A stroke patient living in rural Virginia needs to be seen and the closest neurologist is more than two hours away in neighboring Maryland. Enter telemedicine – the use of technology to monitor patients remotely, store clinical data, or facilitate real-time communication between patients and providers. The recent growth of telemedicine has generally been viewed as a major benefit throughout the healthcare industry. Although it fosters cost savings and improved quality of patient care, many are left wondering why telemedicine hasn’t been adopted nation wide. However, there are a few issues that need to be resolved before the widespread adoption of telemedicine takes place.
One of the biggest obstacles is licensure. Each state has different laws governing a physician’s availability to work. In the above example of the Maryland-based neurologist treating the patient in Virginia; typically the physician must abide by the state laws where he or she is licensed, but now that the patient is located across state lines our neurologist must comply with Virginia’s laws.
“If a physician were to see a patient via telemedicine in another state, the physician must then comply with the local laws in the state where the patient is located,” said Greg Billings, senior government relations director with Drinker Biddle and Reath, LLP, who also heads the Center for Telehealth and e-Health Law. “So, you can see that with 50 different states and sets of laws you start to have a checkerboard of compliance factors to take into account.”
As more states accept telemedicine as a regular form of medical care, the laws in each state are beginning to reflect that. Physicians should be sure to check the most up-to-date and pending legislation in the states in which they practice.
Credentialing is another issue impeding telemedicine. Current regulations mandated by CMS state that the originating hospital admitting the patient grant privileges to physicians, including telehealth professionals, as though they are on-site.
This leaves small hospitals to then bear the burden of privileging the hundreds of specialty physicians at large academic medical centers that would be available to them via telemedicine resources. In other words, there are tremendous financial and human resource implications.
“CMS is currently in the process of propagating a final rule that changes credentialing to be more lenient specifically to deal with telemedicine,” said Billings. “Previously doctors would submit their credentials to a hospital and then the hospital would decide whether or not to privilege the doctor based on hospital specific factors. This process works fine until you have a doctor that is going into 12 or more hospitals per day via telemedicine and needs to constantly be credentialed on short notice.”
The new final rule will streamline the credentialing process and will allow hospitals to rely on previous information obtained from another facility and base decisions specifically on the physicians relation to telemedicine.
To prescribe medicine, it’s important for a doctor to have a good rapport with his or her patient to help prevent abuses like “doctor shopping,” and to help cut down on negative drug interactions. Telemedicine adds another element to this, as in many cases there is not physical proximity to the patient, and sometimes there is not even face-to-face contact, yet the same principles still apply.
The American Medical Association has set up general “touch the patient” guidelines for physicians when treating a patient before they prescribe medications. These also vary by state.
“Some states currently make exceptions for telemedicine in their prescribing laws,” said Billings. “In Virginia, a physician can prescribe medication only if the patient was examined either physically or they use instrumentation and diagnostic equipment through which images and medical records may be transmitted electronically.”
This clearly makes it easier for doctors to practice telemedicine.
However, in Maryland, a physician can only prescribe medications to a patient that he or she has physically examined. The Board of Medicine there also notes that ‘prescribing medication over the Internet fails to meet the standard of quality care if the medication is issued to an unknown patient’.”
There is a clear disconnect in some states regarding telemedicine and the ability to physically see patients in order to treat them.
With so many payers and rules, insurance reimbursement is confusing enough, but when you introduce telemedicine, it adds a whole new layer of complexity.
Medicare dictates that to be eligible for telemedicine benefits they must be “presented from an originating site located in either a rural health center or in a county outside of a metropolitan area”. Medicaid on the other hand has at least 27 states that have acknowledged some reimbursement for services provided via telemedicine.
“Reimbursement through CMS is very specific regarding telemedicine,” said Billings. “The doctor must be in a certain category and located in a certain type of facility. For Medicaid it varies by state, but many states are opening up more to telemedicine and reimbursing for services. For example, some states with more aggressive reimbursement policies see the benefit specifically as it relates to the prison system and understand the value in having a doctor see the patients remotely.”
Are These Insurmountable Odds for Telemedicine?
“Telemedicine is here and is constantly being pressed and tried out,” said Billings. “As the technology becomes more available and younger members of society come to expect instant access to healthcare, the need for this type of service will become more popular. What remains on the table is for regulators to ensure patient safety.”
Despite several large obstacles standing in the way of the advancement of telemedicine, its benefits seem to far outweigh the current setbacks. Physicians appreciate the ability to use technology to treat more patients in ways that are efficient and convenient, better, easier access to patients means better care, and faster detection of conditions and diseases. Patients who are sick can be released from care earlier because they can be monitored remotely. And patients who are treated earlier or discharged faster help cut down on the overall cost of care.
To learn more, visit the Center for Telehealth and e-Health Law.