AHA finds shortcomings in 21st Century Cures telemedicine provisions

 from: Healthcare DIVE

By  | January 29, 2015
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Dive Brief:

  • The House Energy and Commerce Committee released a “discussion document” seeking feedback on its 21st Century Cures initiative, which is filled with a number of healthcare IT proposals.
  • Key provisions include one that would create a process at the US Food and Drug Administration to expedite the review of “breakthrough” medical devices; another that would require that data be shared by those receiving grants from the National Institutes of Health; and a third to advance telemedicine opportunities for Medicare beneficiaries.
  • However, while suggestions within the provision for improving Medicare’s telehealth policy are broadly considered to be a step in the right direction, a letter from the American Hospital Association to committee chairman Rep. Fred Upton (R-MI) says they don’t go far enough.

Dive Insight:

The “Advancing Telehealth Opportunities in Medicare” proposal calls on HHS to draw up a methodology to expand coverage and payment for telehealth services nationally. There are limitations to the provision, however. It will only apply if the Centers for Medicare and Medicaid Services find that those telehealth services “would reduce [or would not result in any increase in] net program spending under this title.”

According to the AHA, the proposal does not address technology limitations within Medicare itself, or how remote monitoring would be funded.

“We also are concerned that the requirement for the Medicare actuary to certify telehealth cost neutrality for specific services would be hard for HHS to operationalize, and would add a time consuming step when technology is advancing at a rapid pace,” the AHA wrote.


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January 29th, 2015

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Telemedicine barrier: Why are physicians and their Arkansas state medical board so obstinate?

In Arkansas, Rules Restrict e-Services By Physicians

Teladoc Inc. of Dallas is the latest telemedicine provider to be shut out of Arkansas because of Arkansas State Medical Board rules involving physician-patient relationships.

The board has traditionally defined the establishment of a doctor-patient relationship as: an in-person history and a physical,” board attorney Kevin O’Dwyer told Arkansas Business recently.

And without that, the telemedicine doctors — unless they’ve seen a patient in person — can’t treat Arkansans, making Arkansas one of the handful of states that don’t allow telemedicine companies in their state.

O’Dwyer said the only reason the board has the requirement is to protect the patient.

Still, O’Dwyer said the board discusses the issue “regularly. … We haven’t seen a model from any of these companies that would satisfy, in the board’s opinion, the regulation.”

Teladoc had been offering the service in Arkansas since 2008, its CEO, Jason Gorevic, said. But recently, the board “made it clear that they would take action against physicians who were practicing telemedicine,” Gorevic said.

Teladoc suspended its service in November, pending approval from the board. It has 70,000 members in Arkansas.

338px-Flag_of_Arkansas.svgGorevic said Teladoc has been trying to get a meeting before the board to explain its practice and telemedicine.

“They have, unfortunately, declined our offer to come in and present,” Gorevic said. “In the meantime, there are many other parties in the state who are interested in telemedicine and see its promise for reducing costs, improving quality of care and improving access to care.”

Teladoc offers services across the country except in Arkansas and Idaho, where it also recently suspended its service because of its medical board rules. But Gorevic said he hopes that Teladoc will be allowed to practice in Idaho soon, thanks to pending legislation.

Teladoc sells its services primarily to employers and health plans to use as part of their benefits packages. The members then have full-time access to a national network of board-certified, state-licensed physicians who can be connected to a patient within about eight minutes, Gorevic said.

The patient can decide to interact with the doctor by a video or phone consultation. Or a patient can send a photo of the ailment to the doctor.

Comments: Since 2008 and now the Board is weighing in? Refusing to meet with Teladoc? Patients are free to use to service or NOT? What kind of message is the Arkansas state medical board telling their citizens?


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January 26th, 2015

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House Lawmakers Float Draft Bill on Medicare Telehealth Payments


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January 22nd, 2015

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Telemedicine and technology: What’s holding us back?


By Humayun J. Chaudhry M.D. the president and CEO of the Federation of State Medical Boards.

One of the more fascinating and exciting elements of living in these times is the rapid development and deployment of technology designed to enhance and improve our lives. But the technology often outpaces us and advances rapidly, leaving gaps between what technology can offer and what it actually achieves.

We’ve seen this happen in many industries. Smartphones for example, are becoming an increasingly important tool not just to text your mother, but to manage her healthcare in later years.  Even with smartphones, the technology is moving so fast that cutting edge technology from just a few years ago is now obsolete. Take a look at the differences between an iPhone 4 and an iPhone 6.

Medicine has recently been at the forefront of technological advancement and telemedicine is the latest, and potentially most significant, area of advancement when it comes to access and quality of care. Telemedicine is the use of technology and electronic communications across distances to expand access to care, enhance care options for patients, improve patient and provider education, and streamline health administration processes.Expanding access to care through the technology available today in a safe and closely monitored system is important.  But while state medical boards and other policy makers and care providers are putting technology to work for patients, the existing technology infrastructure – from  a system of medical reimbursement for fee-for-service care, to deficiencies in access to broadband internet, to weaknesses in physician education and training about technology  – is holding us back.

The Alliance for Connected Care, a special interest group that advocates for the expansion of telemedicine, contends that data from 2009 shows that of the 43 million Medicare participants receiving care, just 14,000 received that care through telehealth systems. They cite federal geographic and site restrictions on Medicare reimbursements to doctors as the underlying cause for this discrepancy.

Despite these challenges, telemedicine is moving forward and utilization will undoubtedly increase.

Earlier this year, representatives of the nation’s state medical licensing boards unanimously adopted a Model Policy on the Appropriate Use of Telemedicine Technologies in the Practice of Medicine, providing much-needed guidance and a basic roadmap for state medical boards to use in overseeing the use of telemedicine technologies in the practice of medicine. The policy also serves to educate licensees as to the appropriate standards of care in the delivery of medical services using telemedicine technologies.

Among its key provisions, the model policy calls for maintaining the same standards of care that have historically protected patients during in-person medical encounters for medical care delivered electronically. Care providers using telemedicine must establish a credible “patient-physician relationship,” the policy says, ensuring that patients are properly evaluated and treated and that providers adhere to well-established principles guiding privacy and security of personal health information, informed consent, safe prescribing and other key areas of medical practice.

The guidelines are designed to provide flexibility in the use of various types of technology by physicians – ranging from telephone and email interactions to videoconferencing – while maintaining widely recognized standards of patient care. The guidelines are advisory, meaning that state medical boards are free to adopt them as is, modify them, or retain their own current policies regarding telemedicine. They reflect a good faith effort by state medical boards to offer constructive solutions to some of the challenges facing telemedicine in the years ahead.

At the same time, federal leaders are beginning to take a closer look at how to responsibly and safely enable telemedicine to reach more Americans in need of care but unable to easily access the health care system in their community. While real questions about the quality of care, costs, accessibility, efficiency and other challenges remain, the technology and health care industries are moving ahead in this direction and telemedicine is already becoming part of the fabric of discussions about modern health care.

If telemedicine is to succeed, however, the technology supporting it needs to improve and be more interoperable.  Congress should examine policies that modernize the delivery of medical care while protecting the quality of care for patients.  Moving quickly, but deliberately, is important. We need compatible and secure technologies that can talk to each other. In the end, we can’t succeed in a smartphone world with a flip-phone infrastructure.



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January 15th, 2015

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U of Miami School of Medicine Offers Haiti Telemed Trauma Support

From Health Data Management

The University of Miami’s Miller School of Medicine recently launched a telemedicine program that provides doctors at Haiti’s only trauma, critical care, and rehabilitation hospital with access to around-the-clock medical support through live video communication with UM trauma specialists.

Located in Port-au-Prince’s Village Solidarite neighborhood, Hospital Bernard Mevs sees a high volume of adult and pediatric patients with a range of critical injuries and conditions doctors there are not fully equipped to handle.

“Although the basics of stabilization are in place and can be done by the majority of the Haitian staff, there are cases that require more sophisticated and specialized attention to manage properly,” said Antonia Eyssallenne, M.D., who developed the program in collaboration with Carl I. Schulman, M.D.

With the new telemedicine project, guidance from an on-call UM trauma doctor will be a phone call and a few computer clicks away — enabling the staff at Hospital Bernard Mevs to better diagnose, stabilize injuries, and provide longer term care to patients.

In addition to providing trauma support, Schulman said the live video technology will allow UM doctors to assist with some of the regular critical care hospital rounds.



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January 13th, 2015

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The Future of Medicine Is in Your Smartphone

Over the past decade, smartphones have  changed many aspects of our everyday lives, from banking to shopping to entertainment. Medicine is next. The patient, are about to take center stage for the first time.

With the smartphone revolution, an increasingly powerful new set of tools—from attachments that can diagnose an ear infection or track heart rhythms to an app that can monitor mental health—can reduce our use of doctors, cut costs, speed up the pace of care and give more power to patients. Digital avatars won’t replace physicians: You will still be seeing doctors, but the relationship will ultimately be radically altered.

This transformation is already under way.

Examples include:

    • Diagnosis and treatment of skin rashes
    • Diagnose ear infections  and recommend treatments;
    • Blood pressure readings and ECG’s;
    • Estimate the costs of medical procedures, tests, scans and other types of care;
    • Facilitate video consultations with physicians at the same cost of a typical copayment 24 hours per day;
    • Track individuals’ heart rhythms; and
    • Monitor patients’ mental health.

You can obtain on demand  secure video consultation with a doctor via smartphone at the same cost (about $30-$40) as the typical copay charge through employer health plans.

Now a smartphone can generate your own medical data, including measuring your blood-oxygen and glucose levels, blood pressure and heart rhythm. A smartphone attachment will let you perform an easy eardrum exam that can rapidly diagnose the problem without a trip to the pediatrician.

Other wearable sensor tools for the future include necklaces that  monitor your heart function and check the amount of fluid in your lungs, contact lenses that can track your glucose levels or your eye pressure (to help manage glaucoma), and head bands that can capture your brain waves. Even gait monitoring for Parkinson’s is on the way.

Smartphones to monitor your exposure to radiation, air pollution or pesticides in foods will be available. And your medications could soon be digitized to provide you with reminders to ensure that you’ve taken them as prescribed.

It isn’t just hospitals’ rooms that are on their way out; so are their labs. Smartphone attachments will soon enable you to perform an array of routine lab tests via your phone. Blood electrolytes; liver, kidney and thyroid function; analysis of breath, sweat and urine—all can be checked with small fluid samples in little labs that plug directly into smartphones. And you can do your own routine labs at a fraction of the current cost.

Smartphone selfies are all the rage, but smartphone physical exams are just taking off. The ability to make a definitive DIY diagnosis of an ear infection with a phone is just the first step. Apps are now being developed to handle all aspects of the eye, the throat and oral cavity, and the lungs and heart. Meanwhile, nearly all sophisticated medical imaging devices are being miniaturized: Hand-held ultrasound devices are already available, and some medical schools have begun issuing them in the place of the old-school stethoscope. Hand-held MRI (magnetic resonance imaging) machines aren’t far behind, and engineers at UCLA have come up with a smartphone-sized device that can generate X-rays. It won’t be long before you can take a smartphone X-ray selfie if you’re worried that you might have broken a bone.

In the near future you will be able to place nanosensors  in your bloodstream. These microscopic sensors will be able to keep your blood under constant surveillance for the first appearance of cancer, autoimmune attacks on vital tissues or the tiny cracks in artery walls that can lead to heart attacks or strokes.

Big changes can be expected in mental health, which is also the leading cause of disability in the U.S. and many other developed countries. Smartphones can be particularly helpful here. New apps aim to quantify your state of mind by a composite of real-time data: tone and inflection of voice, facial expression, breathing pattern, heart rate, galvanic skin response, blood pressure, even the frequency and content of your emails and texts.

Just as the printing press democratized information, the medicalized smartphone will democratize health care. Anywhere you can get a mobile signal, you’ll have new ways to practice data-driven medicine. Patients won’t just be empowered; they’ll be emancipated.



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January 12th, 2015

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from POLITICO by ASHLEY GOLD | 01/06/15 10:02 AM EDT

With help from David Pittman, Joanne Kenen and Arthur Allen

The American Medical Association has drafted model legislation for states on familiar telemedicine issues such as licensure, reimbursement and standards of care. AMA provided three model bills to state medical and specialty societies, a person with knowledge of them told POLITICO’s David Pittman. This is the first year that the country’s largest doctor group has offered model bills on telemedicine for state lawmakers, who are expected to be busier than everwith the topic this month.

The AMA’s House of Delegates this summer approved guidelines for the practice of telemedicine, and the model legislation follows them closely. For example, telemedicine providers must conduct a “face-to-face” examination if it would be required to treatment without telemedicine. The legislation would also block telephone or online evaluations as a standard of care, according to draft language sent to the Texas Medical Board and obtained through a public records request. Texas was one of several states the AMA worked with to create the model bills. Model legislation around reimbursement would require health plans to pay for telemedicine services at the same rate they reimburse in-person care. Also, health plans would be unable to deny coverage because it was delivered via telemedicine. New York last month become the 22nd state along with the District of Columbia to enact a law along those lines.


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January 6th, 2015

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New York lawmakers help with telemedicine

January 5, 2015

A law that just took effect is streamlining the push to expand the telemedicine industry, which is redefining how people access health care on the go.

Gov. Andrew Cuomo signed the law as part of a series of last-minute actions at the close of 2014.

The law improves regulations tied to insuring and paying businesses and nonprofits behind the ongoing expansion of telemedicine offerings, including a range of new digital health care products on smartphones, and computers.

Many health care providers have been urging lawmakers to better protect them against lawsuits and other potential risk as they pursued telemedicine. Millions of dollars have already been invested in these new health care technologies by major national insurers and the largest hospital systems.

For example, Empire BlueCross has been offering virtual doctor’s visits via the Internet for more than 3.5 million people through their respective employers’ health plan.

Ellis Medicine, a hospital system based in Schenectady, New York, has been partnering with grocery stores and pharmacies to shift more forms of health care away from the more costly hospital settings.

Dr. Michael Cropp, president and CEO of Independent Health, among the largest insurers based in Buffalo, New York said significant investments required to grow telemedicine are playing key roles in major partnerships transforming thousands of health care jobs.

Just look at the game-changing collaboration taking shape between Independent Health and CDPHP, the second-largest insurer based in Albany.

“Much of this technology is going to be pretty much the same in terms of needs, whether they’re in Buffalo, or Albany,” Cropp said.

The Healthcare Association of New York State, a trade group based in Rensselaer, lobbied for the new telemedicine law, which is related to related to insurance and Medicaid payment for telehealth and telemedicine services. The group represents more than 250 hospitals and other health care providers in New York, making it among the largest health care groups in the state.


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January 5th, 2015

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Dr. Phil invests in telemedicine

Dr. Phil in an interview with USA Today discusses he and his son’s investment intelemedicine:




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January 4th, 2015

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FDA reform, telehealth top of health IT legislative agenda

From POLITICO PROFDA_reform__telehealth_top_of_health_IT_legislative_agenda_-_David_Pittman_-_POLITICO

The GOP promise, as is well known, is to spend less taxpayer money and unfetter the creativity of business. These goals extend to the party’s 2015 program for health IT, though not everyone believes they will achieve either.

Legislation to restrict FDA action in the health IT sphere is expected to move in the 114th Congress, since all three candidate bills enjoy bipartisan support. Some critics, however, say the bills aren’t really necessary because FDA has already clarified that it won’t regulate low-risk IT.

Another item atop the legislative agenda would expand Medicare payments for telemedicine services — which champions of the technology are confident would lower overall health costs in spite of a battle over congressional cost estimators.

Here is a rundown of the top legislative items, mainly restricted to telemedicine, expected in the coming year:

A staffer for Blackburn called the SOFTWARE Act a “linchpin” of the House Energy and Commerce Committee’s 21st Century Cures bill, which would include items aimed at stimulating development of medical devices and drugs. The committee has been drafting a bill after six months of hearings. A “discussion draft” of the Cures legislation is expected to be circulated in January. But Blackburn said SOFTWARE could move on its own.

The Hatch-Bennet bill could have the upper hand, some say, given the influence of its sponsors and its greater specificity about what products should be regulated. Hatch and Bennet were behind the 2012 FDASIA language, which directed FDA to study how it would regulate health IT.


Telemedicine is sure to be a component of the 21st Century Cures package, the committee and lobbyists say. The question is how much change lawmakers will seek.

Medicare’s restrictions are so tight that the program paid a mere $12 million for telemedicine last year; those who want to free up more money are hampered by the lack of evidence that it will help older Americans while saving Medicare money.

Legislation offered by different lawmakers in the last year would expand the service at different rates.

The Telehealth Enhancement Act, which has backers in the House and Senate, would waive Medicare’s restrictions for home health services, critical access and sole community hospitals, and in some cases, hospice care, home dialysis patients and homebound seniors.

The Medicare Telehealth Parity Act expands coverage of certain services to federally qualified health centers and health clinics in three phases — covering small, medium and larger metropolitan areas.

It remains to be seen which bill will stick. Much depends on the Congressional Budget Office and what it has to say about how much different legislative proposals will cost. Reports that CBO Director Doug Elmendorf could be on his way out, if true, could mean the GOP will find a budget chief more to its liking, but that doesn’t necessarily mean a better score for telemedicine.

Much also depends on how far the House Energy and Commerce Committee wants to go with its 21st Century Cures bill. The bigger the swing, the more money it will cost and harder it will be to pass.

Licensure is another area of potential change. The TELE-MED Act, backed by Reps. Devin Nunes (R-Calif.) and Frank Pallone (D-N.J.), would allow physicians to treat Medicare patients in all 50 states with a single medical license. The measure has 64 co-sponsors, but isn’t guaranteed passage.

Hospitals have asked Congress to create new exceptions in federal anti-kickback laws to allow purchases of telemedicine equipment for doctors’ offices that would otherwise have trouble affording it. Such practices are illegal now because the purchases would theoretically provide hospitals unfair referrals. Similar laws are gray on the area of lending home health and remote monitoring equipment to patients.

Those who have met with Energy and Commerce staff say the committee is open to their requests. But one telemedicine lobbyist said to expect more incremental progress than touchdowns.


Arthur Allen contributed to this report.



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January 3rd, 2015

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