Yaghi S1, Harik SI2, Hinduja A2, Bianchi N2, Johnson DM2, Keyrouz SG2.
- 1Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR email@example.com.
- 2Department of Neurology and the AR Saves Program of the Center for Distant Health, University of Arkansas for Medical Sciences, Little Rock, AR.
The purpose of our study is to determine whether the transfer of patients to hub hospitals is beneficial.
- Retrospectively analyzed data from our prospectively collected cohort in the AR SAVES (Stroke Assistance through Virtual Emergency Support) telestroke network from November 2008 till January 2012.
- We compared the outcome of patients who were transferred to a “hub” with those who remained at the “spoke” hospital where thrombolysis took place.
- We stratified patients according to stroke severity using admission NIHSS scores into two groups: patients with mild stroke (NIHSS <8) and those with moderate to severe stroke (NIHSS ≥8). We defined good outcome as a modified Rankin Scale (mRS) score ≤2. Statistical analysis was performed using Fisher’s exact test, two-tailed, and significance was considered at p < 0.05.
- Out of 894 telestroke consultations, 206 patients received thrombolytic therapy; 134 patients had moderate to severe strokes and 160 patients (78%) were transferred to the hub after thrombolytic therapy.
- The percentage of patients with good outcome at 3 months was similar between patients transferred to hub and those who stayed at the spoke (61% vs. 55%, p = NS).
- However, when only patients with moderate to severe strokes were analyzed, patients transferred to the hub were more likely to have good outcomes at three months post t-PA (50% versus 24%, p = 0.026).
Patients with moderate to severe ischemic strokes who were treated with t-PA in a telestroke network may potentially benefit from expert care at a primary stroke center.
Many tele-stroke programs are based upon the hub-spoke model. Often in rural hospitals without ICU’s the obvious course is to start tPA then transfer to a hub center. The question then comes up, for these less severe patients, do we still need to transfer them after tPA is given. In depth data on complications in this cohort needs to be reviewed. Outcomes as far as survival look very good.
(PRWEB) May 14, 2015 — WASHINGTON- Thursday, May 14, 2015— The American Telemedicine Association (ATA) recently elected Reed V. Tuckson, MD, as President of the Association’s Board of Directors. Dr, Tuckson has been recognized among the 50 most influential physician executives and top 25 minority executives in healthcare. With a distinguished career that has spanned over 35 years, Tuckson has served in a variety of senior posts including the Senior Vice President for Professional Standards of the American Medical Association and the Executive Vice President and Chief of Medical Affairs for UnitedHealth Group. He is currently the Managing Director of Tuckson Health Connections.
Tuckson is joined by the following members of the Board’s executive committee: – President-Elect, LTG (Ret.) James Peake, MD, Senior Vice President, CGI Federal, former U.S. Secretary of Veterans Affairs and Surgeon General of the United States Army – Vice President, Peter Yellowlees, MD, MBBS, Professor of Clinical Psychiatry, Department of Psychiatry and Behavioral Sciences, UC Davis Health System – Secretary and Treasurer, Herb Rogove, DO, FCCM, FACP, President & CEO, C3O Telemedicine – Immediate Past President, Yulun Wang, PhD, Chairman & CEO, InTouch Health In addition, two other individuals recently joined the Board of Directors: – Amnon Gavish, ScD, Senior Vice President of Vertical Solutions, Vidyo, Inc.; Chair of ATA’s Industry Council – Kristi Henderson, DNP, NP-BC, FAEN, Chief Telehealth and Innovation Officer, the University of Mississippi Medical Center; Past Chair of ATA’s Institutional Council “We are pleased to announce the addition of this group of prestigious individuals to the Board and officers of this Association,” said Jonathan Linkous, CEO of ATA. “This reflects ATA intention to work with a balance of leaders from both the ranks of healthcare providers and industry in order to fulfil our goal to improve healthcare delivery through the use of telecommunications technology.” Other current at-large Board members include Ellen R. Cohn, PhD; Naomi Fried, PhD; Alexis Gilroy, JD; John Glaser, PhD; Julia L. Johnson, JD; Roy Schoenberg, MD; and Andrew R. Watson, MD.
About the American Telemedicine Association The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership work to fully integrate telemedicine into healthcare systems to improve quality, equity and affordability of healthcare throughout the world. Established in 1993, ATA is headquartered in Washington, DC. For more information, visit www.americantelemed.org
As telehealth becomes an integral component of our health care delivery system and patients become mroe accustomed to its convenience, hospitals, health systems and other providers will seek new ways to use the rapidly evolving technology in diverse and innovative ways. This TrendWatch focuses on the legal and regulatory challenges that may arise when using telehealth technologies. Legal and regulatory challenges abound in the following areas:
- Coverage and Payment;
- Health Professional Licensure;
- Credentialing and Privileging;
- Online Prescribing;
- Medical Malpractice and Professional Liability Insurance;
- Privacy and Security; and
- Fraud and Abuse.
After attending the ATA 2015 meeting in Los Angeles last week, one might be interested in the research being done in mental health utilizing mobile devices for young patients. It appears that in the journal, Cyberpsychol Behav Soc Netw, just published last fall, a review article appeared to address this issue. Only seventeen articles to date have been published and were discussed.
Four gaps in current knowledge were identified: the scarcity of studies conducted in low and middle income countries, the absence of information about the real-life feasibility of mobile tools, the need to address the issue of technical and health literacy of both young users and health professionals, and the need for critical discussion regarding diverse ethical issues associated with mobile phone use. The authors suggested that mHealth researchers and clinicians looking at mental health carefully consider the ethical issues related to patient-practitioner relationship, best practices, and the logic of self-surveillance.
Section 106(c): Telehealth
Medicare currently reimburses physicians for certain services provided at certain sites through live video conferencing for eligible Medicare beneficiaries. 42 U.S.C. § 1395m(m). MACRA requires the Government Accountability Office (GAO) to draft two reports to be submitted to Congress within two years of MACRA’s enactment; the first report will pertain to the Medicare telehealth program, and the second will focus on remote patient monitoring technology and services. The first report on the Medicare telehealth program will evaluate circumstances that help or inhibit the use of telehealth under Medicare and the possible effects of an expansion of telehealth on payment and delivery systems under Medicare and Medicaid. The second report will examine incentives for adopting patient monitoring technology and services by private health insurance, as well as barriers for adopting this technology by Medicare. This report will also look at which patients and circumstances may receive the greatest benefit from this technology. Many health care practitioners believe that the time for government studies of telehealth has long passed and legislative action is needed now to expand beneficiary access, particularly in rural areas.
After watching the two-hour hearing on Advancing Telehealth through Connectivity convened by Senator Roger Wicker (R-Miss), one has to be impressed by both the expert witnesses and the Senate Subcommittee on Communications, Technology, Innovation, and the Internet. The full hearing can be heard at http://1.usa.gov/1QpNu6Y.
- Kristi Henderson, Chief Telehealth and Innovation Officer, University of Mississippi Medical Center
– Mr. Jonathan D. Linkous, Chief Executive Officer, American Telemedicine Association
– Dr. M. Chris Gibbons, Distinguished Scholar in Residence, Connect2HealthFCC Task Force, Federal Communications Commission
– Mr. Todd Rytting, Chief Technology Officer, Panasonic Corporation of North America
- Broadband is vital and is the major way to provide telemedicine and its dissemination has languished because of regulatory issues and funding.
- The FCC needs to re-engage, streamline regulation and act by enhancing Broadband availability.
- Even metropolitan areas such as in NYC have Wi-Fi issues in high-rise buildings with poor and elderly citizens.
- CMS needs to remove the barrier of paying only for non-MSA populations. Reimbursement was raised several times and many agreed this was a major barrier to address.
- Two Senators explored whether telemedicine could have an impact on mental health and drug abuse. The witnesses answered in the affirmative.
- Some of the Senators were reassured by the witnesses that HIPAA and other patient privacy issues could be protected during telemedicine encounters.
- The committee members very well understood quality and affordable healthcare delivery through telemedicine. Some of these Senators have very robust eHealth centers within their home states.
- Mr. Linkous, ATA CEO, said states could help with medical licensure reciprocity as a way to solve the century old problem of interstate practice. He added the federal government could help by supporting these state initiatives.
- The issue of the need to have another agency oversee all the current agencies that participate in telehealth was raised. Again, Mr. Linkous felt that a high level coordinating committee might be the best answer.
- Finally, the really good news was that all the members of this bipartisan subcommittee appear to be very enthusiastic supporters of telemedicine.
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.
State medical licensure for telemedicine is discussed in the April issue of Telemedicine and eHealth, by Drs. Hunter, Weinstein, and Krupinski. One of the authors in fact sat on the Arizona state medical board so a unique perspective is presented.
While progress is forthcoming for state reciprocity through an Interstate Compact initiated by the Federation of State Medical Boards (FSMB), licensure process may be slightly easier but the costs for licensing will remain.
Here are some key points:
- Article X of the U.S. Constitution states that individual states have the authority to insure health, safety, and welfare for their citizens. This explains why there is no universal medical license in the United States.
- There is tremendous variability among the states as far as requirements. See Rogove et. al. in this same journal
- The major exception to state requirements is through the federal government, which allows physicians to possess only one state license to practice at medical facilities such as the VA system.
- One of the biggest barriers to reciprocity is having a history of a malpractice suit. This will result in a major and lengthy investigation, often resulting in approval for most physicians.
- Interstate Compacts will not change the state’s existing medical practice act.
- The practice of medicine is defined in the state in which the patient is present and not the state where the physician resides.
- The significant challenges include:
- When is the physician-patient relationship established? Some states are now creating chaos by requiring the relationship must begin with a fact-to-face encounter.
- Assuring patient privacy.
- Limiting physician prescribing to certain classes and types of medication.
A process that has been in existence for 100 years is up for a remake to help enter the twenty first century. We have reached a cautious but optimistic time for pushing telemedicine towards reaching its important position in healthcare delivery.
Telemedicine can have a significant impact upon the existing racial disparity of healthcare access through home monitoring of hypertensive patients. It is a well know fact that hypertension and hypertensive heart disease is predominant among the African-American population, especially males. It is also known that access to care for all communities has been less than optimal.
In a recent review in Curr Hypertens Rep there was evidence of better compliance, very good acceptance by patients, and a lower utilization of high cost facilities such as the emergency department. The review also concludes that it is not only hypertension but also chronic heart disease including CHF and Diabetes that also benefit from close patient monitoring. While the review has demonstrated some excellent outcomes, the authors are the first to admit more studies are needed.
The study begins the discussion where patients with hypertension now have access to healthcare professionals who can monitor and advise patients in a convenient and cost-effective model that is all inclusive. When healthcare economists continue to look for value, this solution is simple, easy to implement, and can result in millions of dollars in saving annually.
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.