How Telemedicine Started

This about the start of telemedicine really interested me and it is not often one of the originals tells it. A version of this article first appeared in Telemedicine Magazine. I am using the information that appeared in Medpage Today and am quoting the entire article.

How 'A Stupid Idea' Gave Birth to Telemedicine

by Jay H. Sanders MD

Jay Sanders, MD -- often called "The Father of Telemedicine" for his work introducing telehealth in the Southeast in the 1970s -- can remember the day that telemedicine was conceived, and by whom. To Sanders, the true father of telemedicine is Kenneth Byrd, MD. Here's his story.

It was late summer, 1967. I was working as a senior resident in medicine at Massachusetts General Hospital in Boston. In those days there was no emergency medical specialty. The senior resident and the surgical senior resident rotated two 12-hour shifts, running the emergency room. I was out front in the emergency department waiting for the next Boston traffic accident victim to come through the doors when the doors swung open and in came my professor, who was red-faced and upset.

I knew exactly why he was upset. These professors of medicine at the Massachusetts General Hospital were making a grand total of about $8,000 a year. So many of them moonlighted. One of the jobs that Ken Byrd was doing was moonlighting as the medical director at Logan Airport Medical Station. Anybody who knows Boston knows that the airport's only 3.5 miles away from the Mass General, except for one problem: the traffic.

In those days, there was only one tunnel under the Charles River, not three like there are today. And every day he would have to go back and forth 3.5 miles to Logan Airport to see airport employees or travelers who got sick. And every day he would get stuck in terrible traffic in the Sumner Tunnel. It would literally take him an hour each way.

He got so frustrated this one day in 1967 that he came through the MGH doors with an idea. Since I was the first one he saw, he came up to me and he grabbed my arm and he said: "Jay!" I said, "I understand, Dr. Byrd. I know you got caught in traffic again."

And he said, "No! I did, but I had this idea! What if I bought two TV cameras and put one at Logan Airport and one here in the MGH ER and I began to examine patients over TV? What do you think?"

Now I have to tell you I thought it was the stupidest idea I'd ever heard of in my life. But I had enough common sense to realize he was my professor. I was a resident and I said, "Gee, Dr. Byrd, that's a very interesting idea." And I've been working on his stupid idea ever since.

As told by Jay H. Sanders, MD, president and CEO of The Global Telemedicine Group. A version of this article first appeared at Telemedicine Magazine, a quarterly publication that connects medical providers with the tech innovators revolutionizing the healthcare system.

Time to Transform Rural Health Care

I need to start this with a statement that I think my definition of rural healthcare differs from the definition used in this article. The article uses 19.3 percent as the number living in a rural area, and says only about 10 percent of physicians practice in rural areas. The article also declares that 65 percent of all Health Professional Shortage Areas are in rural areas. It is small wonder that many must travel long distances to see a specialist after months waiting for an appointment.

Even in areas where rural primary care providers (PCPs) remain committed and engaged in the community, often having been raised and educated there, these providers often lack close connections to specialists who tend to be based in larger, urban academic medical centers (AMC). The result is a worsening gap in specialty care access, in turn leading to a deteriorative effect on rural provider morale and retention.

Much of this is because many local hospitals are being bought out by regional hospital groups and becoming larger and more incapable to serving rural primary care providers (PCPs). We are seeing this in our community and now the local hospital sends many patients out to other hospitals. What is disturbing is that most patients are transported by medical helicopters at added costs rather that by ambulance which still are expensive, but about a tenth of the cost of a helicopter.

Most of the efforts to improve rural care have focused on enhancing the patchwork of federally regulated safety net programs, with the goal of increasing quality of care by increasing access to primary, routine, and emergency care. Innovative communications technologies, decision support tools, and initiatives to enhance “broadband” access in rural areas are enabling some frontline rural health care professionals, and even patients and family members themselves, to implement new approaches to delivering high-quality care even with limited availability of physicians, and particularly expert physicians.

I do not understand why authors of many articles dance around the issues. Telemedicine and its use are not new technologies – just underused technologies that many third party payors (medical insurance companies and Medicare) do not want to pay for and constantly put obstacles up to stop its use.

Some states are attempting to install high-speed internet lines, but the political issue is being lobbied heavily against from many businesses and internet providers. In addition to improving quality and capacity of care within rural communities, these approaches also have the potential to generate cost savings. Receiving more specialized treatment from a PCP may reduce complications and emergency department visits, as well as the volume of costly and unnecessary referrals to tertiary centers. Provider education and electronic consultation approaches may also provide cheaper ‘junior’ specialty care as this dissemination of knowledge enables PCPs to provide more care themselves.

Yes, telemedicine can do this and more. Yet, despite this potential for improved care and cost savings, the United States health care system is not set up to recognize and reward these approaches. Because they represent a traditional health care facilities and in-person consultations and services, they are often not supported under traditional fee-for-service payment systems like Medicare.

Changes are supposed to happen under the Affordable Care Act, but many of the provisions are being postponed by the President or his Health and Human Services department. However, until our Congress decides that rural healthcare is important, very little will be accomplished. Funding of telemedicine to obtain the cost savings many know has potential will not happen until Congress does something positive to force the insurance industry to support telemedicine.

Telemedicine to Help Manage Diabetes

Telemedicine is obtaining a chance to prove itself in the state of Mississippi. With the second highest rate of diabetes diagnosis behind West Virginia, Mississippi has developed a plan for delivering top of the line diabetes management to some of its neediest residents.

This plan is implementing steps to cut the devastating effects on the state economy - $2.7 billion annual cost and improve the overall health of Mississippians. In January, the University of Mississippi Medical Center and three private technology partners developed a plan to help low-income residents manage their diabetes via telemedicine. This will be accomplished by helping these residents keep the diabetes in management and avoid unnecessary hospitalizations while remaining active and productive.

The Mississippi legislature passed and Governor Phil Bryant signed the bill which was enacted in March. This requires private insurers, Medicaid and state employee health plans to reimburse medical providers for services dispensed via computer screens and telecommunications at the same rate they would pay for in-person medical care. This means those with insurance or Medicaid will have their providers reimbursed. The telemedicine project will be free to the poor uninsured participants.

Mississippi's telemedicine law goes further than any other state to remove what the telehealth industry considers its biggest impediment, lack of insurance reimbursement.  Twenty states, plus the District of Columbia, have requirements that private insurers must pay for some telemedicine services. Most states pay for certain services through Medicaid, but the Mississippi law requires parity from all insurers for all types of telemedicine services. In April, Tennessee joined Mississippi with a similar law.

Beginning in June, about 200 people with diabetes in one of the state's poorest regions, the Mississippi Delta, will be given internet-capable computer tablets load with the necessary software. Then medical professionals at the University of Mississippi and North Sunflower Medical Center, will be able to monitor patients' test results and symptoms. The third technology partner will provide technical support for the wireless telecommunications services required to transmit the medical data.

Local clinicians in Sunflower County are choosing diabetes patients who are the sickest in the community. The idea is to show that even patients with the least-managed diseases can see improved health outcomes with careful monitoring. Each patient will have a baseline exam and a treatment program. This will require each patient to check blood glucose levels two to four times daily using a home testing kit. These results will be transmitted to medical teams at both hospitals. Patients will also check their weight and blood pressure daily and transmit the information.

The medical team at the University of Mississippi will include a dietitian, a pharmacist, an ophthalmologist, an endocrinologist, a diabetes education expert, and a nurse practitioner. They will work with the medical providers at Sunflower Medical Center to assist and provide a full range of specialty care for the patients. A member of the team will consult with patients daily using video teleconferencing to make sure they are making the lifestyle changes needed to improve their conditions.

This proactive patient monitoring should improve patient care and patient health outcome. It will be interesting to see the interim progress if we are informed and I will be watching for these reports. The diabetes project will run 18 months and interim results will be released during this time. Hopefully the progress will be significant in 18 months that other states will feel encouraged to do longer studies and the results will stem the diabetes epidemic.

Telemedicine Use May Be Expanded by Medicare

I am not sure this will happen or when, but this is what is reported in MedPage Today back in December 2013. “Medicare officials and members of Congress are taking steps to expand the use of telemedicine services by dropping -- or proposing to drop -- restrictions on their use.”

I was not sure so I have held this until I could hear back from my representative. He was not aware of this and had not seen any proposed legislation. He did state that it could be part of the 'doc-fix' bill that is currently stalled, but he had not reviewed it and would not until it became actionable.

The MedPage Today article said the following, “Both the 2014 Medicare physician fee schedule and legislation to repeal the program's sustainable growth rate (SGR) payment formula have provisions designed to improve access to telemedicine.”

"Many of the states [through Medicaid] do a much better job of using telehealth than does the Medicare program," Gary Capistrant, senior director of public policy at the American Telemedicine Association, told MedPage Today. "Medicare may be the last to move forward."

Currently only 20 states and the District of Columbia require that private insurers cover telehealth the same as they cover in-person services. When Medicare started paying for services delivered through telemedicine systems, it was limited to patients in rural, underserved areas who had a Medicare provider present with them. This was very restrictive and limiting.

Medicare's Sustainable Growth Rate (SGR) restricts the growth of telemedicine and technology's use. Even if Congress passes the doc-fix and repeals the SGR, the government will still need to get out of the way and allow providers to perform their duties.

Until the bills are passed, we will have no improved method for the expansion of telemedicine. There are still barriers in the current laws and Congress is not currently considering removing these barriers. Capistrant says, "We need to move rapidly to a system where we're just talking healthcare, and not special restrictions on the use of technology for health."

I am concerned that Congress will work piecemeal at fixing the barriers to telemedicine, thereby making telemedicine not effective for several years. 

Note:  Unless this is separated from the SGR, it is basically a dead issue for this year. 

More Efficient Use of Telemedicine

Dr. Robert Kocher wrote a blog on TheHealth Care Blog site and he explains the need for doctors to be able to practice across state borders. He states that federal standards govern medical training and testing, but the individual states each have their own licensing board, often referred to as a state medical board. The reason he is using is to promote telemedicine, which has had its good on display, but many detractors and many doctors in opposition because they do not want to have telemedicine in their backyard.

I agree with Dr. Kocher, but think he is banging head against the wall. The American Medical Association and many state medical boards are busy lobbying against telemedicine. Until there is more public demand and state legislatures start deciding that telemedicine is needed for their state and pass legislation, I doubt this will happen. In addition most state medical boards do not recognize license reciprocity and want the revenue they can receive.

Now this is only my opinion, but I think many doctors want telemedicine to succeed. I also think until more states adopt in state telemedicine, a national call will not succeed.  The example that I can think of is what has happened in the state of Kansas. The University of Kansas Center for Telemedicine & Telehealth (KUCTT) is a recognized world leader in telehealth services and research. KUCTT is part of the KU Medical Center. The following is from the KUCTT.

“Beginning in 1991 with a single connection to a community in western Kansas, the Kansas telehealth network now has more than 100 sites throughout the state. KU Center for Telemedicine and Telehealth has conducted thousands of clinical consultations for Kansans and hosted hundreds of educational events for health professionals, teachers, students and the public across the network.

KU Center for Telemedicine and Telehealth has been an integral piece of several national and international collaborations that have demonstrated the potential of telehealth to eliminate distance as a barrier to healthcare. With more than 24,000 clinical consultations and educational events, KU Center for Telemedicine and Telehealth is one of the oldest and most successful telehealth programs in the world.”

If other states would use this as a model for their state, then telemedicine would be given a big boost and possibly be ready to take on national importance and then legislatures or Congress might consider new licensing to be able to operate across state borders.

Think of the importance this could have for those of us with diabetes in our own state. What happens when the weather is like this winter when travel is often impossible and blizzard warnings are issued. A medical appointment is probably missed and important information can be withheld from you and the doctor. If telemedicine was available, the appointment might not be a total loss if you had a local doctor on the network that could do the necessary tests or a local hospital where the tests could be done.

I can only hope that more people will consider the suggestion and make telemedicine available to more without having to cross state borders. Then the doors may open for telemedicine nationally.

Deadly Physical Examination Requirements (PER)

When I wrote this blog back in July 2012, I thought I would never see it again. Then on March 12, it reappeared in two places, here, and here. This time I found an email for one of the authors and have a copy of the study. It is very interesting and with the articles and study, I will try to emphasize what the medical profession is doing to prevent telemedicine from happening.

First a little background about what started the rush to require the physician examination requirement (PER) before a prescription could be issued. Our internet pharmacies let their greed create much of this, but only those that did not follow the laws of the state in which they had facilities. There are three core models of the Internet pharmacy to consider. The first model is either part of or partnered with existing brick and mortar pharmacies. This means they adopted the procedures of traditional pharmacies including accepting prescriptions only from patients' physicians.

The second model of online pharmacies permitted patients to complete online health status questionnaires that were evaluated by physicians under contract with the pharmacy. After a favorable review, the prescription was written, filled, and shipped. The third model of online pharmacies is all located outside of the USA. They do not follow any rules other than to make the sale happen. The second and third model is what generated the rush to PER. I have no problem with this because of the problems these pharmacies have caused. The first model was not supposed to have been caught is this, but has when lawyers thought they could make some money.

The first PER restriction was implemented by the medical board of the District of Columbia in 1998. Between 1999 and 2006, 32 more states have put regulations in effect. The last state in 2006 to do this was Idaho. Only 17 states have not adopted PER.

Although PER was not specifically directed at telemedicine, the imposition of PER certainly had the potential to adversely affect key aspects of it. The practice of medicine at a distance, what we now call telemedicine, had its roots in 1960s. However, telemedicine expanded dramatically in the 1990s, as improvements in technology made it more useful and reliable. Telemedicine should generate significant savings in time costs rather than the monetary cost of telemedicine. This is the reason that the study calls for more studies to separately investigate the effect of telemedicine on those groups that experience the largest savings; people located in predominately rural areas and those living in areas of low physician densities.

From the intent to prevent access to a variety of non-beneficial drugs, the regulation has had the effect of raising the implicit cost of telemedicine. This created a trade-off of reducing access to medical care for some and giving some patients a higher quality of medical care. PER adoption has its greatest impact by elevating mortality in rural areas and areas of low physician density.

In 2008, the federal government implemented a nationwide PER, prompted by concerns over non-therapeutic access to drugs from foreign-based Internet pharmacies. Although some of the circumstances leading up to the federal legislation differ from those observed earlier at the state level, the methods we used may be of value in subsequent examination of the effects of this federal law. The findings are also relevant to policy discussions of the appropriate regulation of telemedicine. It seems that even if (as suggested by others) telemedicine offers somewhat lower quality care, its effect on access to care in rural and physician–deprived locales may be important in improving overall health outcomes. Finally, the results help illuminate some of the key margins to consider in the broader discussion over the regulation and provision of medical care, emphasizing the importance of identifying the relevant trade-offs between access and quality of care.

In my personal opinion, all PER laws need a careful review to eliminate the burden on telemedicine and allow telemedicine to proceed in rural and sparse physician areas. Yes, we still need laws to stop the two models of pharmacy sales that do not follow state or federal laws, but we do need to make allowance for legitimate telemedicine in largely rural areas where travel can be a real burden.

Volunteering As a Peer Mentor

Whew, I had hoped for an easy session for the first time. It was more a complicated mix of questions about my diabetes and why I am on insulin. Also in the questions was several about why I blog about diabetes and some of the other topics I blog about. I had been warned ahead of time that there would be questions like this although I was still surprised by the questions asked.

The group of eight diabetes patients that participated in the shared medical appointment were above average patients, and I was talking to only six at a time while two others met with the doctors. The range of ages was from 30 years of age to one patient of 89 years young. Length of time for each having diabetes varied from two months to almost 20 years. All had type 2 diabetes and were comparing notes. I was also pleased by the group as all were regularly exercising and the eldest was doing the most exercising and was managing his diabetes with exercise and diet. He was the first to speak and thanked me for providing the websites to their doctors and he was enjoying reading the blog by Tom Ross, as it was easy for him to relate to his experiences.

The next question was about why I had supplied so many sites as this person could not read them all. I answered by saying, I did not expect them to want to read all of the sites. The variety was to allow each person to find one or two that they enjoyed reading and maybe a few for information that they would bookmark and visit from time to time when looking for specific information. I also stated that these were not required reading, but that many would also have tidbits from time to time that they may find worthwhile, or can adapt to their lifestyle. We covered a few type 1 bloggers that two of the group had found and I answered that each was a good site for the information presented. I then summarized by saying that each blogger had her/his style of writing and would appeal to different readers.

We moved on and the next question was about my diabetes. Why was I on insulin and why did I not have a recommendation for the best insulin to use. To begin with, I was diagnosed late after diabetes already had a good hold on my life and at the time I was already overweight and my doctor did not talk about exercise. I explained that my purpose is not to recommend any medication but I had blogged about them and given references (links) to charts on the Internet to make people aware of the different types. I then stated that it was up to them to become knowledgeable and discuss them with their doctor to see if they had what was best for them. I said this applied to any medication they may be taking. I stated that the doctor would make the best selection based on the tests done, what he learned from your history, and from the questions he had asked before prescribing the medication.

I also emphasized that when they became knowledgeable about the different medications, they would not be out of line to revisit the topic with the doctor and discuss this in more detail. I had seen one of the doctors enter the room as I started talking about this, and she stated that is what they hoped would happen and the reason for having the shared medical appointments and for me answering questions as a peer mentor. It was for them to gain confidence as patients and ask these questions. She continued that sometimes doctors do prescribe what they believe the information tells them, but that does not mean that another medication might not be better suited for them. She rightfully stated that occasionally they may find that another medication is better, and they will do their diligence to investigate the possibility. She also warned them that they (the doctors) will not be bullied into a medication change just because a patient had heard about a medication and wanted it. They would listen to the patients to find out what knowledge they had on the medication and then start asking questions to determine if a medication change should be made.

The next question was about statins. I could see the doctor stop almost out the door. I said this was a question that was open to discussion and would depend on the health of the patient, the lab test results, family history, and other factors that only the doctors would be qualified to discover. I went on that there were two sides to the controversy and they should not be afraid to ask questions of their doctor. I would provide URLs to anyone needing them to help educate themselves about statins. The doctor gave me a thumbs up and let the door close. I asked how many were on statins and only two of those present were. Both were women and I asked for their ages. I asked one more question (both nodded yes), and asked if they had gotten my email address which they said they would use. I said I would send a copy to the doctor and both agreed.

We then moved onto testing and the questions were mostly about obtaining sufficient numbers of test strips. I said I knew of another doctor that was working on this problem and I would email him asking about their progress and make sure the doctors were aware of his progress. I would also give their doctors his email address so they could communicate.

The next was about the actual pricking of their finders and alternate sites. I demonstrated on my fingers and watched as they flinched, and knew that I had their attention. I showed them my lancet device and said there were others, but thought that all had an adjustment area and they needed to learn to use it. I showed that mine was set on 4 and that the number one would be the lightest setting and a click past 5 would be the deepest setting. I explained that they should try to see what it felt like after a few more instructions.

I next took a ballpoint pen and drew the best area on the sides of two fingers. I expected the next question, which was about the fingertips themselves and the pads of the fingertips. On two other fingers, I drew these areas and they said yes that was where they were testing and it often caused pain. I said that the first areas I had drawn contained less nerves and the second areas were full of nerves so there would be more pain. I could see one person getting out her lancet device so I stopped and said go ahead. She did and said OMG he is right. She said she was never exposed to the best places, so this was very surprising for her. I held up my hand and carefully showed them the areas I had outlined as I could see others going for their lancet devices. I also suggested that they consider the same areas of their thumbs unless for some it was too painful. I also described rotating the sides of the fingers and emphasized not to repeat on the same site for days on end.

I took time to show them the alternate area on their arms and demonstrated on mine. Since I have mine set a little deeper than some, it hurt, but I had a good supply of blood. I explained that this site would be between 15 and 20 minutes later than the fingertips and if they were experiencing a low blood glucose episode, this delay could be deadly. One woman said that at home she often did this on her legs and I reminded her that again the readings would be about 20 minutes behind a reading on her fingers. I explained that even though this was called lagging, the reading from alternate test sites were actually about 20 minutes older that one taken from the fingertips now. I asked her what her readings typically were and she came prepared and started giving them to us. I asked her the readings for her fasting blood glucose readings and they were very consistent. I then asked why she was avoiding her finders and got a logical response. She did a lot of needlepoint design and embroidery work and did not want to desensitize her fingertips. She stated she was on an oral medication and had never had as reading below 70 mg/dl.

Others were now saying they had no pain in the areas I had shown them and asked how I knew this. I referred them to my blog series number four and the links to Alan Shanley's blog. I also said I would find the other links I had with diagrams that I would send to the doctors for them to forward out. I went back to the woman that had been using areas on her legs and I suggested that she was probably okay where she was testing. She countered that she wanted to try the sides of her fingertips like I had shown as she had tried the tips and pads and did not like the pain. I then showed them that I could lance there and not have pain also as long as I stayed away for the area closest to the nail. I also stated that this would not work for most people. A couple reminded me that was where they always tested and did not like the pain.

We discussed when to test and how often to test. I asked how many test strips their insurance would reimburse and the answer was two per day. I suggested that they analyze the day and when they were having the most trouble, the highest readings, and adjust to them if they were satisfied with their fasting blood glucose readings. We talked about not jumping around on times but selecting times before or after a meal and doing this for a month. I emphasized the importance of looking for trends and if the readings were creeping up for the times selected, they needed to discuss this with their doctor. If the readings were consistent for a month then the following month select another time to test. Also covered was what to do during an illness and this encouraged more questions.

We then had two questions about medical alert jewelry. Why was it important and is there a real need. I answered yes to both questions and started to explain why it is important. At this point both doctors returned and the eight patients were all together. I repeated the two questions. Both said continue and I explained that if for no other reason, in an emergency situation, most emergency responders would look for a medical alert bracelet, a necklace, or a tattoo in a conspicuous place. With diabetes, if they need to start an IV of fluids, most would contain dextrose and this would normally be continued in the emergency room. This could raise your blood glucose to unacceptable levels. If one of the responders found your medical ID, they would know then that they would then need to monitor your blood glucose levels and administered insulin once your blood glucose was above a certain number. Or, if you had hypoglycemia, they would know that dextrose would be needed in a more concentrated level.

At this point, the husband of the two doctors, asked to have the floor. He stated that in some areas, first responders now have glucose solutions to add to the IV in cases of hypoglycemia. Without the medical alert jewelry, the first responders do not have a clue that a person is diabetic and may need special treatment. At that point the eldest patient held up is arm to show his medical alert bracelet and stated that about six months after diagnosis, this had saved his life when he passed out from over extending his exercise and he had a low he was not aware of. A passer by had discovered him and called 911 and reported that he was wearing a medical ID bracelet that said he was a person with diabetes. When the first responders arrived, they tested his blood glucose and immediately attached a glucose bag to the IV and adjusted the rate per the doctor's instructions. When he came to in the hospital (he had been admitted), he asked what his blood glucose was reading. He was told it was being held at 180 mg/dl. He asked to have the level brought to 120 mg/dl and was refused.

He said he then asked to talk with his doctor and was refused, but another doctor did come in and told him hospital policy was to maintain at 180 mg/dl. Since he was not sure what to do, he thought he would see of he could get up. Then he found that he was strapped down by his feet. He said at that point he was angry and insisted upon being released. That brought on the wrist straps and now he knew he was in trouble.

He now asserted that he was dismissing himself from the hospital against advice of doctor's orders, and expected to be allowed to leave, but was ignored. When the staff had left his room he was able to convince his roommate to dial 911 and get the police there. He was dismissed and one of the police officers did drive him home. He immediately tested this blood glucose and found it at almost 300. To shorten his story, he said he settled for no bill from the hospital, attorney costs, and an apology for their treatment. I asked about the ambulance cost and he said his insurance paid for that. The doctors asked how long it took him to get his blood glucose level down and he said he had gone to his doctor then and had it down within four hours with insulin and then a glucose tablet.

The doctors asked to call a halt to things for that day. I could hear a few groans. The doctors both asked if I would be available for email questions and I said as long as they did not expect an immediate answer, and I could copy them with my answer. Everyone agreed and the computers were shut off.

I had fun even with some pretty direct questions and the finger pricking discussion got the most interest. This is one facet of telemedicine I had never expected to become part of, but it was enjoyable. I have received several emails with thanks for the areas that had interested them and quite a few questions which now I will need to do some research to answer. From a few questions, I see that I need to develop a paragraph that will explain that it is not in my agreement or authority as a volunteer peer mentor to provide recommendations about medications, that only the doctors can do this. If there are several issues to a question like I had on statins, I can present articles from both sides of the issue for them to read, and a recommendation to make this a question for discussion at the next appointment.

Telemedicine – the Beauty and the Beast

There are several good definitions of telemedicine and I will cite the one from the American Telemedicine Association, which reads as follows, “Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth.

Telemedicine is not a separate medical specialty. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services.

Telemedicine encompasses different types of programs and services provided for the patient. Each component involves different providers and consumers.”

This is broader in scope than I had envisioned, but in many ways more inclusive than I would have defined telemedicine. And yes, telemedicine has a national association. It needs one for all the issues that telemedicine encounters when crossing state and international boundaries.  

The beast is the many state medical associations and groups that have succeeded in putting limits on telemedicine by lobbying state legislatures. They are attempting to restrict it even further. At present, over 30 states have laws requiring that doctors have a physical examination requirement (PER) before any prescription is issued. These have become so restrictive that some patients are dying because they cannot obtain access to doctors. Fortunately, in some of these states, universities are stepping forward and establishing telemedicine programs utilizing nurses, nurse practitioners, and physician assistants that travel to rural areas and do the physical examinations for the doctors and communicate via video conferencing.

This study by the University of Tennessee while small, shows what can be accomplished and bring in the primary care physicians of the patients at the same time. For those wanting to check if a university in their state has a telemedicine operation, you will need to use your search engine and type in something like “telemedicine by universities”. There may be a list, but I have not located it. It is unfortunate that more universities with medical programs are not doing more to promote telemedicine.

Telemedicine is fraught with legal landmines and areas where the law has not kept pace with technology. Some medical practices such as psychology is pushing the envelope in hopes that they will be an influence to prevent state and federal lawmakers from passing laws that further restrict good medical practices. Read this article about some of the activities of the American Psychological  Association.

Even patients are wanting to be able to use telemedicine when traveling outside their home state or across international borders. However, most states currently do not allow doctors to practice across state lines unless they are licensed in the state. Reciprocity is a term foreign to the medical profession and state medical associations or chapters of national associations are mounting stiff opposition to this. I think that a patient that lives in Minnesota, for example, and travels to Florida for a few months should have the legal right to stay in contact with their doctor back home in Minnesota for new prescriptions and consultations via telemedicine. Currently this is not legally permissible.

There are patients that obtain extra prescription before traveling, but even some states are working to prevent these prescriptions from being filled in another state. Some pharmacies that are regional or have outlets in many states do fill these prescriptions because they have access to the patient's file and can see the doctor list for the patient and prescriptions previously filled.

For those wanting to do more reading, here is a magazine that is still on the Internet but last copyrighted in 2002, in other words a dead magazine. It does list a few organizations that are still active on the page, bottom center.  There is also a journal for telemedicine here.

Telemedicine Aids Diabetes Management

The American Association of Clinical Endocrinologists 21st Annual Meeting and Clinical Congress in Philadelphia, PA has had some interesting topics coming out of its sessions. While they are not of an official nature until something shows acceptance or is passed through peer review, some topics are interesting just the same. Telemedicine is an acceptable way to deliver care to endocrinology patients in rural areas, according to a study given at the meeting.

Even with many states passing laws requiring patients to be seen by doctors before being issued prescriptions, this still should not stop this proposal from gaining traction. In a conversation with a friend from a northwestern state, he mentioned that a few doctors were considering and doing this, but another group of doctors is opposing them. He commented that this is very amusing for several reasons. Doctors bickering with doctors, but he found that it was the better doctors that were wanting to do this and the doctors losing patients that were in opposition.

I asked if these were endocrinologists and he said they were from a variety of specialties and primary care. He said that a few were already doing this with success and others were hoping this could be a big help for patients that needed to travel long distances in cutting down their travel. He also stated that another doctor had several patients that needed to travel over long distances and did not have computers, so he was consulting with them on the telephone.

I agree that it is time for doctors to take the initiative and this statement is true. "There is an increased prevalence of diabetes in rural compared with urban areas, which is compounded by the problem of a lack of endocrinologists," said Rabia A. Rehman, MD, an endocrinology fellow at the University of Tennessee Health Science Center in Memphis.

The study took place in Tennessee and the telemedicine unit of the University of Tennessee. There were 66 patients from five rural areas that were referred by their primary care providers. The study lasted two and one-half years.

Patients were interviewed and examined using the video conferencing in the telemedicine studio. A nurse was used at the patient site and assisted the physician in assessing the general condition of the patient. The nurse looked for swelling in the legs and did a thyroid exam. Laboratory tests and management strategies were sent to the patients' primary care physicians for follow-up.

The study author stated that, "We think it may be a little costly to set up the equipment up front. However, in the long-run, this will be cost effective, not only for the patients but for overall healthcare," She continued, "This will save patients from traveling long distances, resulting in timely consultation and leading to better control. Improvement of HbA1c will also result in prevention of the multiple morbidities and complications that result from uncontrolled diabetes."

Telemedicine Coming of Age?

This is not about diabetes, but may affect treatment of diabetes in the future. Telemedicine has been around for a few years, but with many of the advances in recent years, there is now cause to feel more confident about its use and the good that it can do to help areas without large medical centers and specifically rural areas.

Telemedicine is finally getting the light it seems to deserve. In three articles appearing on May 3, 2011, advances in telemedicine are moving forward. The Centers for Medicare and Medicaid Services (CMS) has open the door to make it easier for smaller hospitals to take advantage of doctors with specialties they can not afford. Prior to the new rules, they were required to perform medical checks on all doctors they used as if they were employing them.

Now they are required to do this only for doctors not employed by hospitals elsewhere. If the doctor is already on a hospital staff, they are deemed eligible to operate via electronic means in any hospital that needs their services and Medicare and Medicaid will cover the costs when there is a proven need. The full article covering this is here.

The more important one for me is that our veterans will now get the attention they deserve for PTSD (post-traumatic stress disorder). This will allow veterans to avoid long travel times to centers distant from where they live to get the care they need in dealing with PTSD. Previously the veteran was required to travel to major medical centers for the care they needed.

This was not conducive to many veterans because of cost, and for many the fear of traveling and going into places that may be crowded. The studies have shown that costs are less, patients are happier, and the long-term benefits have increased. Not measured is the improvement in the quality of life for the veterans receiving treatment via telemedicine. Read this article here.

The third article is from Florida and also showed improvement in patient care for trauma patients and those needing medical attention immediately. Instead of automatically transporting the patient to the local hospital to have them forward the patient on the the trauma center at a cost of approximately $10,000, telemedicine can determine with the medical personnel on the scene where to send the patient.

This saves time and some monies as if the trip to the trauma center is necessary assistance can be provided en route to the emergency personnel. The center can also assemble the team necessary to treat the patient more effectively upon arrival.

These three articles emphasize the importance and possible cost savings of telemedicine for the advantage of the patients. Expect to hear more about telemedicine during the coming year. Read the last article here.