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Telemedicine, Today and
Tomorrow
David Voran, MD
Southwest Clinical Society
Kansas City, 10/29-31/2015
http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
+
Agenda and Objectives
 Review the status of telemedicine globally and locally
 Legislative, reimbursement initiatives, interstate licensing and
ACA effect
 Examine newer technologies and services available to
clinicians
 Make some projections
http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
+
Where is telemedicine
today?
… an update of sorts
Objective 1
http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
Telemedicine SW Clinical Society
+
Growth Types in Telemedicine
 Traditional hub and spoke
telemedicine encounters
increasing organically
 Over 200 networks with 3,500
service sites in US
 Over half of US hospitals using
some form of telemedicine
 Adding more spokes
 Specialty driven telemedicine
expanding primarily in ED’s
 Provider-to-Provider
consultation
 Retail telemedicine pilots are
expanding and gaining traction
 Portal-based telehealth
services are normal part of
practice
 Direct to consumer services
popping up spurred by ACA
Organic – Logarithmic Inorganic - Exponential
+
Telehealth Growth Curve
HIS Telehealth Report 2014
+
Organic Growth
continues in Hub
and Spoke Networks
Avera eCare
+
Expanding
Telemedine’s reach:
In-House
Telemedicine
Nebraska Medical Center
+
eVisits Booming
“Almost one in six doctor visits will be
virtual this year”
Up 400% since 2012
eVisits have … saved UPMC an average of
$86.80 per member visit compared with the
cost of an office visit
This year [2014] in the U.S. and Canada, 75
million of 600 million appointments with
general practitioners will involve electronic
visits, or eVisits
+
Medical Centers
Jumping In
+
Mid-Level Telemed
“Load Balancing”
 CVS Minute Clinic Experience
 California
 Off loading volume to remote APRNs
 Lower level LPN performs registration and
hands on
 Remote APRNs are MC providers in the same
state who are in-between live patients
 Over 4,000 visits in last year
 Reimbursement same as face-to-face
 Survey results (1,700 patients)
 33% prefer video to face-to-face, 50% liked it
about the same and 10% found it worse
+
Retail Telemedicine Expansion
 Collaborative Coverage
 Physician shortages
 Rate limiting steps
 Chronic condition management
 Cooperation with IDN
 CCM reimbursement not
dependent on face-to-face visits
 Increasing range of services
 Beyond APRN scope of practice
 Clinic expansions
+
Kicking it up a notch
Looking at where telemedicine industry is really heading
Telemedicine SW Clinical Society
+
Telemedicine Studio in your Pocket
Nearly every smart phone owner has more resolution, bandwidth and capability than all
telemedicine facilities built in the 1990’s.
Telemedicine SW Clinical Society
+
Retail gets personal
Telemedicine SW Clinical Society
+
Daily “telemedicine”
 Phone messages
 Patient Portal
 eVisits
 Retail direct-to-consumer
 Low cost answers to
questions
 Phone conversations
 Peer based videoconferencing
 Face Time
 Skype
 Retail direct-to-consumer
 Most by phone
 Maybe 10% video
Asynchronous Synchronous
+
My own experience with e-Visits
using Vgo Robot
 Inexpensive, ad-hoc use of
mobile systems
+
Dabbling in
Retail Visits
Signed up with HealthTap
Telemedicine SW Clinical Society
+
Other developments
 75% of large employers would
be offering telemedicine
benefits for employees within
the next year
 57% of broadband households
access at least one portal per
month
 ACA health plans are or will be
offering telehealth coverage in
most plans
 Health insurers offering their
own telehealth or video
consults for enrollees
 mHealth use expanding
 Most new devices capable of
measuring some health
parameters
+
Telemedicine Savings
 Would require all employees
and dependents to use
technology-enabled interactions
in lieu of face-to-face visits
 37% employers will offer
telemedicine consultations in
2015
 > 80% of insurance providers to
offer telemedicine
reimbursement by 2019
+
Legislative Updates and
Initiatives
… still struggling with “what IS is”
Objective 2
Telemedicine SW Clinical Society
+
Medicaid.gov
 Telemedicine seeks to improve a patient’s health by permitting
two-way, real time interactive communication between the
patient, and the physician or practitioner at the distant site.
 Means the use of interactive telecommunications equipment
that includes, at a minimum, audio and video equipment.
 Asynchronous or “store and forward” applications would NOT
be considered telemedicine but may be utilized to deliver
services.
+
HIPAA
Does NOT consider an interactive video consultation to be
protected health information, so it does not govern telemedicine
encounters.
Not considered PHI unless it’s recorded.
Device encryption and a private internet connection are
recommended for patient security and privacy.
Most videoconferencing tools are encrypted.
Other types of telehealth, such as the transmission of patient data
or images, ARE considered protected health information and
must be managed according to HIPAA requirements.
Fine line between real-time video transmission and the same interaction that is being
stored.
+
Medicare Reimbursement
 Performed By
 Physician
 Nurse
 Midwife
 Clinical Psychologist
 Registered Dietitian
 Clinical Social Worker
 Originating Site (Patient)
 Office (Physician/NPA)
 Hospital
 Critical Access Hospital
 Renal Dialysis
 Federal qualified health
center
 Skilled Nursing Facility
 Community Mental Health
Center
 Charges
 E&M +
 Facility ($24.24)
 HCPCS Q3014
 Type of Service “9, other
items and services”
Telemedicine SW Clinical Society
+
Legislative Action
 Fostering Independence Through Technology Act
 Sens. Amy Klobuchar (D-Minn), John Thune (R-S.D.)
 TELEhealth for MEDicare (TELE-MED) Act of 2013
 Reps. Devin Nunes (R-Calif) and Frank Pallone (D-N.J)
 HR 3077
 H.R. 5380 creates a phased approach over four years to expand
coverage of telemedicine-provided services and remove
arbitrary barriers that limit access to services for Medicare
beneficiaries. Included in these provisions are the gradual
removal of geographic restrictions to patient care, and the
addition of coverage for healthcare services that take place in
other locations such as the home and walk-in retail health
clinics
+
Federation of State Medical Boards
 Interstate Medical Licensure Compact
 Expedited license
 Recognized by all member states
 Compliments, does not replace existing State
licensure
 Interstate Medical Licensure Compact
Commission
 Administrate physicians applying for this type of
license
 Spearheaded by Wyoming State Board of
Medicine
 Requires a minimum of 7 states to participate
 Looking to form in 2016
+
Available Guidelines
 Formal Policies and Procedures
 Guidelines and Consensus Documents
 Operational Procedures
 Foundation for formal deployment
American Telemedicine Association
+
Telehealth Grades for States
+
States with Telemedicine Parity
+
What’s Happening Around
Here?
…probably more than most of us realize
Local Activity
KU Center for
Telemedicine &
Telehealth
+
Report Cards 2014
+
2015 Grades
+
KU Med
Telemedicine
Overview
Eve-Lynn Nelson, PhD
Director, Center for Telemedicine &
Telehealth
Professor, Pediatrics
(913) 588-2413
enelson2@kumc.edu
Telemedicine SW Clinical Society
+
Kansas
 Medicaid covered some TM
services since 2004
 Physician, Psychotherapy,
Pharmacological management
– GT modifiers
 Requires patient to be present
at originating site
 Requires State Licensure
Kansas
 Center for TeleMedicine &
TeleHealth
 Kansas Medical Center
 60 nodes
 4,500 (1,500 unique pts)
 Become more research
oriented
 Dependent on grants
 Exploring using system to
provide urgent care for whole
state
+
KU Center for Telemedicine and
Telehealth
 Approximately 4,000 consults
per year across 40 providers
 Behavioral consults most
common
 Traditional model in supervised
settings
 Team-based services with
trainee participation
42
+
Kansas iCare
+
Project Echo
Mission
To expand the capacity to provide the
best practice care for common and
complex diseases in rural and
underserved areas and to monitor
outcomes
Extension for Community Health Outcomes
+
Missouri
 HB 986 – prohibits plans from denying
telehealth coverage and
reimbursement (7/2013)
 Covers services that would have been
delivered in-person
 Mo-Healthnet requires 2-way
interactive video
 No restrictions on type of technology
being used
 No store and foreward
reimbursement
 Require prior face-to-face physical
exam
 Defined clinical locations
 Hospital, CAH
 Rural Health Clinic
 Federally Qualified HC
 Nursing Home
 Dialysis Center
 Mo State Rehab Center
 Community Mental Health
 Requires State Licensure
 Missouri Telehealth Network
 University of Missouri, Columbia
 202 node MOREnet 2 gigabit
backbone
Missouri
+
Missouri Telehealth Network
Psychiatry
47%
Dermatology
19%
Autism
19%
Ped
Endocrinology
6%
Neurology
4%
Other
5%
2011-2012 Encounters
+
Why Isn’t Telemedicine the Norm?
 TM visits reimbursed at lower
rates than face-to-face visits
 RVU based productivity
 Parochial nature of medicine
 Site-specific credentialing
 State licensing requirements
 Store-and-forward prohibition
 Scheduling issues
 Culture of convenience
 E-mail, texting favored over
synchronous communication
Regulatory and Reimbursement Logistics and Culture
+
The Future of Telehealth
…where it becomes personal
Objective 3
+  Activity tracking devices + Apps
 Fitbit, Fuel band, Vivofit, Gear
 Biometric monitors
 External
 Implanted medical devices
Quantified Self Movement
+
Game Changers
 Devices (moving out of the exam room)
 AliveCor ECG
 Cellscope
 Proscope
 Fitbit
 Services
 Cloud based storage and sharing
 Multimedia Patient Portals
 Embedded video conferencing
 Communities (Fitbit)
FDA approved mobile apps and
devices.
Selling to patients directly.
Allowing them to record and share
with physicians, family and friends
…pushing cost and control to patients
(Consumer Directed Care)
+
iOS Health Kit
Apple Watch
Healthcare embedded into operating
systems
Enhancing real time research
Openning door to real-time clinical
population monitoring and intervention
Will the exam room survive?
+
+Convenience
+Coverage
+Consumerism
Time Magazine,
November 9, 2015
+
+Convenience
+Coverage
+Consumerism
Time Magazine,
November 9, 2015
+
Forecast: Telemedicine Potential
 Operational costs of clinics and hospitals become
unsustainable
 Reimbursement paradigm reaches inflection point
 Telemonitoring capabilities embedded in all devices
 Adequate universal spectrum
+

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Telemedicine SW Clinical Society

  • 1. + Telemedicine, Today and Tomorrow David Voran, MD Southwest Clinical Society Kansas City, 10/29-31/2015 http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
  • 2. + Agenda and Objectives  Review the status of telemedicine globally and locally  Legislative, reimbursement initiatives, interstate licensing and ACA effect  Examine newer technologies and services available to clinicians  Make some projections http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
  • 3. + Where is telemedicine today? … an update of sorts Objective 1 http://www.slideshare.net/Dvoran/telemedicine-today-and-tomorrow-for-southwest-clinical-society
  • 5. + Growth Types in Telemedicine  Traditional hub and spoke telemedicine encounters increasing organically  Over 200 networks with 3,500 service sites in US  Over half of US hospitals using some form of telemedicine  Adding more spokes  Specialty driven telemedicine expanding primarily in ED’s  Provider-to-Provider consultation  Retail telemedicine pilots are expanding and gaining traction  Portal-based telehealth services are normal part of practice  Direct to consumer services popping up spurred by ACA Organic – Logarithmic Inorganic - Exponential
  • 6. + Telehealth Growth Curve HIS Telehealth Report 2014
  • 7. + Organic Growth continues in Hub and Spoke Networks Avera eCare
  • 9. + eVisits Booming “Almost one in six doctor visits will be virtual this year” Up 400% since 2012 eVisits have … saved UPMC an average of $86.80 per member visit compared with the cost of an office visit This year [2014] in the U.S. and Canada, 75 million of 600 million appointments with general practitioners will involve electronic visits, or eVisits
  • 11. + Mid-Level Telemed “Load Balancing”  CVS Minute Clinic Experience  California  Off loading volume to remote APRNs  Lower level LPN performs registration and hands on  Remote APRNs are MC providers in the same state who are in-between live patients  Over 4,000 visits in last year  Reimbursement same as face-to-face  Survey results (1,700 patients)  33% prefer video to face-to-face, 50% liked it about the same and 10% found it worse
  • 12. + Retail Telemedicine Expansion  Collaborative Coverage  Physician shortages  Rate limiting steps  Chronic condition management  Cooperation with IDN  CCM reimbursement not dependent on face-to-face visits  Increasing range of services  Beyond APRN scope of practice  Clinic expansions
  • 13. + Kicking it up a notch Looking at where telemedicine industry is really heading
  • 15. + Telemedicine Studio in your Pocket Nearly every smart phone owner has more resolution, bandwidth and capability than all telemedicine facilities built in the 1990’s.
  • 19. + Daily “telemedicine”  Phone messages  Patient Portal  eVisits  Retail direct-to-consumer  Low cost answers to questions  Phone conversations  Peer based videoconferencing  Face Time  Skype  Retail direct-to-consumer  Most by phone  Maybe 10% video Asynchronous Synchronous
  • 20. + My own experience with e-Visits using Vgo Robot  Inexpensive, ad-hoc use of mobile systems
  • 23. + Other developments  75% of large employers would be offering telemedicine benefits for employees within the next year  57% of broadband households access at least one portal per month  ACA health plans are or will be offering telehealth coverage in most plans  Health insurers offering their own telehealth or video consults for enrollees  mHealth use expanding  Most new devices capable of measuring some health parameters
  • 24. + Telemedicine Savings  Would require all employees and dependents to use technology-enabled interactions in lieu of face-to-face visits  37% employers will offer telemedicine consultations in 2015  > 80% of insurance providers to offer telemedicine reimbursement by 2019
  • 25. + Legislative Updates and Initiatives … still struggling with “what IS is” Objective 2
  • 27. + Medicaid.gov  Telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.  Means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.  Asynchronous or “store and forward” applications would NOT be considered telemedicine but may be utilized to deliver services.
  • 28. + HIPAA Does NOT consider an interactive video consultation to be protected health information, so it does not govern telemedicine encounters. Not considered PHI unless it’s recorded. Device encryption and a private internet connection are recommended for patient security and privacy. Most videoconferencing tools are encrypted. Other types of telehealth, such as the transmission of patient data or images, ARE considered protected health information and must be managed according to HIPAA requirements. Fine line between real-time video transmission and the same interaction that is being stored.
  • 29. + Medicare Reimbursement  Performed By  Physician  Nurse  Midwife  Clinical Psychologist  Registered Dietitian  Clinical Social Worker  Originating Site (Patient)  Office (Physician/NPA)  Hospital  Critical Access Hospital  Renal Dialysis  Federal qualified health center  Skilled Nursing Facility  Community Mental Health Center  Charges  E&M +  Facility ($24.24)  HCPCS Q3014  Type of Service “9, other items and services”
  • 31. + Legislative Action  Fostering Independence Through Technology Act  Sens. Amy Klobuchar (D-Minn), John Thune (R-S.D.)  TELEhealth for MEDicare (TELE-MED) Act of 2013  Reps. Devin Nunes (R-Calif) and Frank Pallone (D-N.J)  HR 3077  H.R. 5380 creates a phased approach over four years to expand coverage of telemedicine-provided services and remove arbitrary barriers that limit access to services for Medicare beneficiaries. Included in these provisions are the gradual removal of geographic restrictions to patient care, and the addition of coverage for healthcare services that take place in other locations such as the home and walk-in retail health clinics
  • 32. + Federation of State Medical Boards  Interstate Medical Licensure Compact  Expedited license  Recognized by all member states  Compliments, does not replace existing State licensure  Interstate Medical Licensure Compact Commission  Administrate physicians applying for this type of license  Spearheaded by Wyoming State Board of Medicine  Requires a minimum of 7 states to participate  Looking to form in 2016
  • 33. + Available Guidelines  Formal Policies and Procedures  Guidelines and Consensus Documents  Operational Procedures  Foundation for formal deployment American Telemedicine Association
  • 36. + What’s Happening Around Here? …probably more than most of us realize Local Activity KU Center for Telemedicine & Telehealth
  • 39. + KU Med Telemedicine Overview Eve-Lynn Nelson, PhD Director, Center for Telemedicine & Telehealth Professor, Pediatrics (913) 588-2413 enelson2@kumc.edu
  • 41. + Kansas  Medicaid covered some TM services since 2004  Physician, Psychotherapy, Pharmacological management – GT modifiers  Requires patient to be present at originating site  Requires State Licensure Kansas  Center for TeleMedicine & TeleHealth  Kansas Medical Center  60 nodes  4,500 (1,500 unique pts)  Become more research oriented  Dependent on grants  Exploring using system to provide urgent care for whole state
  • 42. + KU Center for Telemedicine and Telehealth  Approximately 4,000 consults per year across 40 providers  Behavioral consults most common  Traditional model in supervised settings  Team-based services with trainee participation 42
  • 44. + Project Echo Mission To expand the capacity to provide the best practice care for common and complex diseases in rural and underserved areas and to monitor outcomes Extension for Community Health Outcomes
  • 45. + Missouri  HB 986 – prohibits plans from denying telehealth coverage and reimbursement (7/2013)  Covers services that would have been delivered in-person  Mo-Healthnet requires 2-way interactive video  No restrictions on type of technology being used  No store and foreward reimbursement  Require prior face-to-face physical exam  Defined clinical locations  Hospital, CAH  Rural Health Clinic  Federally Qualified HC  Nursing Home  Dialysis Center  Mo State Rehab Center  Community Mental Health  Requires State Licensure  Missouri Telehealth Network  University of Missouri, Columbia  202 node MOREnet 2 gigabit backbone Missouri
  • 47. + Why Isn’t Telemedicine the Norm?  TM visits reimbursed at lower rates than face-to-face visits  RVU based productivity  Parochial nature of medicine  Site-specific credentialing  State licensing requirements  Store-and-forward prohibition  Scheduling issues  Culture of convenience  E-mail, texting favored over synchronous communication Regulatory and Reimbursement Logistics and Culture
  • 48. + The Future of Telehealth …where it becomes personal Objective 3
  • 49. +  Activity tracking devices + Apps  Fitbit, Fuel band, Vivofit, Gear  Biometric monitors  External  Implanted medical devices Quantified Self Movement
  • 50. + Game Changers  Devices (moving out of the exam room)  AliveCor ECG  Cellscope  Proscope  Fitbit  Services  Cloud based storage and sharing  Multimedia Patient Portals  Embedded video conferencing  Communities (Fitbit) FDA approved mobile apps and devices. Selling to patients directly. Allowing them to record and share with physicians, family and friends …pushing cost and control to patients (Consumer Directed Care)
  • 51. + iOS Health Kit Apple Watch Healthcare embedded into operating systems Enhancing real time research Openning door to real-time clinical population monitoring and intervention Will the exam room survive?
  • 54. + Forecast: Telemedicine Potential  Operational costs of clinics and hospitals become unsustainable  Reimbursement paradigm reaches inflection point  Telemonitoring capabilities embedded in all devices  Adequate universal spectrum
  • 55. +

Notes de l'éditeur

  1. In a word , GROWING
  2. IHS Telehealth Report 2014 http://info.imsresearch.com/lz/Instances/lz/documents/InMedica/Brochures/Abstract%20-%20World%20Market%20for%20Telehealth%202014%20Edition.pdf Globally telemedicine is expanding rapidly enough to spure market investments.
  3. Large scale systems continue to grow as physician shortages, decreasing revenues put pressure on rural Critical Access Hospitals ability to provide care for which they were intended. Telemedicine services can extend services outward at lower costs than local deliveries. Avera eCare (http://www.americantelemed.org/about-telemedicine/telemedicine-case-studies/case-study-full-page/avera-ecare-supports-675-rural-clinicians-in-the-delivery-of-highest-quality-care#.U-cBLoBdWt)
  4. In addition to using Telemedicine technology to provide outreach some institutions are leveraging the same tools to provide internal care when direct face-to-face care might pose unnecessary risks. Avera eCare (http://www.americantelemed.org/about-telemedicine/telemedicine-case-studies/case-study-full-page/avera-ecare-supports-675-rural-clinicians-in-the-delivery-of-highest-quality-care#.U-cBLoBdWt)
  5. http://www.computerworld.com/s/article/9250262/Almost_one_in_six_doctor_visits_will_be_virtual_this_year Almost one in six doctor visits will be virtual this year eVisits are expected to save $5B this year over the cost of traditional in-office physician visits By Lucas Mearian August 8, 2014 02:36 PM ET Computerworld - With an aging Baby Boomer population and broadband bandwidth improved a hundredfold from a decade ago, telemedicine is exploding as a convenient and less costly alternative to the traditional visit to the doctors' office. This year in the U.S. and Canada, 75 million of 600 million appointments with general practitioners will involve electronic visits, or eVisits, according to new research from Deloitte. The overall cost of in-person primary physician visits worldwide is $175 billion, according to Deloitte. Globally, the number of eVisits will climb to 100 million this year, potentially saving over $5 billion when compared to the cost of in-person doctor visits. The eVisit projection represents growth of 400% from 2012 levels, Deloitte's study showed. Last November, The University of Pittsburgh Medical Center (UPMC) revamped its patient portal, renaming it MyUPMC, and rolling out AnywhereCare, offering patients throughout Pennsylvania eVisits with doctors 24 hoirs a day, seven days a week either over the phone or through video conferencing. UPMC, an $11 billion health care provider and insurer, with 21 hospitals, and more than 400 outpatient sites, said its AnywhereCare service has an 80% satisfaction rating. Patients love the convenience and speed of remote care, according to Natasa Sokolovich, executive director of telemedicine at UPMC. "The new model provides a faster turnaround. Within 30 minutes ... they have the ability to get access to a healthcare provider," Sokolovich said. Electronic visits or telemedicine is comprised of electronic document exchanges, telephone consultations, email or texting, and videoconferencing The vast majority of eVisits, according to Deloitte, are likely to focus on capturing patient information through electronic forms, questionnaires and photos, rather than through direct interaction with a physician using Skype or some other real-time tool. "For example, patients with symptoms of certain illnesses such as sinusitis, strep throat, allergies, bladder infection or acne would complete an online form and then receive a diagnosis and, if required, a prescription," Deloitte stated in a recent report. While not all in-person primary physician consults can be handled by eVisits, even only 30% to 40% implies a $50 to $60 billion total addressable market, according to Deloitte. In order to use its AnywhereCare eVisit service, UPMC patients go online and submit a symptom questionnaire and wait for a response from the first available healthcare professional. Patients also have online access to track appointments, see lab results and view the same medical information as physicians through an electronic medical record (EMR) system. UPMC's original patient portal model allowed only patients with primary care physicians at the facility to contact doctors, and the wait time for a response could be as long as 24 hours. Now any resident of Pennsylvania can contact healthcare providers through the site. Since its launch in November, AnywhereCare has had 2,100 visits. Those eVisits have also saved UPMC an average of $86.80 per member visit compared with the cost of an office visit. Ultimately, Sokolovich hopes eVisits will also free up some of the pressures on primary care practices as physician shortages are anticipated grow industrywide. A 2012 survey conducted for industry group The Physicians Foundationrevealed the average age of 13,575 respondents was 54. That compares with the average age of all American Medical Association (AMA)-listed physicians of 49. Four in 10 active U.S. physicians are age 55 or older, according to the American Association of Medical Colleges. "So we have an aging physician population. And, we know we have a nursing and primary care physician shortage," said David Collins, the senior director of the mobile community of the Healthcare Information and Management Systems Society (HIMSS). "On the other side, we have an aging general population. Ten thousand people a day who are part of the Baby Boomer generation are turning 65," Collins added. "You do the math." The cost of care Another reason for the enormous increase in the adoption of telehealthcare is the Affordable Care Act (ACA). The act places an emphasis on decreasing healthcare costs while increasing quality through standardized methods of care. "Technology is going to be the game changer there," Collins said. The U.S. Centers for Medicare and Medicaid Services Fee Schedule, a 609-page document that details payment rules for each coming year, has for the first time dedicated a significant portion (10 pages) to how physicians should charge for telehealth or eVisits. EVisit usage will likely be greatest in North America, where they will soon represent 25% of the addressable market, according to Deloitte. In the US in 2010 there were 1.2 billion patient visits to physician offices, emergency departments and hospitals (for outpatient services), according to Deloitte; that's the equivalent to 3.3 visits per US citizen. Just over half of physician visits in 2010 were to primary care doctors. Prescription refill, coughs, stomach pain, sore throat, earache and skin rash accounted for over 110 million of the office visits -- all of those requirements could have been be screened or resolved via an eVisit, according to Deloitte. While some older patients will never be comfortable with visiting their physicians online, Collins believes the younger and more computer savvy generation will embrace it as the de facto standard. UPMC's Sokolovich agrees. "As the consumer becomes more aware of these platforms, they're going to start to expect them," Sokolovich said. "It will be a standard for how we access medical care for colds, coughs, pink eye and primary care-type conditions." Lucas Mearian covers consumer data storage, consumerization of IT, mobile device management, renewable energy, telematics/car tech and entertainment tech for Computerworld. Follow Lucas on Twitter at  @lucasmearian or subscribe to Lucas's RSS feed  . His e-mail address islmearian@computerworld.com.  
  6. Another relatively newer use of telemedicine is being piloted by CVS clinics in California where telemedicine units are being placed in CVS Minute Clinics. These clinics are usually staffed by a single APRN who sees patients as they show up. Patients can self register (as usual) but are directed into one of the 2 exam rooms in which a telemedicine unit is placed if the wait times exceed 30 minutes. They then can be seen by a nurse practicioner in another CVS Minute Clinic who is not seeing patients. Internal communication shows this load-balancing use of telemedicine to be acceptable and cost effective and may be expanded to other states. This might have applicability in busy multispecialist clinics with more than one location.
  7. Many states tightly control the collaborative physician / physician extender relationship. Missouri, for example, limits the number of nurse practicioners a given physician may supervise to 3 FTE. These restrictions wind up being the rate limiting step in retail medicine’s growth. Secondly, retail medicine services are tightly limited in order to provide low cost, high volume services. This limitation of services also constrains growth. Telemedicine services that directly connect the retail location to physicians, bypassing the the APRN, are being looked at as a way to grow retail services beyond the traditional scope of practice APRN’s can provide.
  8. http://www.clinical-innovation.com/topics/mobile-telehealth/telemedicine-could-yield-6b-year-savings Telemedicine has the potential to deliver more than $6 billion in healthcare savings per year to U.S. companies, according to global analytics company Towers Watson. Managing such savings would require all employees and their dependents to use the technology-enabled interactions in place of face-to-face visits to the doctor, urgent care center or emergency room for appropriate medical problems, according to the analysis. In a survey 1,000 U.S. employers, 37 percent said that by 2015 they expect to offer their employees telemedicine consultations as a low-cost alternative to emergency room or physician office visits for nonemergency health issues, according to Towers. Another 34 percent are considering offering telemedicine for 2016 or 2017. Overall, the percentage of employers offering telemedicine is expected to rise from 22 percent to 37 percent, a 68 percent increase. “While this analysis highlights a maximum potential savings, even a significantly lower level of use could generate hundreds of millions of dollars in savings. Achieving this savings requires a shift in patient and physician mindsets, health plan willingness to integrate and reimburse such services, and regulatory support in all states,” said Allan Khoury, MD, a senior consultant at Towers Watson, in a statement.
  9. As a rule I generally avoid using politically derived images like this one but in this case it does serve to underscore some of the complexities of the legislative process in getting any regulatory initiatives to stick let alone promulgated through the system.
  10. It is important that everyone understand some basics. CMS excludes store-and-forward applications from it’s formal definition of telemedicine and most of us clinicians are and have been using these technologies that are really asynchronous or near asynchronous (i.e., portal exchange and texting) telemedicine for years. In my opinion one of the primary barriers to personal use of the telemedicine is the dependence on synchronicity. It’s hard enough to find time in a person’s schedule to make a real-time phone conversation let alone get 2 or more people together with the same technology to have a synchronous video interaction. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
  11. What most people do not understand is the transmission of video is not governed by HIPAA regulations as long as that exchange is not recorded. So it’s perfectly fine to use the Skype or Facetime to communicate with a patient just like a phone conversation as long as that session isn’t recorded.
  12. 50 State Telemedicine Gaps Analysis: Physicians Practice Standards & Licensure. ATA, May 2015 When comparing the numerous state laws and differing medical board standards regarding telemedicine, twenty-two states averaged the highest “composite grade” suggesting a supportive policy landscape that accommodates telemedicine adoption and usage. Twenty-six states and D.C. fall in the middle with room for improvement. Two states averaged the lowest composite score suggesting many barriers for telemedicine advancement (Figure 1 and Table 1).
  13. Medicaid recognizes home health care and mental health services already covered by the state plan when furnished using teleconferencing. Home health is limited to certain services. Payment is on a fee-for-service basis for the mental health services, which is the same as the reimbursement for covered services furnished in the conventional manner. Compensation for home health care via telemedicine is made at a reduced rate. Reimbursement is made for only the service furnished at the hub site. Local codes have been established to specifically identify home health services furnished using visual communication equipment. No special modifiers are used for mental health services.
  14. Since 1991, behavioral health leader
  15. Physicians and Surgeons--Therapists--Athletic Trainers--Health Care  Section 334.108  which requires “physical exam” . Heartland limits telemedicine visits to established patients only and doing telemedicine under” cross coverage” provisions.