A recently published study in Telemedicine and e-Health found that despite numerous benefits there are three major barriers to telemedicine implementation and use that need to be addressed.
Telemedicine has and will continue to change care delivery and patient outcomes. Based on this study's survey responses alone, healthcare professionals see the following benefits of teletechnology: immediate patient access, reduced service gaps, improved quality, additional clinical support, better patient satisfaction and improved adherence to care standards.
Telemedicine itself is an established technology; it has existed for over 40 years. However, the advent of powerful computer technology making real-time audiovisual communication feasible — the ability of a physician to remotely consult with a patient via a robot and LCD screen — has transformed care facilitations.
Herb Rogove, DO, FCCM, FACP, CEO and founder of C3O Telemedicine, a provider of virtual presence for hospitals and providers, and the lead author of the study, stated that one of his physician colleagues was traveling across the United States when a stroke victim needed his care. The physician was able to reach the stroke patient while he was in Northern Texas. He merely needed a broadband card, an internet connection from a cell phone tower and a laptop. This example illustrates the amazing potential of telemedicine — remote specialists and physicians can treat patients and save lives. However, as the study found, there are serious human barriers to nationwide telemedicine use.
The study surveyed emergency and critical care remote presence telemedicine users from 53 healthcare institutions across North America and Ireland. One hundred-and-six surveys were completed. Sixty-eight percent of respondents were physicians, 17 percent nurses and nurse practitioners and 8 percent were administrators.
The study uncovered three major human barriers for telemedicine in the areas of regulation and finance. To reap the benefits of telemedicine nationwide, these issues need eradication. Regulatory impediments include the licensing and credentialing for medical staff at individual facilities. The financial barrier is reimbursement. Here Dr. Rogove discusses these three major barriers as well as possible solutions.
1. Licensing for Physicians. A major benefit of telemedicine is the ability to consult remotely. With telemedicine, a physician in California should be able to consult with a patient at a hospital in Florida. However, if a physician practices in one state but wants to practice using telemedicine in another state, he or she would need to a medical license in both states. According to Dr. Rogove, the process for a physician to receive interstate medical licensing is a complicated, unnecessary and expensive process that represents a major barrier. The current approach to medical licensing requires health providers to obtain multiple state licenses and adhere to diverse and sometimes conflicting state medical practice rules. The medical licensing process is not only complicated but also lengthy. Dr. Rogove has spent over a year trying to get a physician from Colorado licensed in California to practice with his company, C30 Telemedicine. Additionally, licenses are expensive. Telemedicine licenses can cost upwards of $1,200, as they do in California. The cost and the time lag for medical licenses across states severely limit the drive among physicians to implement telemedicine.
Possible Solution? According to Dr. Rogove, the creation of a national telemedicine license would be a reasonable move toward solving the problem. However, with state bureaucracy and individualistic approaches to state medical licensure, there are a great many hurdles to overcome. Many states have conflicting policies on licenses: Alabama, Montana, Minnesota, New Mexico, Ohio, Oklahoma, Oregon, Texas, and Tennessee have telemedicine licenses and Nevada has a special-purpose telemedicine license. California, Florida, and New York require full licensure to perform any function relating to patient care, with exceptions for consultation in some instances.
Some states, such as New Mexico, are exploring changes to telemedicine regulation. A bill is currently being drafted by U.S. Senator Tom Udall (D – N.M.) to streamline licensure portability for physicians, easing the burden of practicing telemedicine in more than one state. The bill is expected to be released in April 2012. The proposed legislations would represent an important step towards the usability of teletechnology. According to Dr. Rogove, there is a petition by the American Telemedicine Association for removing medical licensure barriers. Those who are interested could sign the petition to persuade Capitol Hill to overhaul the medical licensure system, says Dr. Rogove. Those interested can visit the American Telemedicine Association website and visit the FixLicensure.org section to sign the petition.
2. Credentialing. Another regulatory problem impeding telemedicine usage is the credentialing physicians must receive. Credentialing can become very complicated especially for hospitals with hub and spoke models. For instance, the Michigan Stroke Network, founded by Trinity Health in Novi, Mich., follows a hub and spoke model. By using telemedicine, physicians at the 33 participating hospitals can access neuroendovascular specialists across the nation. The reason credentialing can become a problem with hub and spoke models is because physicians from each hospital have to have the credentials for telemedicine at every other hospital. "You can imagine how many applications must be completed when more than one physician wants credentials at all those hospitals," says Dr. Rogove. "When administration and billing are major reasons the United States has exorbitant healthcare costs, extraneous applications should be the first to go." Additionally, the amount of paperwork for credentialing takes a great deal of time. The credentialing process has to be completed with primary verification including fingerprinting and copies of medical degrees. The time it takes it to acquire all necessary documents and finish an application is time that could be used training medical staff to use the telemedicine.
"No one ever wants a patient to deteriorate or die while waiting for treatment," says Dr. Rogove. "Time is valuable for patient survival rates. There should never be a patient without access to time-saving telemedicine services because no physician, or not enough physicians, were credentialed — that just should not happen."
Possible Solution? The current method for credentialing should be streamlined to facilitate easier credentialing at multiple facilities, says Dr. Rogove. The Joint Commission and CMS have begun supporting credentialing by proxy, which allows credentialing for the hub hospital of a system or network to apply, by proxy, to its spoke hospitals. For example, if St. Joseph Mercy Oakland in Pontiac, Mich., a Trinity Hospital, were the hub hospital for the Michigan Stroke Network, physicians would only need credentials for St. Joseph to work with all 33 hospitals in the network using telemedicine. With credentialing by proxy, an overwhelming onslaught of applications would be a problem of the past — unimaginable time and administrative costs could be saved. While credentialing by proxy does not address the lengthy primary verification process itself, it is a step toward wider telemedicine implementation and increased accessibility.
Another possible solution is electronic credentialing. A study published in the American Journal of Managed Care found that when electronic credentialing was used, files that passed quality reviews increased from 83 percent to 92 percent. In addition, the researchers found turnaround time for credentialing was reduced from 53 calendar days to 36 calendar days.
3. Reimbursement. A huge financial issue for telemedicine is the lack of reimbursement and capital expenditure for services. Similar to licensing issues, reimbursement models are different across states — each has its own regulation for private payors, if at all. Only Louisiana, California, Oklahoma, Texas, Hawaii, Kentucky, Colorado, New Hampshire, Oregon, Virginia and Maine have regulations for private payor reimbursements for telemedicine. There are also limitations for government payors. Under consultation codes, effective January 2010, Medicare and Medicaid only reimburse if the telemedicine is used by a hospital in a non-metropolitan area that meets certain criteria such as being a critical access hospital, says Dr. Rogove. "There are metropolitan areas without specialists. Limiting reimbursement in those areas under-serves those patients," says Dr. Rogove. Medicaid pays for telemedicine services in 24 states but under strict specifics like the need for a local physician to be present. Additionally, there is no consistency for telemedicine reimbursement, says Dr. Rogove. "The big question is who pays for it, and the burden is currently on the hospitals," says Dr. Rogove. "Reimbursement needs to be ironed out so telemedicine can reach its full potential in our healthcare system."
Possible Solution? According to Dr. Rogove, payment mechanisms need to go beyond currently restrictive practices. Billing for the delivery of critical care via telemedicine is not currently permissible. Grants from the USDA and other organizations can only take telemedicine implementation so far especially when they are tailored to rural health areas. Other forms of funding, like reimbursement from private and government payors, need to increase to circumvent the issue.
The study in Telemedicine and e-Health showed that over half of respondents use robotic telemedicine for critical care. Other studies have shown the feasibility and safety of its practice. Many healthcare organizations have implemented telemedicine and seen improved patient outcomes. For instance, a telemedicine trial in the U.K. found that telemedicine reduced emergency admissions by 20 percent, elective admissions by 14 percent and bed days by 14 percent. The trial looked at 3,030 individuals with diabetes, heart failure and chronic obstructive pulmonary disease.
Although many parties in healthcare believe in the benefit of telemedicine, certain barriers continue to pervade, impeding its widespread implementation. Complex medical licensing, lengthy credentialing and inadequate reimbursements prevent patients across the United States from experiencing the value of telemedicine. "It makes no sense when someone living in California, or any state, cannot get the best possible healthcare from specialists across the country," says Dr. Rogove. "A patient should even be able to receive the same type of care in the middle of nowhere and in a metropolitan area because of telemedicine and remote presence. If telemedicine can increase a patient's odds of recovering because it allows them to consult with the very best, what is wrong with that?"
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Telemedicine has and will continue to change care delivery and patient outcomes. Based on this study's survey responses alone, healthcare professionals see the following benefits of teletechnology: immediate patient access, reduced service gaps, improved quality, additional clinical support, better patient satisfaction and improved adherence to care standards.
Telemedicine itself is an established technology; it has existed for over 40 years. However, the advent of powerful computer technology making real-time audiovisual communication feasible — the ability of a physician to remotely consult with a patient via a robot and LCD screen — has transformed care facilitations.
Herb Rogove, DO, FCCM, FACP, CEO and founder of C3O Telemedicine, a provider of virtual presence for hospitals and providers, and the lead author of the study, stated that one of his physician colleagues was traveling across the United States when a stroke victim needed his care. The physician was able to reach the stroke patient while he was in Northern Texas. He merely needed a broadband card, an internet connection from a cell phone tower and a laptop. This example illustrates the amazing potential of telemedicine — remote specialists and physicians can treat patients and save lives. However, as the study found, there are serious human barriers to nationwide telemedicine use.
The study surveyed emergency and critical care remote presence telemedicine users from 53 healthcare institutions across North America and Ireland. One hundred-and-six surveys were completed. Sixty-eight percent of respondents were physicians, 17 percent nurses and nurse practitioners and 8 percent were administrators.
The study uncovered three major human barriers for telemedicine in the areas of regulation and finance. To reap the benefits of telemedicine nationwide, these issues need eradication. Regulatory impediments include the licensing and credentialing for medical staff at individual facilities. The financial barrier is reimbursement. Here Dr. Rogove discusses these three major barriers as well as possible solutions.
1. Licensing for Physicians. A major benefit of telemedicine is the ability to consult remotely. With telemedicine, a physician in California should be able to consult with a patient at a hospital in Florida. However, if a physician practices in one state but wants to practice using telemedicine in another state, he or she would need to a medical license in both states. According to Dr. Rogove, the process for a physician to receive interstate medical licensing is a complicated, unnecessary and expensive process that represents a major barrier. The current approach to medical licensing requires health providers to obtain multiple state licenses and adhere to diverse and sometimes conflicting state medical practice rules. The medical licensing process is not only complicated but also lengthy. Dr. Rogove has spent over a year trying to get a physician from Colorado licensed in California to practice with his company, C30 Telemedicine. Additionally, licenses are expensive. Telemedicine licenses can cost upwards of $1,200, as they do in California. The cost and the time lag for medical licenses across states severely limit the drive among physicians to implement telemedicine.
Possible Solution? According to Dr. Rogove, the creation of a national telemedicine license would be a reasonable move toward solving the problem. However, with state bureaucracy and individualistic approaches to state medical licensure, there are a great many hurdles to overcome. Many states have conflicting policies on licenses: Alabama, Montana, Minnesota, New Mexico, Ohio, Oklahoma, Oregon, Texas, and Tennessee have telemedicine licenses and Nevada has a special-purpose telemedicine license. California, Florida, and New York require full licensure to perform any function relating to patient care, with exceptions for consultation in some instances.
Some states, such as New Mexico, are exploring changes to telemedicine regulation. A bill is currently being drafted by U.S. Senator Tom Udall (D – N.M.) to streamline licensure portability for physicians, easing the burden of practicing telemedicine in more than one state. The bill is expected to be released in April 2012. The proposed legislations would represent an important step towards the usability of teletechnology. According to Dr. Rogove, there is a petition by the American Telemedicine Association for removing medical licensure barriers. Those who are interested could sign the petition to persuade Capitol Hill to overhaul the medical licensure system, says Dr. Rogove. Those interested can visit the American Telemedicine Association website and visit the FixLicensure.org section to sign the petition.
2. Credentialing. Another regulatory problem impeding telemedicine usage is the credentialing physicians must receive. Credentialing can become very complicated especially for hospitals with hub and spoke models. For instance, the Michigan Stroke Network, founded by Trinity Health in Novi, Mich., follows a hub and spoke model. By using telemedicine, physicians at the 33 participating hospitals can access neuroendovascular specialists across the nation. The reason credentialing can become a problem with hub and spoke models is because physicians from each hospital have to have the credentials for telemedicine at every other hospital. "You can imagine how many applications must be completed when more than one physician wants credentials at all those hospitals," says Dr. Rogove. "When administration and billing are major reasons the United States has exorbitant healthcare costs, extraneous applications should be the first to go." Additionally, the amount of paperwork for credentialing takes a great deal of time. The credentialing process has to be completed with primary verification including fingerprinting and copies of medical degrees. The time it takes it to acquire all necessary documents and finish an application is time that could be used training medical staff to use the telemedicine.
"No one ever wants a patient to deteriorate or die while waiting for treatment," says Dr. Rogove. "Time is valuable for patient survival rates. There should never be a patient without access to time-saving telemedicine services because no physician, or not enough physicians, were credentialed — that just should not happen."
Possible Solution? The current method for credentialing should be streamlined to facilitate easier credentialing at multiple facilities, says Dr. Rogove. The Joint Commission and CMS have begun supporting credentialing by proxy, which allows credentialing for the hub hospital of a system or network to apply, by proxy, to its spoke hospitals. For example, if St. Joseph Mercy Oakland in Pontiac, Mich., a Trinity Hospital, were the hub hospital for the Michigan Stroke Network, physicians would only need credentials for St. Joseph to work with all 33 hospitals in the network using telemedicine. With credentialing by proxy, an overwhelming onslaught of applications would be a problem of the past — unimaginable time and administrative costs could be saved. While credentialing by proxy does not address the lengthy primary verification process itself, it is a step toward wider telemedicine implementation and increased accessibility.
Another possible solution is electronic credentialing. A study published in the American Journal of Managed Care found that when electronic credentialing was used, files that passed quality reviews increased from 83 percent to 92 percent. In addition, the researchers found turnaround time for credentialing was reduced from 53 calendar days to 36 calendar days.
3. Reimbursement. A huge financial issue for telemedicine is the lack of reimbursement and capital expenditure for services. Similar to licensing issues, reimbursement models are different across states — each has its own regulation for private payors, if at all. Only Louisiana, California, Oklahoma, Texas, Hawaii, Kentucky, Colorado, New Hampshire, Oregon, Virginia and Maine have regulations for private payor reimbursements for telemedicine. There are also limitations for government payors. Under consultation codes, effective January 2010, Medicare and Medicaid only reimburse if the telemedicine is used by a hospital in a non-metropolitan area that meets certain criteria such as being a critical access hospital, says Dr. Rogove. "There are metropolitan areas without specialists. Limiting reimbursement in those areas under-serves those patients," says Dr. Rogove. Medicaid pays for telemedicine services in 24 states but under strict specifics like the need for a local physician to be present. Additionally, there is no consistency for telemedicine reimbursement, says Dr. Rogove. "The big question is who pays for it, and the burden is currently on the hospitals," says Dr. Rogove. "Reimbursement needs to be ironed out so telemedicine can reach its full potential in our healthcare system."
Possible Solution? According to Dr. Rogove, payment mechanisms need to go beyond currently restrictive practices. Billing for the delivery of critical care via telemedicine is not currently permissible. Grants from the USDA and other organizations can only take telemedicine implementation so far especially when they are tailored to rural health areas. Other forms of funding, like reimbursement from private and government payors, need to increase to circumvent the issue.
The study in Telemedicine and e-Health showed that over half of respondents use robotic telemedicine for critical care. Other studies have shown the feasibility and safety of its practice. Many healthcare organizations have implemented telemedicine and seen improved patient outcomes. For instance, a telemedicine trial in the U.K. found that telemedicine reduced emergency admissions by 20 percent, elective admissions by 14 percent and bed days by 14 percent. The trial looked at 3,030 individuals with diabetes, heart failure and chronic obstructive pulmonary disease.
Although many parties in healthcare believe in the benefit of telemedicine, certain barriers continue to pervade, impeding its widespread implementation. Complex medical licensing, lengthy credentialing and inadequate reimbursements prevent patients across the United States from experiencing the value of telemedicine. "It makes no sense when someone living in California, or any state, cannot get the best possible healthcare from specialists across the country," says Dr. Rogove. "A patient should even be able to receive the same type of care in the middle of nowhere and in a metropolitan area because of telemedicine and remote presence. If telemedicine can increase a patient's odds of recovering because it allows them to consult with the very best, what is wrong with that?"
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