging patient requests for videoconferences, using some form of co-pay, or making the virtual visit available only to patients for whom a physician believes it would be most beneficial.

Home Telemonitoring

Many technologies are available that measure health indicators of patients in their homes and transmit the data to an overseeing provider. The provider, who might be a physician, nurse, social worker, or even a non-clinical staff member, can filter patient questions and report to a clinical team when necessary. Several studies show the potential benefit. In a cardiac study at Partners Healthcare, 3000 congestive health failure patients received in-home monitoring of weight, blood pressure, heart rate, and pulse oximetry. Decision support software helped identify high-risk patients. As a result, readmissions dropped by 44%, saving the health plan $10 million in 6 years.15 The VHA also implemented a home telemedicine program in which the more than 17,000 patient participants had a 25% reduction in the number of bed days of care and a 20% reduction in the number of hospital admissions compared with usual care.16

As new payment models that reward cost savings spread, providers will have incentives to adopt these home monitoring technologies as part of routine care. Early reports suggest that providers are responding to these incentives: ACOs are planning to use home monitoring to prevent more costly hospital visits or emergency care.10 As with virtual visits, the new payment models will encourage telemonitoring to be used only for patients who will likely benefit from the service.

CONCLUSIONS

Telemedicine technologies have the potential to benefit patients by increasing access to care, promoting convenience, enhancing quality of healthcare, and reducing costs.1 However, payers and providers are unlikely to support adding telemedicine as a reimbursed service because of its uncertain effect on provider payments and its potential for overuse. Direct reimbursement might still be needed for certain telemedicine services, but such payments will likely be the exception, not the rule. Emerging payment models offer the greatest hope that telemedicine will be widely adopted and used in a way that will make it worth the cost.

Take-Away Points

  • Telemedicine offers the potential for better care, lower costs, and increased convenience.
  • Expanding existing fee-for-service payment models to include telemedicine may lead to its overuse. Already there are many skeptics among payers and providers regarding this method of payment.
  • The greatest potential for effective and efficient use of telemedicine services lies in the use of emerging payment models.
Author Affiliations: From RAND Corporation, Boston, MA (RSR, DA, AM), and Santa Monica, CA (MZ).

Source of Funding: Some of this work was funded by a generous gift from Teletracking, Inc.

- See more at: http://www.ajmc.com/publications/issue/2014/2014-vol20-n12/Paying-for-Telemedicine#sthash.jv9FU6N8.dpuf

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December 12th, 2014

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In China: Telemedicine calls as population ages


 

2014-11-26 13:23

China Daily

D-Phone Group, China’s largest mobile phone retail chain store, has announced a 10 million yuan ( $1.63 million) investment in the telemedicine industry with the establishment of the China-based WorldCare China.

As the exclusive representative of WorldCare International in the country, WorldCare China will closely cooperate with the members of WorldCare Consortium in providing medical resources and related services to patients in China.

The partnership will allow clients in China to receive top international medical opinions when it comes to diagnosis and treatment, saving time and effort spent in referral appointments and long-distance travel.

Founded in 1992, WorldCare International is a medical service consortium consisting of several United States hospitals. It is also a world leader in the field of global telemedicine services and consultations. The alliance has at least 20,500 doctors, and the total investment in medical research by its member hospitals exceeds $4.3 billion annually.

The consortium includes Boston Children’s Hospital, Duke University Health System, Mayo Clinic, Jefferson University and Hospitals, Partners Healthcare System, Penn Medicine and UCLA Healthcare, all of which are ranked among the top hospitals in the US.

It offers medical services to millions of members across 65 countries.

“D-Phone is the initial investor in WorldCare China, and it has a 20 percent stake,” Liu Donghai, president of D-Phone Group, told 21st Century Business Herald newspaper.

The telemedicine market in China will exceed 10 billion yuan within the next three years, driven by the country’s large and increasing aging population, according to Beijing-based S&P Consulting.

With a growing population of affluent Chinese individuals seeking medical treatment abroad, many foreign medical institutions have come to explore the market in China. Those trends are supporting demand for telemedicine services in the country.

Tian Lanning, deputy secretary-general of the China Association of Social Welfare, told a telemedicine forum in October, that in China, the number of people aged above 60 is about 200 million, and half of them are empty-nesters.

However, the number of medical personnel is just about 6 million, making it difficult to satisfy the face-to-face medical service demands of every senior citizen.

The investment in Internet in China’s healthcare industry reached about 22.6 billion yuan in 2013, increasing 21.5 percent year-on-year.

In the telemedicine sector, the market was valued at 2.16 billion yuan in 2012, and it has grown at an annual rate of 18 percent in recent years, according to S&P Consulting.

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November 27th, 2014

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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.

 

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C3O Telemedicine News

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November 19th, 2014

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In an ideal world: a slice just arrived – Stroke Mobile + Telemedicine


We are told “time is brain” so get that patient to the ED STAT. Well now, the Cleveland Clinic makes stroke treatment house-calls including a CT scanner and telemedicine evaluation in the ambulance. The European community has been doing this before and Israel was giving tPA via their paramedic systems years ago. Welcome to the real twenty first century and congratulations.CCFMobileStrokeUnit

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November 18th, 2014

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Teleneonatology: a major tool for the future.


Abstract

 The neonatal intensive care unit (NICU) at Utah Valley Regional Medical Center in Provo, Utah, began an aggressive redesign/quality improvement effort in 1990. It became obvious that our care processes were designed for health care deliverers and not for the families. An ongoing revamp of our care delivery processes was undertaken using significant input from a parent focus meeting, parental interviews, and development of a parent-to-parent support group. As a result of this work, it became obvious we needed a new model to truly empower parents. The idea of “NICU is Home” was born. We elected to make a mind shift, not to focus on what families think, but rather on how they think. Web cams and other video apparatus have been used in a number of NICUs across the country. We decided:

  1. Our equipment requirements would need to include high-resolution cameras, full high-definition video recording, autofocus, audio microphones, automatic noise reduction, and automatic low-light correction.
  2. Our conferencing software needed to accommodate multiple users and have multiple-picture capabilities, low band width, and inexpensive technology.
  3. It was recognized that a single video camera feed was insufficient to adequately capture the desired amount of information.
  4. Verbal communication between parents and their babies’ principal care providers is critical.
  5. Parents loved the idea of expanding the remote NICU web cam of their baby to a two-way physician-parent communication bedside monitor.
  6. Doctors at Utah Valley Regional Medical Center now have a mobile desk using a WiFi computer/camera/audio to communicate with the family in real-time or leave a recording.

Copyright 2014, SLACK Incorporated.

 

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November 18th, 2014

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STATE MEDICAL BOARDS MEET OVER TELEMEDICINE


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.

 

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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

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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.

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C3O Telemedicine News

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November 9th, 2014

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