Doctor Group Requires Actions To Fulfill The Promise Of Telemedicine

The American Medical Association (AMA) seems very proud of their new,  just announced policy “for ensuring the appropriate coverage of and payment for telemedicine services.”  They believe telemedicine, properly implemented according to their guidelines, can “strengthen the patient-physician relationship,” increase quality of care, improve health outcomes, and save money. Wow. Who would not be in favor of that? But is this one of those instances when something that seems to good to be true, is?  A closer look at the policy report from AMA’s Council on Medical Service  shows that while much optimism is totally justified and appropriate, many reasons for caution remain.

First, a little background on the players and concepts. The Council on Medical Service (CMS) “recommends AMA policies and actions for consideration by the AMA House of Delegates on the socioeconomic factors that influence the practice of medicine.” In this instance, on June 11, 2014 at the AMA annual meeting in Chicago, the AMA voted to adopt a report of the CMS titled, “REPORT 7 OF THE COUNCIL ON MEDICAL SERVICE (A-14): Coverage of and Payment for Telemedicine.” Furthermore, in the report, telemedicine is defined to include all “three broad categories of telemedicine technologies: store-and-forward, remote monitoring, and (real-time) interactive services.” Now let’s look closer at the details.

Statuette of ancient Egyptian physician Imhotep, the first physician from antiquity known by name. (Photo credit: Wikipedia)

While the report articulates 8 specific recommendations, the actual standards of care and practice guidelines are to be left to the “national medical specialty societies and state medical associations.” In other words, what’s good for the dermatologists may not be good for the radiologists. Plus, a rural state in need of additional medical expertise may adopt more telemedicine-friendly policies than a state with large numbers of physicians looking to protect turf. The potential for confusion rather than coordination across specialities and state lines is significant. I think this requires more attention than given it by current AMA policy.

Our techno-future is so compelling we tend to forget how seductive it can be. Technologically-enabled utopian visions abound, including in telehealth. The American Telemedicine Association is a good example of all benefit and no cost, gain without loss. But there is never a free lunch, even in a world of abundance. And the CMS report did a nice job balancing promise and peril. It keeps an eye on both the promise inherent in “future innovation in the use of telemedicine” and the peril of diminished quality of care, impaired physician-patient relationship, and breaches of confidentiality.

The best part of the report was their emphasis on research. One of the 8 specific recommendations is to “encourage additional research to develop a stronger evidence base for telemedicine.” After all, telemedicine is great idea with tremendous game-changing promise. But who knows? As messy and difficult as science can be, it is still the best way we have of finding out what works, what harms, and what is just ineffective. You don’t want to bet your life, or someone else’s, on just a great idea. The history of healthcare is replete with things that seemed like a great idea at the time only to be shown by later research to be, well, not so hot. And telemedicine is bound to be full of such practices.

To their credit, they also emphasized protecting the physician-patient relationship.  In telemedicine, the CMS report asserts a “valid patient-physician relationship must be established, through at minimum a face-to-face examination, if a face-to-face encounter would otherwise be required in the provision of the same service not delivered via telemedicine.” This will prevent, for example, prescribing some medications based on simply filling out a web form.

Unfortunately, the report goes on to state the “face-to-face encounter could occur in person or virtually through real-time audio and video technology.” Such an assumption of functional equivalence between being bodies together and meeting each other as 2-D representations on screens is just wrong. And dangerous.

First, diagnostically relevant dimensions of interaction are blocked with video. I remember one patient in my psychology practice at an initial consultation who was well and carefully dressed. He denied problems. I would have wondered what he was doing in my office at all except for the fact that he smelled bad, like he hadn’t showered in many days, which he had not. Might I have missed this and missed the significant depression he was trying to hide had the interview been done via “real-time audio and video technology.” Perhaps. And for a physician, olfaction can be an even more important dimension of diagnostic information.

Second, and more dangerous and important for a physician, are the different limits each kind of interaction has. Simply put, there is no possibility of touching on video. A physician cannot follow-up a complaint by, for example, palpating lymph nodes. And because of that maybe a patient will not bother to even complain in the first place. The idea that hands-off medicine is functionally the same as hands-on medicine is not just wrong, it also undermines the physician-patient relationship and diminishes us all.

Finally, hope is a fragile thing; placebos a powerful medicine. Equating being bodies together with video interactions seems like trying to get nutrition from a recipe. Sometimes you need the actual meal for full effect. And the power of hope shows us that the representation of a relationship may not heal the same way as do actual relationships.

So, we should appreciate the AMA’s effort, despite some issues. The significant promise of telemedicine deserves care and tending. It just needs to be said we will most likely fulfill that promise by focussing on both what technologies can do and what they can not do. And assuming a video chat is functionally equivalent to sitting in a room with someone is a dangerous mistake that will likely interfere with the ongoing evolution of telehealth.

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Doctor Group Requires Actions To Fulfill The Promise Of Telemedicine

Can Telemedicine Lessen Nursing House Expenses?

Overall health Affairs, a overall health policy newsletter, reported on an revolutionary research accomplished to find out if employing telemedicine in nursing houses when a doctor was not available would stop hospitalizations.  Medicare is reported to spend more than a billion bucks yearly on these hospitalizations.

Physicians are not normally existing 24/seven in nursing residences. They are on-get in touch with in off hours, this kind of as nights and weekends.  The managed study involved eleven nursing residences in Massachusetts, all of whom contracted with the telemedicine services to offer real time videoconferencing with doctors when a resident required evaluation, consultation or doctor observation to figure out if hospitalization was required.  Some items cannot be determined over the mobile phone, as the physician demands to consider a appear at or talk with the patient as nicely as the nurse in attendance.

The nursing homes chosen for the examine had been not the “best” ones, as they had reduced top quality ratings, more beds and fewer staff than typical in that state.  Both employees members and physicians had to be educated about how to use the service and persuaded to use it below research protocols.  Not all facilities selected for the examine were equally engaged in the telemedicine project.

Did telemedicine conserve Medicare bucks? Certainly it did in this research.

The average financial savings to Medicare for a nursing residence that was a lot more engaged with telemedicine was calculated to be $ 151,000 per nursing home per year. The yearly cost of the telemedicine service in this examine was $ thirty,000 per nursing residence.   By their calculation that would end result in a net cost savings of approximately $ 120,000 per nursing property per yr in the more engaged services.

It sounds good, but there are obvious disincentives to utilizing this newer strategy to stopping hospitalizations.The nursing homes need to make the investment in products and coaching, but Medicare reaps the advantage.  Worse however, when a Medicaid resident goes into the hospital and stays a number of days, they then return to the nursing residence.  It can then bill Medicare for an accredited period at a larger daily rate than they had been receiving before, underneath Medicaid.

Beneath the Cost-effective Care Act, funding is supplied for a number of sorts of demonstration programs.  One of these is the accountable care organization, which backlinks payment across settings so that the organization is accountable for all of the care charges of its enrollees.  Under that model, investment in telemedicine would make excellent sense and the disincentive for price containment is removed.  The organization would be motivated to reduce its personal hazards of the increased expense of unnecessary hospitalizations.

Employing video teleconferencing seems like an outstanding adjust from how items have typically been accomplished in nursing residences.  The doctor will get a lot more and much better actual time data about the resident and can make better judgment calls about treatment.  The nurses caring for the individuals have greater accessibility to physicians, to whom they are necessary to report specified changes in the resident’s condition.  Having invested time in nurse’s shoes myself, I can attest to the aggravation of trying to reach the physician by mobile phone at evening or on a weekend and possessing an on-call physician who does not know the resident send him or her to the ER, “just to be safe”.

Family members with aging dad and mom have no handle in excess of any of these selections.  However, any family members would most likely want their elderly loved 1 to be seen by a medical doctor via video rather than sent to ER for lack of encounter to face contact with the on-call MD.

When the sometimes needless trip to the ER occurs, we all pay out for the Medicaid resident’s additional fees.

If telemedicine could bring the physician to the resident far more often, far more very easily and value effectively, it seems like an clear price containment answer.

Telemedicine may most likely result in significantly less taxpayer burden as properly as greater good quality of care for nursing house residents. That’s an end result well worth functioning for in any state.

Till following time,

Carolyn Rosenblatt

AgingParents.com

Can Telemedicine Lessen Nursing House Expenses?