Tele-Medicine – The Future

Remote, and in control: DOs reach new patients as telemedicine comes of age

In rural Oklahoma, a patient visited his local rural hospital complaining of chest pain. The attending physician set up a videoconference, which allowed the patient to consult with a cardiologist based in a bigger city. The cardiologist could tell via remote listening tools that there was excess liquid on the patient’s heart that had to be drained right away, so the patient went to see the specialist face-to-face. Within a few hours, the patient was going in to surgery.

This patient’s life was likely saved because he had access to a cardiologist near the small town where he lived—even though the cardiologist was in a city miles away. It’s one example of the success story that is telemedicine in rural America, says William J. Pettit, DO, the associate dean for rural health at the Oklahoma State University (OSU) Center for Rural Health.

“It’s good for the community and its employers, and it’s just good business,” Dr. Pettit says.

Dr. Pettit, through OSU’s department of telemedicine, which his center now oversees, has been active in the burgeoning field since 2001. The department oversees telemedicine in rural hospitals and pairs specialists in bigger cities with these outposts. It also helped establish Oklahoma’s Medicaid reimbursement laws for telemedicine, and it provided guidance on establishing network privacy standards in the state.

Dr. Pettit

“All the medicines that have to be prescribed can be picked up locally at the pharmacist. And if there are lab tests to be done, they are ordered in the local economy.” Dr. Pettit

OSU’s telemedicine department has facilitated more than 64,000 patient encounters this year as of August, or roughly 263 per day. The state’s booming telemedicine industry is mirrored across the country. Nationwide, the use of telemedicine is mushrooming, says Jon Linkous, the CEO of the American Telemedicine Association (ATA). He estimates that some 10 million Americans now receive care via telemedicine, which is a 50% increase from six years ago. He expects the current number to double within 10 years.

In contrast to such rapid growth, issues such as reimbursement are still taking shape. Reimbursement rules for telemedicine now vary by state. In 2011, 39 states offered some level of reimbursement for telemedicine via Medicaid, according to the Center for Telehealth and e-Health Law. Medicare also reimburses for telemedicine, but stipulates that the patient must receive care in either a rural or other underserved area or at a Medicare telemedicine demonstration project site. Many private insurance plans cover telemedicine, though they typically focus on remote areas as well, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans.
Inpatient vs. outpatient telemedicine

As telemedicine evolves, it takes various forms. Physicians should be aware of the different ways the industry is using telemedicine and the different levels of care they facilitate, says Darren Sommer, DO, MPH, a vice president of Premier Physician Services in Dayton, Ohio, and an adviser to the Ohio State Medical Board on telemedicine. He distinguishes between inpatient telemedicine, in which a patient has access to a remote specialist from a clinic or a hospital, and outpatient telemedicine, in which a patient virtually visits a physician from home, a pharmacy or another nonclinical location.

While inpatient telemedicine is often nearly indistinguishable from an in-person encounter short of the hands-on exam, Dr. Sommer says, outpatient telemedicine offers less comprehensive care to varying degrees.

Recently, several new companies have unveiled services offering consumers access to care outside the physician’s office. For instance, Healthspot Inc. provides a health “station” that can be placed anywhere—a pharmacy, an urgent care center, a rural clinic. Inside the station, a remote physician, with the help of an in-house medical assistant, can use tools in the station to check a patient’s vital signs. For instance, the physician can look inside a patient’s throat or ears using a digital otoscope that can transmit pictures and video back to the physician via a secure network. And at the same time, the patient can also see what the physician is seeing on a video display inside the station.

Healthspot CEO Cashman

“What we’re trying to end is the disconnected and inefficient use of the emergency department and urgent care as a primary care center.” Healthspot CEO Cashman

Established in October 2010, Healthspot operates five stations, but is in the process of rolling out 20 more, says company CEO Steve Cashman. Cashman hopes to see 1,000 Healthspot stations in the U.S. by the end of 2013. The stations are an affordable alternative to urgent care centers and emergency rooms, he says. The out-of-pocket charge for a Healthspot visit is $59, but patients can also use insurance.

“Really what we’re trying to end is the disconnected and inefficient use of the emergency department and urgent care as a primary care center,” Cashman says.

Although Dr. Sommer mentioned that Healthspot offers a less robust level of care, he sees the merits of the service. In particular, he says the stations could help patients who lose access to care in emergency situations such as Superstorm Sandy.

“You could go ahead and fill a lot of the scripts that people need and take care of a lot of chronic conditions,” he says.

Another company, DocLogic LLC, offers patients access to a physician via phone, email or webcam from home. Companies such as DocLogic offer the least robust level of service, Dr. Sommer says.

“You cannot do vital signs, you cannot touch the patient, you cannot do anything but take the patient’s word,” Dr. Sommer says. For instance, when a patient complains of a routine headache, the physician on the phone can’t check blood pressure or other readings that might indicate a need for immediate medical attention.

Telemedicine is still in its infancy, Dr. Sommer says, and there’s a real possibility evolving laws will mean a company such as DocLogic won’t be able to operate in its current state.

“What likely is going to happen is that physicians and other entities are going to push back on the idea of being allowed to prescribe medication to a patient you’ve never examined,” he says. “I think the laws will become more restrictive for a company like DocLogic and not less restrictive.”

Representatives at DocLogic did not return requests for comment.
Telemedicine resources

The American Telemedicine Association offers news, webinars and guidelines on its website.
Federal Telehealth Resource Centers provide region-specific resources and advice on using telemedicine.
The Center for Telehealth and e-Health Law has current information on all the laws surrounding telemedicine.
For information on medical technology in osteopathic medicine, see the American Osteopathic Association of Medical Informatics.
The American Medical Informatics Association gives broader background information on all things related to medical technology.

Another law to watch is state licensure. All states now require a physician practicing telemedicine to be licensed in both the state where the physician is based and where the patient is receiving care.

The ATA’s Linkous says this is a problem, and his organization advocates a fix for it, whether it’s national licensure or a reciprocity agreement between the states.

The AOA House of Delegates expressed its opposition to national licensure in July, when it passed a revised telemedicine policy. States should retain control of licensing, the policy says.

The policy also says the AOA recognizes the potential for telemedicine to provide care to those who couldn’t otherwise access it. And it stresses that care provided via telemedicine should be as close as possible to the care provided during a face-to-face visit.
Boost for rural health care

In rural hospitals and clinics across the country, DOs strive to do these two things.

“Part of the guiding principle of telemedicine is that you want it to be the same quality of care that you get in an urban area,” says Jeff Hackler, JD, the assistant to the dean for rural service programs at the OSU Center for Rural Health. “It’s not just specialty care in a rural area.”

Telemedicine benefits rural economies, patients and primary care providers, says Dr. Pettit of the OSU Center for Rural Health.

“The patient doesn’t have to leave home, and all the medicines that have to be prescribed can be picked up locally at the pharmacist. And if there are lab tests to be done, they are ordered in the local economy,” he says.

Rural patients who travel great distances to see specialists often have trouble getting back to the city for follow-up care, Hackler says. Telemedicine can eliminate the need for multiple trips.

Primary care physicians may feel threatened by some aspects of telemedicine, Dr. Pettit says. They may worry they’ll lose patients to physicians based in bigger cities or neighboring states. But they should view it as an asset instead, he says.

“Let’s face it, you’re a lone provider in a small community 70 to 100 miles from the academic health center,” he says. “You suddenly have the availability of a subspecialist. It makes you feel less isolated. It gives you great support.”

Telemedicine can also address the growing U.S. physician shortage. Jed G. Magen, DO, the chairman of the psychiatry department at the Michigan State University College of Osteopathic Medicine in East Lansing, has seen firsthand how telemedicine alleviates his state’s psychiatrist shortage.

“There’s a tremendous maldistribution of psychiatrists and a real shortage,” he says. “So this is a way that we can provide services to these places where there are no psychiatrists or few psychiatrists. We show up on the screen, and we can provide direct service and/or consultation.”


“We’ll hear from cardiologists who say, ‘I can hear things using this digital stethoscope that I can’t hear when I have somebody in my office.’ ”OSU’s Hackler

MSU psychiatry faculty members provide care through telemedicine to patients at eight rural sites and two urban sites throughout the state. The program has grown steadily; in 2006, it started with just one site. Through the program, Dr. Magen works with patients in remote juvenile detention facilities and geriatric communities. It’s particularly difficult—impossible even—for these patients and their caregivers to travel hours away to get care, he says.

“Our geropsychiatrist deals with patients in a long-term care facility,” he says. “Prior to her showing up, to get any psychiatry services—and these are frail, elderly patients in a nursing home setting—they would have had to pack into a van, drive an hour and a half to get seen, then pack back in the van to drive back. So now they get the services without moving.”
Critics’ concerns

For all of telemedicine’s virtues, critics raise concerns about the quality of care.

There’s a worry that without face-to-face access to the patient, the physician will miss something important. Dr. Pettit says this is a valid issue, but one that most physicians using telemedicine keep in mind.

“We all understand that there are limitations of telemedicine,” he says. “The biggest limitation is that you can’t touch and can’t feel, but I don’t think that’s necessarily a big concern among physicians. They understand that limitation, and they are not at all reluctant to say, ‘I think I just need to see this patient.’ ”

Hackler agrees. But on the other hand, he says, the technology used for telemedicine is sometimes better than what physicians use for office visits.

“I’m always surprised how impressed the specialists are with the technology,” he says. “We’ll hear from cardiologists who say, ‘I can hear things using this digital stethoscope that I can’t hear when I have somebody in my office.’ ”