By Calvin Bruce
Jackson & Coker
An Historical Overview
Telemedicine has come a long way from its inception in the 1960s, when NASA first put astronauts in space and “telemetered” their physiological responses from their space craft and space suits. Later on, NASA and a private scientific research group engaged in experiments “to determine the minimal television system requirements for accurate telediagnosis.” The result was production of a high-quality videotape made showing a nurse conducting a medical exam while being supervised by a physician observing on closed-circuit TV. 
Several decades later, the application of telemedicine was refined as part of disaster response and emergency preparedness during the mid-1980’s and beyond. The incidences of natural disasters such as massive earthquakes and -since 9/11-the threat of nuclear and chemical hazards and bioterrorist events makes it all the more important to be able to manage treatment of patients who might be remotely isolated from caregivers.in traditional medical settings. 
Since the new milleniium, telemedicine has become a commonplace occurrence in a wide variety of settings: hospitals and clinics, medical laboratories, doctors’ offices, nursing homes and assisted-living facilities, as well as correctional institutions. In terms of geographical outreach, telemedicine services extend into rural areas across the United States, to peacekeeping missions in distant lands, oil rigs in the Gulf of Mexico, and other healthcare stations around the globe.
The website http://www.telemedicine.com/ includes a directory of telemedicine vendors and provider organizations currently operating in all continents around the globe.
Technology and Applications
Broadly defined, “telemedicine” refers to such patient caregiving methods as virtual office visits and virtual rounding. It also refers to the interplay of various information technologies and clinical applications that capture medically significant data, diagnoses, and consults and transmit them from one location to another. The process typically involves web-based reporting via secure Internet connections, in-house case tracking, and often with a 24-hour help desk for end-users.
The panoply of technologies utilized in telemedicine includes standard telephone connections, facsimile, personal computer, modem, webcam such as Skype, still images, video (and video-conferencing), robotics, virtual reality interfaces, satellite transmission, and smart phones.
Smartphones, in particular, have been cited as facilitating and enhancing patient care, including triage and medical specialty consults. As noted in a professional journal for surgeons: “Smartphones provide fast and clear access to electronically mailed digital images and allows the oral/maxillofacial surgeon free mobility, not restricted by the constraints of a desktop computer.” 
Most telemedicine applications occur in real time, enabling healthcare providers in one location to observe patients and test results in another location, and subsequently render a clinical judgment or extend medical care irrespective of distance. Asynchronous applications permit medical diagnosis and patient treatment recommendations to be captured at one point in time and transmitted and/or viewed later on.
Thus, a Boston dermatologist can view problematic skin lesions on a patient at a satellite clinic in New Haven. A Nantucket psychiatrist can consult with a troubled patient housed in a Maine correctional setting. And a Vermont-based radiologist can provide “nighthawk” reads for patients x-rayed in Ft. Lauderdale.
Professional Telemedicine Associations
One noteworthy trend in telemedicine is the involvement of more professionals working in some facet of telehealth to align themselves with organizations that promote a shared objective: making their services more accurate, affordable, and compliant with quality standards.
Long gone are the days when telemedicine was practiced by isolated technicians and medical providers pursuing the dream of merging remote patient monitoring with state-of-the-art, computer-driven technology.
Today, many professionals involved in some facet of telemedicine are members of the Association of Telehealth Service Providers (ATSP), headquartered in Portland, Oregon. The group’s mission is to promote improvement of health care through adoption of advanced telecommunications and Internet-based technology to expand telehealth services to a wider, more diversified market.
ATSP also hosts and updates information shared on the Telemedicine Information Exchange (TIE). “The TIE’s mission is to provide an online, unbiased, all-inclusive platform for information on telemedicine and telehealth” for users around the globe. 
Similarly, the American Telemedicine Association (ATA) is an institutional membership organization devoted to advancing the goal of improving telemedicine services to the constituencies its members serve. ATA’s website lists the following New England-based member institutions:
Fletcher Allen Health Care – Burlington, VT
Yale New Haven Hospital – New Haven, CT
Joslin Diabetes Center – Boston, MA. .
As telemedicine becomes more refined, sophisticated and widespread, it is likely that more individuals and organizations (including those based in New England) will align themselves with such associations that set “best practice” benchmarks.
Widespread Usage of Telemedicine
Another notable trend concerns the widespread usage of telemedicine services by various sectors of the health care industry. Combining all of its subspecialty “flavors,” interactive telemedicine is big business. With an estimated annual growth of ten percent, telemedicine services in North America now exceed $500 million. 
Although the prime example of telemedicine is Teleradiology, there are other applications that demonstrate the innovative adoption of telemedicine in patient care and medical education. Here are some notable examples:
- Telemedicine has merged with emergency medicine. An article appearing in the American Hospital Association newsletter mentioned that telemedicine services performed in ambulances is being tested in Maryland. “The first phase of the study examined how mobile telemedicine systems could provide two-way audio and video communication between [a] moving ambulance and a computer in a doctor’s office.”  Without doubt, examining patients en route to the emergency room will definitely help save lives when every second is critical. Heart attack and stroke victims, in particular, are likely to be prime beneficiaries of this telemedicine application.
- “MedTV” refers to a telehealth program sponsored by the University of Texas Medical Branch at Galveston that serves the state’s correctional system. Reputed to be the nation’s largest telemedicine network, the UTMB program covers 31 different medical specialties and involves more than 100 remote sites. Tertiary care is provided to 80 percent of the statewide prison population. That translates into treating 140,000 inmates, mainly housed in rural areas. The video portion of the telemedicine protocol is especially valuable, since doctors viewing patients remotely can detect subtle changes in skin color and texture that warrant closer medical examination. 
- Mental health providers are increasingly using telemedicine in caring for patients with psychiatric or neurological conditions. For instance, recently researchers at the University of California-Davis investigated the benefits of asynchronous tele-psychiatry for remote consultations. The study involved videotaped patient interviews and “store-and-forward” technology that allowed psychiatrists to provide feedback to patients’ primary care doctors more quickly than ordinarily would be the case. 
- Teleneurology advancements include establishment of a “telestroke network” linking neurologists and patients in rural settings who have been diagnosed with various neurological conditions such as stroke, Bell’s palsy and apoplexy. In particular, this German study concluded that immediate diagnosis by point-of-care physicians–along with early-on teleconsulting with other specialists– proved particularly helpful in providing medical care for patients during the initial stages of neurological impairment. Prompt referral of patients to neurological specialists, speech therapists, physical rehab professionals and other caregivers resulted in dramatic improvement of the patients’ medical conditions. 
- The collaboration of providers practicing in a dozen hospitals on five Hawaiian islands is made possible via a video-teleconferencing system. The project has connected doctors to patients of all ages presenting various medical conditions across the Pacific Islands. Referred to as the State of Hawaii Telehealth Access Network (STAN), the telemedicine initiative has also brought together over 13,000 healthcare professionals for continuing medical education courses. 
- Teledermatology is gaining widespread acceptance by patients who are beyond immediate care of a doctor. Forty-two percent of Americans live in areas that are underserved by dermatologists, according to Dr. John Bocachica, chief of dermatology and teledermatology at Alaska Native Medical Center in Anchorage, Alaska, and chair of the American Telemedicine Association’s Teledermatology Special Interest Group. 
He explained that non-dermatologic physicians along with other healthcare providers at the point of care use a “teledermatology platform” that includes a brief patient history and high-resolution images to capture and transmit data to a dermatologist consulting from anywhere around the globe. Interactive telemedicine can include video-conferencing in real-time, or store-and-forward applications (which are more popular) that allow dermatologists to provide consultation following more extensive review of images and related data.
Telemedicine advancements have made their mark on other medical services: surgery, ophthalmology, cardiology, OB/GYN, family medicine, pediatrics, ambulatory care and urology, to name a few. Arguably, telemedicine will demonstrate increasing influence in the practice of medicine, especially as millions more patients are brought into the health system as a result of recently passed health care reform.
As more healthcare institutions adopt telemedicine as an integral part of their service offerings, certain questions and concerns take on added importance. Among them:
Licensure. Licensure requirements for telemedicine practitioners vary from state to state. As a general rule, physicians who provide telemedicine services must be licensed in the state where they provide medical diagnosis and consults as well as in the states or commonwealths where the patients served by telehealth applications reside.
Obviously, it becomes quite problematic for physicians to maintain licensure in all the states covered by their teleconsulting work. Factor in additional costs of taking exams and traveling for interviews with licensing governing boards, and it becomes quite expensive to meet this standard licensing requirement.
It’s an even greater concern when telemedicine providers work in other parts of the world. Clearly, licensing requirements vary from country to country, some being much more stringent than others.
This raises certain questions: Is it possible to adopt international standards for regulating licensure requirements worldwide? If so, what would be the government body to regulate and enforce such quality standards?
Meanwhile, a Google search indicates that there are service organizations that advertise providing assistance for telemedicine professionals who seek multi-state licenses. How reliable their services are is a matter of speculation.
Credentialing. A similar issue relates to credentialing. In May 2010, the Centers for Medicare and Medicaid (CMS) proposed changes in the credentialing and privileging requirements of hospitals and medical facilities that receive Medicare and Medicaid reimbursements.  CMS acknowledged that it is particularly burdensome for smaller hospitals that generally don’t have the credentialing and privileging resources to comply with existing regulations applicable to larger institutions.
A statement issued on June 9, 2010, indicated that CMS has delayed the Joint Commission’s requirement to effectively implement telemedicine standards for general and critical access hospitals until March of 2011.  It remains to be seen what will be the scope of regulations finalized next spring.
Privacy. A host of privacy issues swirls around telemedicine practice. Chief among them are the HIPAA rules and regulations associated with safeguarding patients’ privacy and protected health information. From a technical standpoint, it is critically important to ensure that all the images and data associated with telemedicine operations are secure, encrypted, and backed up electronically. It is equally important to safeguard personnel access to information captured through telemedicine technology and protected by privacy regulations.
Payer reimbursement. The widespread growth and impact of telemedicine on the health care industry is indisputable. One problematic matter concerns reimbursement. A study by Michigan State University examined various facets of the reimbursement issue and raised a number of germane questions: .
- What telemedicine services should be considered billable?
- Is it helpful to compare telemedicine procedures similar to traditional delivery modalities?
- Should there be a difference in what’s considered reimbursable by private versus government payers?
- What’s considered an equitable split between reimbursement to teleconsulting doctors and referring practitioners?
- How helpful are state mandates concerning reimbursement for telemedicine services?
- Should there be standardized “origination facility fees”?
- How expansive should CPT codes be in covering telemedicine reimbursement?
- Is it helpful to think about a “universal private payer reimbursement”?
While raising these sorts of questions, the investigation did not offer definitive recommendations, except to conclude, “Without progress in the area of private payer reimbursement, we cannot expect to see the widespread adoption of telemedicine services in the immediate future.” 
There’s no certainty as to when or how these concerns will be resolved. Meanwhile, there is strong public perception that telemedicine fills a much-needed void in health care delivery to patients without adequate, customary access to medical specialists.
Case in point: The telehealth services provided by the University of Kansas Center for Telemedicine and Telehealth. According to the organization’s website, the program began in 1991 with a single connection to a western Kansas community. Since then, it has established telehealth access to over 100 sites throughout the state, has facilitated thousands of clinical consultations for Kansas residents, and hosted hundreds of events for healthcare professionals, educators, students and the general public. 
Similarly, a multi-faceted telemedicine program at UCLA aims to teach primary care physicians and medical students innovative uses of telehealth initiatives to provide care especially to patients in rural areas.
One particular project involves patients with cardiovascular problems using a “smart scale” for weighing themselves each morning. “The scale automatically transmits this data to UCLA’s internal medicine department, where it is reviewed daily by a nurse, nurse practitioner or other health care worker.”  Evidence of sudden weight gain in patients with heart problems, for example, could indicate dangerous retention of fluid in the heart and lungs-making it necessary for the patient to seek immediate medical attention.
Clearly, the public perceives this type of telehealth service as quite valuable. In fact, a bond initiative passed in 2006 has resulted in an infusion of funding for UCLA’s David Geffen School of Medicine to expand its telemedicine service. A payout of nearly $200 million will be allotted to UC’s five medical campuses to train healthcare providers to practice in clinical settings state-of-the-art telemedicine applications.
It remains to be seen how extensively telemedicine services will be incorporated into health care delivery throughout the United States, especially as the nation moves toward adoption of widespread health care reform. One thing is certain: as hospitals and medical groups adopt more sophisticated telehealth services and applications, the question of who pays for what services will take on added importance.
The perspective of two researchers of telemedicine’s impact on society and the medical community is noteworthy: “If a rational coverage policy is to be developed, policymakers, payers, and legislators must recognize that one size does not fit all. Fine-grained distinctions must be made among different telemedicine applications.” 
Surely the public expects the thorny issues surrounding telemedicine to be resolved as they benefit from the advancements being constantly made to telehealth services.
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http://www.connected-health.org/policy/commercial-payers/external-resources/private-payer-reimbursement-for-telemdicine-services-in-the-us.aspx (link to pdf).
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Calvin Bruce serves as Senior Staff Writer for Jackson & Coker and Managing Editor of the Jackson & Coker Industry Report. He also contributes to Healthcare Review.