Finale

Although I only skimmed the surface, I learned that telemedicine has great potential to improve health care for everyone - especially for those with the greatest need. To fully realize its potential, significant investments must be made to expand the technical infrastructure that telemedicine requires. Statutory changes are also necessary to expand telehealth services across the United States. But in spite of these challenges, telemedicine has been proven to be successful, and new technology pilots show that it continues to gain support.

This concludes my brief exploration of telemedicine. I enjoyed my journey, and hope you did as well.

Lisa

Interstate Telemedicine Licensing is THE Legal Barrier

When I started researching telemedicine legal issues, I expected that liability would be a major topic. So I was quite surprised to discover that interstate licensing is actually the greatest legal impediment to the expansion of telemedicine across the United States.

While the Constitution grants states the authority to establish health care licensing standards, it also limits state rights to create barriers that inhibit interstate commerce, including the practice of health care. The convergence of inconsistent state licensing requirements with the technical potential to provide telemedical care across state lines raises legal concerns that remain unresolved.

• Competency and Practice Standards: Most states require that medical professionals be licensed to ensure that patients receive safe care are protected from incompetent practitioners. However, broad differences exist in licensing standards between states. States differ in defining the type of health care that must be licensed, which can lead to conflicting expectations between patients and care givers when medical care is delivered electronically. As an example, some states consider remote monitoring a type of delegated medical practice that does not require the same licensing requirements as direct medical care provided by nurses or physicians.

• Jurisdiction and Liability: Differences in state requirements also raise question about state jurisdiction and liability insurance questions. No guidance is in place that defines the legal rights and limitations of states to enforce compliance with licensing requirements. Additionally, because the laws and licensing requirements for interstate telemedicine are unclear, liability insurance does not always provide sufficient coverage for this area of clinical practice.

In a 1997 report to Congress, several potential solutions were presented. The proposed licensure models include:

• Endorsements refer to allowing states to grant licenses to health care professions already licensed by other states that have equivalent standards.

• Mutual Recognition would allow states granting licenses to enter into a legal agreement to accept the licensure policies and procedures of the out-of-state health professional’s licensing state.

• Reciprocity is a mutual agreement between two states where each state agrees to give licensed professionals of the other state equivalent privileges to practice.

• Registration occurs when a licensed health care professional licensed in one state notifies another state of an intent to practice in that state part time, with the agreement to comply with the other state’s legal authority and jurisdiction.

• Limited Licensure requires health care professionals to obtain licenses to practice a limited scope of services in other states.

• National Licensure provides for standardized licensing criteria administered by a state or national organization, which would allow health care professionals to receive a single license allowing them to practice through the United States.

• Federal Licensure would require that health care professionals would receive a Federal license to practice that is accepted throughout the United States.

To date, no federal legislation has been introduced to pilot any of these models, nor has Congress seriously considered any other proposed solutions. This is likely because control of professional licensures is a state constitutional right. However, in order for telemedicine to truly thrive in this country, practitioners must have legal licenses to practice it across state borders.

Next Post: Recent Success Stories

References

Hutcherson, C. (2001). Legal Considerations for Nurses Practicing in a Telehealth Setting. Online Journal of Issues in Nursing. Vol. 6 No. 3, Manuscript 3. Retrieved 9 May.

Klein, S. & Manning, W. (1995). Telemedicine and the Law. Healthcare Information Management. Summer 1995.

Telemedicine Report to Congress. (1997). Legal Issues--Licensure and Telemedicine.

The Center for Telemedicine Law. (2003). Telemedicine Licensure Report.

Pendrak, R, & Ericson, P. (1996). Telemedicine and the law.

U.S. Department of Health and Human Services. (2003). Telemedicine Licensure Report.

Recent Success Stories

Although legal issues and technical challenges seem to inhibit the growth of telemedicine in this country, I believe its many success stories prove that this technology can enhance the quality of health care for everyone. Here is a sampling of recent successes and new initiatives.

• Robotic Surgery: Remote robotic surgery was used last month to correct an atrial heart flutter in an 70-year-old man in Britain by a surgeon working in an external room where he was able to work without wearing the heavy protective shielding necessary to protect against x-ray radiation used during surgery. And in In 2007, a Johns Hopkins surgeon used a robot to teach a laparoscopic procedure to surgeons located in 5,700 miles away in Argentina.

• Stroke Telemedicine: The Mayo Clinic and other large, centralized hospitals are using audiovisual communications and tele-radiology to improve the care given to stroke patients located at remote hospitals that lack adequate emergency care expertise for stroke patients.

• Cancer Screening and Dermatology: Doctors from The University of Pennsylvania use mobile phones with built-in cameras and custom software to screen for cervical cancer at remotely located villages in Africa. Primary care givers use the phones to send photos and patient information to doctors who review the information and provide clinical guidance to the caregivers. The University of Pennsylvania also successfully piloted the system for dermatology care in Africa.

• Behavioral Health: Telehealth services using interactive video conferencing are used to provide mental health services to patients located in rural locations. Some examples of telehealth services are nutritional therapy, psychiatric diagnostic examinations, consultations, and psychotherapy. The use of asynchronous transmission of health care records to support telehealth is being piloted for patients located in remote regions of Alaska and Hawaii.

• Online Health Records, Prescriptions, and Medication Monitoring: The Geisinger Health System provides patients with online access to their medical records, lab results, prescriptions, and renewals. The hospital’s electronic system also provides on-line communications with health care providers and an online health and fitness library.

• Home Monitoring: Several pilots are underway in Maryland to test the feasibility of in home monitoring of chronic health conditions like diabetes, high blood pressure, and congestive heart failure. Patients use simple devices to check their weight, blood pressure and blood sugar. The results are automatically fed into a computer and sent to a remote monitoring site. If the readings fall outside predetermined limits, patients and doctors are notified.

Next Post: Finale

References

Demaerschalk, B. et al. (2009). Stroke Telemedicine.

Gormley, R. Kovarik, C. Use of Mobile Telemedicine for Cervical Cancer Screening in Gaborone, Botswana.

Geisinger. (2010) My Features.

Medical News Today. (2009). Telemedicine for Stroke.

Medicare. (2010). Learning Network Telehealth Services Fact Sheet.

Olson, E. (2009). The Virtual Doctor Visit. The Washington Post.

Reuters. (2010). Remote Robotic Surgery Successful in First Human Heart Surgery.

Thai Medical News.com. (2007). Robotic Surgery is the Future of Health Care.

The Telemedicine Infrastructure

I've been wondering if an infrastructure exists that can fully support telemedicine. I have a feeling one doesn't exist yet, and it won't be built until our government invests in it. I decided to learn more about what our government is doing create a telemedicine infrastructure for our country. Here's what I learned.

The Federal Government intends to spend $15 billion on health care related IT systems by the year 2014. Congress approved an additional $19 billion to create health information exchanges and electronic health records systems.

The Health and Human Services Department (HHS) is reviewing a draft version of the privacy and consent policies that will be required to share our future electronic health records across organizations and systems. The HHS is also providing $17 billion in economic stimulus incentives to doctors and hospitals that implement electronic health record systems (HRS).

The Veterans Affairs Department (VA) has joined Internet2, and plans to use IPv6 for the delivery of Internet video telemedical services for home health care. The VA is also evaluating computer applications that will support disaster recovery and the rapid creation of ad hoc support networks.

The Federal Communications Commission (FCC) is also aiding the creation of the telemedical infrastructure. In its National Broadband Plan, the FCC identified long term goals for increasing to broadband so that all Americans have access to affordable high-speed Internet connectivity, and that all hospitals and health providers have the broadband access they need for electronic health records, the health data exchange, and telemedicine. The FCC also recommended that data sharing standards be developed to support health care data exchange across systems.

A proposed procurement worth $3.5 billion by the Defense Information Systems Agency (DISA), and the General Service Administration (GSA) is underway for new commercial satellite communications services called Custom SatCom Solutions (CS2). The system will provide interactive services that support distance learning, telemedicine, and emergency responder operations.

Next Post: Legal Issues in Telemedicine

References

Jackson, W. (2010). VA joins Internet2 consortium. [Online article]. Retrieved 23 April 2010 from Government Computer News.

Lais, S. (2010). DISA, GSA preview #3.5B satellite opportunity. [Online article]. Retrieved 23 April 2010 from Washington Technology.

Lipowicz, A. (2010). Agencies to spend $15B on health IT by 2014. [online article]. Retrieved 23 April 2010 from Washington Technology.

Lipowicz, A. (2010). Broadband plan lays groundwork for health IT growth. [Online article]. Retrieved 23 April 2010 from Federal Computer Week.

Lipowicx, A. (2010). HHS advisory panel considers patient consent framework. [Online article]. Retrieved 23 April 2010 from Federal Computer Week.

Palmer, J. (2010). New FCC Broadband Plan Advocates e-Health Technologies. [Online article]. Retrieved 23 April 2010 from Collective Imagination.

What is Telemedicine? (Part 3: A More Strategic Approach)

As I was learning about the different ways of classifying telemedicine, it occurred to me that Porter’s three generic strategies might be a useful way to organize telemedicine value chains.

In the 1980’s Michael Porter developed three basic strategies for business success, cost leadership, differentiation, and focus. The relationship between market volume (broad or narrow), and cost (low or high), is the basis of the strategies, as shown:

• Cost Leadership is the “assembly-line” strategy, where a high volume of products or services is produced efficiently at a low cost. Some examples are Honda cars and car washes.
• Differentiation is a strategy used to identify a particular product or service line as unique, and therefore more valuable (and more expensive) to customers than the low cost counterpart is. Apple and luxury spas are examples of companies using the differentiated strategy.
• Focus means that companies tailor their offerings to specific target markets, such as bakeries that only produce specialized cakes, or lawn care chemical companies that spray for weeds. The niche markets may be high or low cost.

What does this have to do with telemedicine? Over the years, I have noticed that the systems I support generally fall into one or more of the following three categories:

• Low Cost/High Volume - workload in such systems is managed using the Cost Leadership strategy.
• High Cost/High Volume - this type of workload requires value added work, and a Differentiation management strategy is used.
• Low Volume/Low or High Cost – this type of workload tends to have narrowly defined work and data processing requirements, and it is managed using the Focus strategy.

I wondered if it was possible to overlay Porter’s generic strategy and the technical and human categories of telemedicine. When I attempted this, I found that a correlation exists between the strategy and the type of technology used to support the process, as shown in the following table.

Organizations that have been able to successfully integrate technology and business strategy have created significant business returns (Weiss and Anderson, 2004). This is as fundamental concept of enterprise architecture, and is essential to the successful implementation of telemedicine.

My conclusion is that applying Porter’s generic strategies to technical delivery methods is a useful way to align the human and technological aspects of telemedicine. This strategic approach also provides valuable guidance on how to identify the appropriate technology for each link in the telemedicine value chain, and then connect those technologies together in a meaningful way.

Next Post: The Telemedicine Infrastructure

References

Learn Marketing.com. (2010). Michael Porters Generic Strategies. [online article]. Retrieved 25 April 2010.

Marketing Teacher Ltd. (2010). Generic Strategies. [online article]. Retrieved 24 April 2010.

Weiss & Anderson. (2004). Aligning Technology and Business Strategy: Issues & Frameworks, A Field Study of 15 Companies. [online article]. Retrieved 24 April 2010 from the IEEE Computer Society website.

Wikipedia. (24 April 2010). Porter’s Generic Strategies. [online article]. Retrieved 24 April 2010.

What is Telemedicine? (Part 2: The Human Definition)

In my last post, I described the commonly used technical categories of telemedicine. Now let's look at how telemedicine is classified in human terms.

The American Telemedicine Association (ATA) organizes telemedical categories based on how patients and heath care providers experience it. These classifications are broken into two sub-categories, telemedicine services and delivery methods.

Telemedicine services are the various types of distance clinical support delivered using one or more technologies.

• Specialist referral services are communications and information sharing between primary health care providers and specialists using VTC/VoIP and store and forward technology.
• Patient consultations refer to diagnosing and developing treatments for remotely located patients using a combination of VTC/VoIP, store and forward, and web/wireless technologies.
• Remote patient monitoring is the oversight of homebound patients' vital signs using store and forward and web/wireless communications.
• Medical education refers to distance learning for health care providers, generally using web/wireless communication and VTC/VoIP.
• Consumer medical and health information is the sharing of medical and health related information to the public and individuals, usually through multimedia via the Internet.

Delivery methods describe the information technology systems that support telemedical services.

• Networked programs are high speed telecommunications connections used for sharing store and forward information among an association of health care providers, clinics, and hospitals.
• Point-to-point connections are private networks used to provide store and forward data and VTC services.
• Primary or specialty care to home connections refers to single line VoIP used to deliver clinical care to homebound patients.
• Home to monitoring centers consists of web/wireless and VoIP technology for real-time sharing of homebound patients’ vital signs with health care providers.
• Web-based e-health patient service sites use web and wireless technology to share health and medical information with remote users.

My conclusion after learning a bit about the technical and human approaches to classifying telemedicine is that both are important. Brown’s technical categories clearly define telemedicine's underlying communication systems. This is essential to building and improving telemedical infrastructures. The ATA’s human classifications are equally valuable because they identify the types of human processes that telemedicine supports, and they show that many telemedical processes depend on a combination of telecommunications technologies.

Next post: What is Telemedicine? (Part 3: A More Strategic Approach)

References

American Telemedicine Association. (2010), Telemedicine Defined. [Online article]. Retrieved 10 April 2010.

Brown, Nancy. (1996), Telemedicine Coming of Age. [online article from the Telemedicine Information Exchange]. Retrieved 10 April 2010.

Wikipedia. (9 April 2010), Telemedicine. [Online article]. Retrieved 11 April 2010.

What is Telemedicine? (Part 1: The Technical Definition)

So, what exactly is Telemedicine?

Basically, it’s a variety of distant clinical and administrative medical services using some type of technological media. The challenge lies in determining how to categorize telemedicine so as to better understand it and further its development.

I found two classification approaches, one based on human experiences of telemedicine, and another based on its underlying technologies. Let's start with telemedicine's technical categories.

In her 1996 article "Telemedicine Coming of Age"; Nancy Brown described telemedicine in terms of the technologies that support it. Brown's technical categories include:

Store and Forward – This is the asynchronous movement of electronic data between systems as the result of one health care provider requiring some type of action on that data by another health care provider, such as:

• A specialist’s staff requests a patient’s medical history from the primary care provider’s electronic system
• A hospital lab sends a digital image taken by a hospital lab technician to a specialist and the primary care provider
• A pharmacy receives an electronic prescription from a health care provider

Interactive Television (IATV) - IATV is better known today as video teleconferencing (VTC). Voice-over IP (VoIP) via the Internet provides a similar capability. Some clinical applications of this technology are:

• Interactive diagnostic and counseling care for patients who cannot travel because of physical limitations or distance
• Referrals and other medical assistance from doctors located remotely from the site where care is provided

Web & Wireless Communications - Brown noted that wireless technology and data sharing via the web were emerging as new methods of supporting telemedicine. This technology has since shown itself to be valuable in supporting interactive clinical care and real-time data sharing, for example:

• A patient's vital signs are sent to a physician's wireless device for immediate evaluation
• Traveling health care vehicles with satellites support the delivery of clinical care using VTC/VoIP and wireless diagnostic tools; send patients' "store and forward" data to their electronic medical file; and send their prescriptions to their pharmacies for mail delivery.

Next post: What is Telemedicine? (Part 2: The Human Definition)

References

American Telemedicine Association. (2010), Telemedicine Defined. [Online article]. Retrieved 10 April 2010.

Brown, Nancy. (1996), Telemedicine Coming of Age. [online article from the Telemedicine Information Exchange]. Retrieved 10 April 2010.

Wikipedia. (9 April 2010), Telemedicine. [Online article]. Retrieved 11 April 2010.