8- TELEMEDECINE & TELEHEALTH by PHARMAGEEK

As with any healthcare innovation that is disruptive in nature, it takes validation and time, as well as the right catalyst before it gets completely embraced by the global community as a feasible solution. With the ongoing COVID-19 global health emergency, one such innovation that acquired center stage for being highly functional and transformed healthcare delivery in a never-seen-before manner was telemedicine.  

Just last year, telemedicine grew from less than 1% of primary care visits to nearly 43.5% in a mere span of two months (February to April). 

With telemedicine’s current rapid adoption rate and trajectory, it wouldn’t be wrong to say that this state-of-the-art innovation holds the potential to turn the medical industry completely upside-down, redefining the way in which health systems deliver care, operate, and manage costs.

This will further set the foundation for a highly optimized and tailored healthcare experience in the future.

To illustrate the impact telemedicine will make in the future, we have come up with a few predictions backed by robust statistical data. 

1) Telemedicine will Become a Standard Service Offered across all Care Settings

Healthcare leaders across the globe are increasingly realizing telemedicine’s potential. 

One recent survey conducted by the Deloitte Center for Health Solutions in collaboration with the American Telemedicine Association (ATA) found that close to 50% of the total number of healthcare executives interviewed thought at least a quarter of all outpatient care, preventive care, long-term care, and well-being services would move to virtual delivery by 2040.

Not only has telemedicine been the most sought-after health tech innovation of recent times, but waivers from the Centers for Medicare and Medicaid Services (CMS) have made it possible for providers to begin implementing this technology with minimal resources and restrictions in place, resulting in its skyrocketing adoption over the past one year alone. 

While the waivers currently in effect are likely to be withdrawn once the pandemic subsides, elected officials will have good reason to contemplate more lasting regulatory changes given how providers can use telehealth expansion to make care more accessible across specialties. 

This is especially true because telehealth is one solution that has successfully demonstrated its potential on the majority of healthcare fronts - from streamlining primary care visits, to making specialized care more accessible for people with chronic conditions, and furnishing robust data security to patients’ health records and other confidential information. 

Therefore, industry experts are continually urging Congress to address the geographic expansion of telehealth access post-COVID. In case that happens, amendments to current reimbursement policies will soon follow. Once these measures are fully implemented, telemedicine adoption will become accelerated further across all care settings and specialties.

2) Telemedicine will Become an Efficient Option for Preventative Care

Today, chronic disease management continues to be one of the biggest challenges for both healthcare providers and their patients across the country. 

One recent study shows that nearly half of all adults in the US have a chronic disease and almost 33% of the population is living with more than one chronic disease. Just about 7 chronic diseases, namely – cancer, diabetes, heart disease, hypertension, stroke, pulmonary conditions and mental illness – have a total impact on the US economy of close to $1.3 trillion annually.

Telemedicine has emerged as an effective solution on this front. Physicians and specialists can use mobile devices, live audio and video, mHealth apps, and other smart digital tools to monitor a patient’s condition from a distance and at any given point in time. 

For instance, developing a healthcare mobile app that tracks vital signs and keeps a live record of an individual’s exercise, diet and medication regimen would be a great way to boost patient engagement levels and improve patient compliance with medical treatment plans.

Integrating such a healthcare app with telemedicine software would allow physicians access to this vital data when consulting with patients and leverage data-driven decision making to boost the overall health outcomes.

Therefore, it wouldn’t be wrong to say that telemedicine is soon set to become an efficient option for healthcare providers willing to expand their reach and accommodate preventive care delivery within their modules.

3) Patients will Make Medical Choices based on Telemedicine Access 

Telehealth provides patients and health stakeholders with the ability to advance data interoperability (through EHR integration) and carry out personalized interactions in a remote setting. This can allow for high-quality, convenient access to care that can greatly enhance provider-patient communication in the long run.

As per findings of one recent survey conducted by Doctor.com, close to 83% of patients say they are likely to continue using telemedicine after COVID-19 subsides.

Once patients start seeing what telemedicine has to offer and feel the quality of care is equivalent to but more convenient than an in-person office visit, even from the comfort of their own homes; those same patients will no longer be willing to endure long wait times whenever it can be avoided.

Patients who are homebound, or who live in remote locations, or just can’t take time off their busy schedules to go see a provider in person, should be allowed to access care virtually. Smartphone apps, video conferencing, and online management systems have just scratched the surface of what is eventually possible. There remains much more to be explored on the virtual care front.

Telehealth is already reinventing the process of healthcare delivery and transforming patient expectations for all facets of this vital industry.

With patients growing more accustomed to virtual care given the convenience these systems offer, healthcare organizations that lack telemedicine access are bound to observe lower patient volumes as patients prioritize providers that offer telemedicine over those that do not.

Therefore, it wouldn’t be wrong to say that telemedicine adoption will become increasingly important in order to survive and grow your healthcare practice in a post-COVID world.

Telemedicine has emerged as an effective solution in times when no one is truly certain about what the future holds.

The healthcare industry is one of the fastest-growing job sectors in the United States, with an expected growth rate of 14% over the next eight years, adding around 1.9 million new jobs.

Demand for healthcare services is expected to rise in the years ahead as baby boomers age and the number of Americans living with at least one chronic condition grows. Without access to additional providers, patient outcomes could suffer as existing healthcare workers try to keep up with demand.

Healthcare facilities can use the latest virtual care technology to address and prevent these staffing issues.

Telehealth can reduce the amount of time nurses and other care providers need to spend with their patients, so they have more time to complete their rounds. Companies and facilities looking to fill empty positions should learn more about the benefits of telehealth and how it can reduce staffing shortages.

Reducing the Need for Healthcare Services

Telehealth can help facilities reduce the number of patients that require in-person healthcare services. Patients recovering from surgery and those with severe chronic conditions will need to be monitored by a healthcare professional at all hours of the day.

Providers can use digital health apps, instant messaging, and live video and audio to remotely check up on their patients. With 24/7 access to their patients, providers can use this technology to improve health outcomes and prevent possible emergencies down the line.

Instead of having providers physically walk from room to room, they can use remote patient monitoring tools to keep an eye on these patients while they recover in the comfort of their own homes. Providers can quickly monitor the patient’s vitals, send them important reminders, and help them reach their long-term health goals without wasting precious time throughout the day.

This reduces the need for in-person healthcare services by lowering readmission rates and preventing unexpected trips to the emergency room that can easily overwhelm staff members and raise healthcare costs.

Simplifying Clinical Workflows

Care providers can also use telehealth to simplify their daily routines so they can spend more time caring for patients and less time completing redundant steps and manual processes. Providers can easily collect data on their patients using remote patient monitoring, the Internet of Things, and other wireless medical devices. Electronic health records (EHRs) systems and data analytics programs will organize patient data, helping providers quickly make sense of this information.

This reduces the amount of time providers need to spend entering information into the system, generating reports, and making treatment recommendations.

For example, nurses typically spend about 10% of their time educating patients about their diagnoses and treatment recommendations. With digital health tools, nurses can quickly educate their patients efficiently and effectively.

Attracting the Next Generation of Nurses

As demand for healthcare workers continues to grow around the country, many healthcare facilities may find themselves competing for talent in the years to come, particularly in rural areas or those with existing staffing shortages.

Facilities can use the latest telehealth technology to improve staffing workflows and ease the burden on existing staff members, thus reducing staff burnout rates and other on-the-job hazards.

Healthcare providers tend to suffer from high rates of stress, anxiety, depression, and fatigue. Facilities can use digital tools to keep existing staff members satisfied and fulfilled on the job, thus reducing employee turnover rates and recruiting costs.

The next generation of providers will be more likely to accept a job at a healthcare facility if they know they will have access to technology that’s designed to keep them safe and help them do more with less.

Providers may be wary of accepting a new job if it means reverting to manual processes, trying to manage too many patients at once, or working around the clock.

The long-awaited promise of telemedicine may finally be realized as a response to Covid-19.

For decades, advocates hailed telemedicine as the way forward to improve access and reduce cost, while maintaining high-quality care.

There have been steady gains in investment and growth across the country, and an increasing number of studies suggest that for certain services, namely chronic care management and mental health services, telemedicine may be superior to in-person care. Specifically, studies showed better health outcomes through improved medication adherence, integration of medical tests, and reduced hospital readmissions. However, even with these positive steps, it would be a stretch to claim that telemedicine had transformed the US healthcare system and, in large part, that is because of legal barriers that were in place prior to Covid-19.

In the Fall of 2019, my colleague at the University of Arizona James E. Rogers College of Law, Christopher Robertson, and I identified three major legal barriers in federal and state laws that were inhibiting telemedicine utilization.

We reviewed (1) establishment of a healthcare relationship, (2) state licensure laws, and (3) reimbursement. We focused on these areas because of the legal ambiguities or inconsistencies, which varied across the states. Arguably, these variations could hinder telemedicine operators’ ability to leverage resources across state lines for efficient scalability without necessarily improving quality of care. 

Aging Population

We proposed that the

growing aging population would be the driver to achieve greater utilization of telemedicine services largely because of changes with reimbursement under Medicare Advantage (MA).

The Center for Medicare and Medicaid Services (CMS) issued a rule that became effective at the start of 2020, which relaxed geographic and originating site requirements to allow reimbursement for telemedicine services received directly in the home, irrespective of whether the MA beneficiary lives in a rural or urban area.

In addition, many state Medicaid programs, including Arizona’s AHCCCS, reported plans to expand reimbursement, especially around long-term care services and for home healthcare.

We found that older adults, aged 65 or over, represented a large market that was unfamiliar with telemedicine. A 2018 study found 16-times greater telemedicine utilization among adults aged 24-44 and a 2019 survey reported that while half of older adults would be interested in a telemedicine visit, only four percent had one in the last year.

These findings highlight major growth opportunities, particularly given telemedicine’s demonstrated ability to effectively manage chronic conditions, where 80 percent of older adults have at least one chronic condition, and 77 percent have at least two.

We had no idea that COVID-19 would be the watershed event that would bring the long-anticipated discussion of how to expand telemedicine and care for the aging population to the forefront of this pandemic.

Legal Barriers

Our recommendations for a more unified approach to telemedicine regulation incorporates core bioethics principles of doctor-patient relationship, competence, patient autonomy, as well as population-wide questions of resource allocation and access. In the time of Covid-19, many lawmakers have embraced some of these principles and allow greater flexibility.

Specifically, in how a healthcare relationship may be established outside of a “hands on” visit (see e.g., Maryland’s Governor amended an order to allow formation of a provider-patient relationship to include audio-only calls).

In addition, many states relaxed licensure laws and reimbursement under CMS has expanded to include all Medicare beneficiaries (approx. 56 million people). Section 3701 of the CARES Act went even further to encourage telemedicine use by removing cost-sharing exposure under Medicare for any telemedicine services, irrespective if related to COVID-19.

Conclusion

The threat that Covid-19 poses to the elderly population and a resource-strained healthcare system greatly outweighs some of the former legal barriers to telemedicine expansion. The new economies of scale that have now undoubtedly been achieved have the opportunity to bring the telemedicine promise of - greater access, improved health outcomes, and lower costs – and would benefit from using core bioethics principles as a guide in this new era of virtual care. 

Using telehealth technology still requires good bedside manners - just call it your screen side or website manners. So what do providers need to know that is different between an in-person encounter compared to a telehealth encounter? 

The space involved with making that first impression via telehealth is significantly smaller than meeting in-person in a clinical setting.  Besides being two-dimensional, your space is limited to the size and quality of the monitor projecting your image on the other end of the connection. 

You only get one chance to make a first impression – so make it good.

Important factors to consider to help develop and maintain a positive patient-provider relationship:

Prior to encounter – being prepared is always the best practice.

• Equipment – understand how to use and test; know who to contact to troubleshoot; ensure good placement of the camera, microphone, and speakers
• Physical space – clear of distractions; good lighting; private and secure (HIPAA)
• Provider Appearance – professional; solid, non-distracting (preferably light blue) colors
• Preparation – review patient history chart/file

During the encounter – a little extra explanation can go a long way to foster relationships.

• Confirm connection quality (hear/see) and security of space (HIPAA)
• Introduce self (and others), organization/location
• Have patient introduce self and any others in the room
• Explain the process of taking notes, and only briefly looking away from the camera as necessary, otherwise maintain eye contact
• Periodically ask the patient if he/she has any questions or anything to say
• Reiterate any instructions or follow-up procedures for a patient prior to disconnecting

Developing your screen-side manners in today’s telehealth world is just as essential as developing good bedside manners. 

Patients still need to feel they are being heard and understood by their provider whether in-person or via video connection. The tasks that happen during an in-person visit, (e.g., jotting down notes, or looking at an image), are seen directly by the patient.

These same actions may not be as visible via video, and require some explanation to keep the patient engaged. The patient still needs your full attention.

Empathy is no less important in telemedicine. Being prepared, clearly communicating, and focusing on your patient will help foster a positive patient-provider relationship.

 You can still make meaningful eye contact via telehealth, but the trick is looking directly at the actual camera, and not the projected image of the patient on your screen.

Body language can speak louder than words, but telehealth creates a situation where not all body language is actually visible. 

While a thoughtful hand to the chin while thinking maybe commonplace, on video the same action might communicate disinterest. 

Controlling reactionary movements is vital for telehealth. While standing bedside, a simple action like shifting weight from one leg to another has minimal visual impact compared to being on video and then seeming to shift out of the view of the camera.

Similar to developing a good bedside manner, a good screen-side manner takes practice.  Telehealth is unique in that you can record yourself and review the video before ever connecting with a patient.

By examining your recording, you can get a better understanding of the patient’s perspective of the telehealth connection. This process allows you to make adjustments that might not happen otherwise, creating the best patient encounter possible.

You can put the word "smart" in front of just about anything these days — including an entire city. But what does it actually mean?

The concept of smart cities is incredibly exciting. Cities have always been social, cultural and productive centers of society. But the city of the future will help us work and play even smarter, commute more quickly, and make use of more advanced and affordable products and public services. That includes health care.

As the world explores what smart cities are capable of, we're seeing more ways they'll impact the telemedicine industry and vice versa. Let's take a closer look.

A Holistic View of a City's Health 

Conducting a more proactive monitoring of public health is probably the most important part of a smart city's data-driven telemedicine system. Thanks to electronic health records, location technologies, and cheap and rugged remote sensors, public health officials have an easier time than ever studying disease patterns and profiles, tracking public health worries and outbreaks, communicating with the public about new issues and seasonal disease cycles, understanding and making changes to how people move about a city, and much more.

This brings us to one of the best features of smart cities: smart hospitals. A number of facilities across the U.S. are using more advanced devices and data-gathering systems to better understand changes, even in real-time, that concern citizens on a daily basis. These insights can cover any number of factors associated with city living, including air and water quality, the effects of weather and climate on health and even the relative stress and happiness in one city compared with another.

Better Access to Health Care Even in Rural Areas 

It's a long-running pattern, but residents of cities generally enjoy better access to health services and medical specialists. As a result, residents of rural areas, and those who live a little farther from city centers are more likely to suffer from chronic health problems and to have greater restrictions on their physical activities. Cities are known for their smog and pollution, but they offset some of the harm thanks to convenient access to health infrastructure.

Making cities even smarter seems at first glance like it might make health care inequality even worse. But it may actually do the opposite. Cities have more choices than rural areas when it comes to health care, but residents still face wait times and lines, often for issues that didn't require a visit in the first place.

To that end, we can expect that telemedicine will cut down on congestion in cities, plus make it far easier for rural residents to communicate with doctors and specialists with the same ease as rural citizens. With telemedicine and remote video consultations, distance from a metropolitan area is less likely to decide the quality of one's health care or their life.

More Efficient Public Institutions 

In the U.S. and elsewhere, it's a fact of life that countries must feed, clothe and shelter prison inmates and residents of correctional facilities. This portion of the population is frequently written off or forgotten about, but these are citizens too, and they deserve as quick and competent a response as anybody when they find themselves in poor health. 

Telemedicine can provide a vital function by making it easy for cities to see to inmates' health needs. New York City alone is home to around 55,000 residents of its correctional system, which means the already limited availability of specialist doctors isn't always able to answer the call. Instead, telemedicine makes it simpler for specialists to check in with patients when they can't be there in person while cutting down on the time and expense of transporting these individuals to appointments. 

Walkability and Self-Service Health Care 

Futuristic cities have long been depicted with swarms of flying cars, but that dream is still a little way off. In the meantime, we're busying ourselves rethinking our urban layouts, including making a push to install bike lanes and generally make our cities more walkable and more amenable to cleaner, healthier living. 

Smart technologies like internet-connected cars, plus city infrastructure that can talk to them, will make it easier than ever for pedestrians and cyclists to navigate intersections safely and quickly. Couple this with the fact that insurance companies increasingly turn to wearables to keep customers honest about -- and committed to -- healthy lifestyles. These wearables lend themselves to telehealth in a number of ways, from making remote data sharing simple, to automatically alerting emergency responders, for example, if an elderly resident falls in his or her apartment, or in a park, and can't signal for help themselves.

The truth is, we're only beginning to appreciate what's possible with telemedicine and smart cities. As more medical device manufacturers move into making devices for a connected world, while still maintaining the quality set in place by ISO 13485, it’s easy to see how the relationship between telemedicine and smart cities is just starting. 

The potential here is part of the reason why we will collectively activate some 36 billion internet-connected devices by the year 2021.  

By that time, we'll have even more robust industrial standards for helping public and private data systems work better together, and we'll have an even more thorough understanding of how the advancement of technology can improve how we live and how we pursue health care services. 

For medical students with the University of Arizona College of Medicine – Tucson, weeks of suspense will end on March 15. Otherwise known as Match Day, it’s the day the students will learn where they will go for their residency training, in their chosen medical field, after they graduate from medical school in May.

Sarah Joy Ring, who has completed the College of Medicine – Tucson’s Rural Health Professions Program and a 16-week Rural Health Distinction Track, is hoping for a residency focused on both pediatrics and emergency medicine, potentially in a rural location.  Her “capstone” paper, an in-depth research project that all Distinction Track students are expected to complete, carries the impressive title of “A Survey of Rural Emergency Medicine and the Discrepancy of Care for Pediatric Patients that Present to Rural Emergency Departments.”

During her training, she had opportunities to see how important telemedicine can be in rural communities.

“I was at sites that had telemedicine capabilities and spent some time chatting with the physicians about them. "I can specifically remember two experiences, one while on my family medicine rotation in Tuba City (in northern Arizona, where students learn about American Indian healthcare) and one during my RHPP summer in Flagstaff” (also in northern Arizona).

“Tuba City experiences a significant shortage of mental health providers in general, and specifically for children and adolescents," Sarah says.

“As such, they found using telemedicine helpful to connect the children of that region with services that they would otherwise struggle to receive, due to having to travel large distances to receive help, which incurs financial and time burdens for families.

“Moreover, a point that I found particularly enlightening when learning about this service, was with regard to what it means to live in a small population where it is quite likely you know most people living in the region," Sarah says.

“The physicians found that because of this, many adolescents experiencing difficulties often felt uncomfortable sharing with people who lived in the region, out of fear that they may tell someone, or that they were themselves a relative or family friend, which can be a common experience. Having someone to share with who lived out of the region and was not specifically invested in the region and an integral member of the community made many of these adolescents more comfortable with disclosing their experiences.  

“I also worked on writing about how telemedicine can be used to augment pediatric services in rural emergency departments for part of my "capstone" project and found some very positive results from multiple studies. For critically ill patients, one study found that in particular, telemedicine consults improved the access to critical care specialists, resulting in a reduced frequency of physician-related medication errors. Moreover, another study found that parent satisfaction was higher with telemedicine consults than with phone consults, which is a particularly important outcome when caring for pediatric patients and their family. Many of these same findings also translated to the pre-hospital environment, where ambulances that utilized telemedicine resulted in better assessments, more interventions in the pre-hospital environment, and improved outcomes for pediatric patients in pre-hospital care. 

“Overall," Sarah says, I think that we will continue to find that telemedicine is an excellent resource for rural providers that allows patients to have clinically significant access to additional resources and care that would otherwise be difficult or unavailable to the region."

In developed countries like the United States, stroke is still the third leading cause of death. In fact, each year stroke occurs in more than 700,000 patients, leaving many with disabilities and unable to resume a normal life.

When a stroke occurs, every second counts. The sooner a stroke victim is treated with medication that breaks up blood clots and restores blood flow to the brain, the less chance the patient will suffer permanent damage such as the loss of muscle control, mobility, or the ability to speak.

According to the American Stroke Association, ‘time lost is brain lost.’ That’s because every minute that passes before a stroke patient is treated, means the death of millions of brain cells.

Unfortunately, less than 30% of stroke victims receive clot-dissolving medication inside a recommended window of an hour or less for maximum effectiveness, according to information from Healthcare delivery network Kaiser Permanente.

But the same study reveals how telemedicine – or a telestroke system to be precise – can be a vital tool in getting stroke victims faster treatment – and thereby limiting the debilitating effects of the attack.

A Race Against Time

Basically, a telestroke system requires a neurologist and attending nurse to have a high-speed Internet connection and videoconferencing capabilities on a laptop, tablet or desktop computer.  The purpose is for the consulting neurologist to be able to talk to the patient or an emergency response team about what symptoms the patient is experiencing, evaluating the patient’s motor skills, viewing a computed tomography (CT) scan, making a diagnosis and prescribing treatment.

Data gathered from 300 stroke patients being treated in 21 Kaiser emergency rooms in Northern California shows that those who were diagnosed as having a stroke via a telehealth consultation received clot-busting medication intravenously much faster than the 60-minute guidelines from the American Heart Association and American Stroke Association.

The Kaiser emergency rooms were equipped with telestroke carts, which included a video camera and access to patients’ electronic scans and test results. When emergency room staff contacted a staff neurologist and a radiologist via a telestroke cart, patients received anti-blood clot medicine in an average of 34 minutes. Eighty-seven percent of stroke patients received the intravenous medication in 60 minutes or less, 73% in 45 minutes or sooner and 41% in 30 minutes or less.

A Clear Priority

According to the American Stroke Association, American Heart Association, and the American Telemedicine Association, telestroke services could save thousands of lives each year and cut costs by $1.2 billion over the next decade.

The reason is because processes that used to happen sequentially during a stroke alert are now happening at the same time. That allows medical staff to provide evaluation and treatment to stroke patients more quickly, safely, and confidently, to avoid further brain damage.

The addition of specialized stroke services helps hospitals improve patient outcomes, decrease patient disability related to stroke, and reduce costs, while keeping patients in the community. Providing expert stroke consults remotely via telemedicine allows prompt care close to home for these patients, making a priority for health care providers nationwide.

If you are interested in bridging the gap of care for patients in need, whether they be in remote areas or unable to leave home, telemedicine can help provide quality care to more people in need. Contact TeleMed2U today, at (855) 446-TM2U (8628).

In 2005, Tift Regional Health System began exploring telemedicine as a way to connect its physicians and specialists with patients in the rural area surrounding its Tifton, Georgia, home base.

At that time, telehealth technology largely consisted of a hub-and-spoke network, based out of large tertiary care centers or academic medical centers.

"We understood [telehealth] was the future and we needed to be a part of this technology that could get our patients to the specialists that they needed to see 200 or more miles away," said Jeff Robbins, MD, director of telehealth and neurodiagnostics at Tift Regional Medical Center.

The virtual visits idea was starting to be discussed in rural parts of the country. The Internet was slow, but the tech was getting close to making distant encounters possible.

"In the early days, every encounter was basically a telehealth network within itself," Robbins said. "The technology only allowed us to connect to one endpoint at a time. The technology didn't allow us to network to a new endpoint or customer without a lot of IT involvement. Internet was slow and the devices used to conduct a patient-to-provider encounter were primitive compared to what we have today."

These issues prevented Tift Regional from achieving the outcomes it knew were possible but staff understood, given its track record at other hospitals, that telehealth could play a very important part in delivering healthcare in the near future.

Tift at that point partnered with the Global Partnership for Telehealth, a nonprofit with a 12-year track record in developing and implementing sustainable, cost-effective telehealth programs.

The Global Partnership for Telehealth markets telehealth systems to hospitals and other medical facilities in 11 states. There are a variety of telemedicine technology vendors with varied offerings on the market. These include American Well, Avizia, Cisco Systems, HealthTap, InTouch Health, MDLive, SnapMD, TeleHealth Services and Tellus -- many of those are in the Healthcare IT News Buyers Guide: Comparing 11 top telehealth platforms.

GPT's network of caregivers and its technology gave Tift Regional the ability to connect to nursing homes, school clinics, emergency rooms, stroke teams, specialized wound care teams and advanced critical care teams hundreds of miles away from its rural location in South Georgia.

"I like to say the miracle of telehealth is that it gives us the ability to erase time and distance," Robbins said. "Our patients benefit with virtually no travel time or expenses, decreased time waiting for an appointment, reduced medical costs, and extra value to the patient encounter and extended access to consultations with specialists not offered in their area and usually hundreds of miles away."

The partnership with GPT also allows Tift Regional's employed physicians to increase revenue because they can see patients outside their area, reducing missed appointments, and giving them the tools to treat more patients over time and have better patient follow-ups that improve outcomes, which also cuts down on readmissions, he added.

Telehealth carts generally include a monitor, camera, keyboard and remote control. Peripherals give physicians the ability to monitor vital signs, use a digital stethoscope, and use high-definition cameras for specific types of care such as dermatology or wound care.

Telehealth has become a critical component in Tift Regional's ability to deliver quality healthcare, and the healthcare organization has seen success in using the technology.

"Telehealth has increased access to healthcare within our organization by making it easier for our patients to obtain clinical services," Robbins said. "It also allows our hospital to provide emergency services that we cannot always provide like advanced/emergency stroke care. We have also seen an increase in improved health outcomes."

Telehealth allows Tift Regional to get its patients seen, diagnosed and treated earlier. This leads to improved outcomes and less costly treatments, Robbins explained.

"Telehealth has allowed us to have advanced ICU support and that has reduced mortality rates, reduced complications and subsequent hospital stays," he added. "We are seeing a reduction in healthcare costs through home monitoring, which is lowering costly hospital visits. Our stroke program is reducing the high cost of transferring stroke and other emergencies."

And Tift Regional has used telehealth to address the shortage in healthcare providers by allowing its patient population to see specialists outside Tift's area, also enabling Tift's own specialists to serve more patients, he said.

Before telemedicine, a virtual encounter meant both the presenter and the provider had to switch between many different programs. This presented issues when programs failed and data didn't link up correctly.

"The provider can now see who is waiting to be seen in the virtual waiting room, and data entry has been streamlined to allow patient data and notes to be uploaded into our existing EHR," Robbins said. "And maybe the best improvement is the ability to switch programs, going from Pathways to the stethoscope then the cameras within the same encounter."

Flash back to the brink of the Patient Protection and Affordable Care Act. On the cusp of the passage of the ACA, more than 41 million Americans were uninsured or underinsured, driving one of the largest health care overhauls in history. While controlling costs was an important consideration, the main focus of the ACA was expanding coverage. To increase accessibility to affordable health insurance options, the law employs a mixture of mandates, subsidies, tax credits, and penalties to increase coverage of the uninsured, spur health care innovation, and provide for new payment models to reward quality of care and improved health care outcomes.

More than five years into the ACA era, the White House touts that the number of people without health insurance continues to decline and has dropped by 15.8 million since 2013. Of the roughly 11 million people who enrolled in state or federal Marketplaces in 2015, about 4.2 million were auto-renewals or renewals, indicating that roughly half of all 2015 enrollees kept their 2014 Marketplace insurance plan.

The rurally ignored

Despite the widely publicized successes of the ACA, many rural Americans were forgotten by health care reform. Although the ACA proclaimed a renewed focus on rural America, little was accomplished for rural populations outside of Medicaid expansion. A policy brief published by the National Advisory Committee on Rural Health and Human Services stressed the importance of coverage in rural areas, where the population is disproportionately older, more chronically ill, lower in income, and less insured compared to urban areas.

Where are the rural communities? "Rural" encompasses all populations, housing, and territories not included in an urban area; essentially, it is defined by what it is not. In 2010, the U.S. Census estimated that 59.5 million people – 19.3 percent of the population – lived in rural areas.

Rural residents tend to be poorer, earning a per capita average income of $19,000, which is nearly $7,000 less than what their urban counterparts earn. Although rural Americans account for only 22 percent of the population, rural residents account for 31 percent of the nation's food stamp beneficiaries. Only 64 percent of rural residents are covered by private insurance, and the rural poor are less likely to be covered by Medicaid benefits than their urban counterparts (45 percent versus 49 percent, respectively). Compounding the issue of obtaining affordable coverage, rural areas rarely have access to the same types of coverage. According to the National Rural Health Association, only about 10 percent of physicians practice in rural America, even though nearly 25 percent of the population lives in rural areas. There are only 401 specialists per 100,000 people, compared to 910 in urban areas.

"Rural Americans face a unique combination of factors that create disparities in health care not found in urban areas. Economic factors, cultural and social differences, educational shortcomings, lack of recognition by legislators, and the sheer isolation of living in remote rural areas all conspire to impede rural Americans in their struggle to lead a normal, healthy life."

Perpetuated by the inability to find and afford care, rural populations face higher incidences of chronic disease. Obesity, diabetes, heart disease, and alcohol and substance abuse are all chronic conditions that disproportionately affect rural populations.

Turns out, chronic disease is costly

In the U.S., chronic diseases and the health risk behaviors that cause them account for highest health care costs. In fact, 86 percent of all health care spending in 2010 was for people with one or more chronic medical conditions. The total estimated cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity. Medical costs linked to obesity were estimated to be $147 billion in 2008. Annual medical costs for people who are obese were $1,429 higher than those for people of normal weight in 2006. Of the top 10 states with the highest rural populations, half fell on the list of the states with the highest rates of adult obesity and diagnosed diabetes

So what is the government doing? Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services recently awarded $2.7 million to improve rural health, however, those grants will support 3-year pilot programs designed to train health professionals and expand health insurance coverage in rural areas, rather than impact rural health directly. Essentially, the 20 recipients of the grants (ranging from $75,000 to $200,000) are community colleges, hospitals, health education centers, individual counties, and other various providers, which are to use the money for formal training programs for health professional students. To put it in perspective, HRSA responded to the outcry by millions of rural Americans by awarding grants equal to the price of 17-year-old Kylie Jenner's first home, after spending hundreds of millions of dollars implementing the ACA and federal and state Marketplaces.

Is telemedicine the perfect solution? Maybe

Although the ACA does not specifically link telemedicine to rural populations, "telehealth" or "telemedicine," which is using telecommunication and information technologies to provide clinical health care at a distance, is a critical component of transitioning to value-based treatments, and to better serving rural communities and chronic conditions.

For rural populations, telemedicine has the potential to increase accessibility to providers and specialists who can remotely monitor and treat chronic disease, without the hassle or costs associated with traveling. In many states, telemedicine services are covered by insurance to the same extent as in-person services. It helps eliminate distance barriers to medical services that would often not be consistently available in distant rural communities.

Although it seems like a catch-all, it is important to note that telemedicine is not a replacement for an annual, in-person physical; it is used most effectively to manage chronic condition and preventive health care costs. Even the best physicians in the world cannot take the blood pressure of a patient or press on the abdomen of a sick patient remotely. While certainly this represents a drawback, it also presents an opportunity. The rules governing the practice of medicine do not need to be the same rules that govern the practice of telemedicine. By linking patients with doctors either via telephone or video chat, barriers of distance can be eliminated, which proves crucial for rural areas.

Telemedicine snapshot: Mississippi

To address the prevalence of chronic conditions, Mississippi became the 16th state to pass advanced telemedicine provisions. In 2014, the American Telemedicine Association (ATA) graded existing state telemedicine programs based on reimbursement and physician practice standards, rating Mississippi with the highest possible composite score. Evidence of a collaborative landscape accommodating telemedicine, Mississippi requires telemedicine services to be a 'real-time' consultation, which does not include the use of audio-only telephone, email, or fax. Additionally, the Mississippi legislature also required that telemedicine services are covered to the same extent as in-person services, although a health plan may limit the number of telemedicine providers to a local network.

With the highest prevalence of adult obesity and diabetes in the country, Mississippi prioritized remote patient monitoring services to coordinate primary, acute, behavioral, and long-term social service needs for high-need, high-cost patients. For telemedicine services to be reimbursed, patients must be eligible for remote patient monitoring and specific patient criteria must be met. For example, qualifying patients for remote patient monitoring must be recommended by their physician, be diagnosed in the last 18 months with a chronic condition like diabetes or heart disease, and have a history of costly services because of that condition.

Initial barriers to telemedicine implementation

Although Mississippi has faced relatively little resistance incorporating these laws, many states still need to consider a number of issues or barriers when developing telemedicine programs and policy.

1. Requiring coverage for telemedicine under private insurance, state employee health plans, and public assistance

Reimbursement continues to be a barrier to telemedicine adoption in some states. Medicare, which typically sets reimbursement standards, reimburses for telehealth services with relatively stringent requirements. Medicare pays for telemedicine services only when patients live in Health Professional Shortage Areas (HPSAs) and those who engage in "face-to-face" interactive video consultation services and some store-and-forward applications (e.g., teleradiology, remote electrocardiogram applications). As stated in a report by the American Hospital Association, "Without adequate reimbursement and revenue streams, providers may face obstacles in investing in these technologies."

Plan administrators and providers need to work together to discuss telemedicine benefits and determine coverage options and reimbursement policies, similar to the Mississippi State Legislature passing a bill requiring private insurance to pay for telemedicine services at the same rate as it does for in-person care. States considering telemedicine will have to wrestle with similar decisions about what to cover (e.g., video consultations, asynchronous store-and-forward platforms, patient monitoring) and review technology guidelines that determine reimbursement eligibility to ensure maximum reimbursement. To put it simply, if providers are not getting paid, they cannot provide.

2. Patient consent and education

Consent is a vital component of health care and is more complicated with a telemedicine platform. States must consider requirements for how to approach and obtain patient consent. The risk of consent-based claims for providers is a concern, and malpractice laws are currently geared toward face-to-face interactions; if consent-based claims become rampant, the willingness of providers to administer health care via telemedicine will likely decrease. Nebraska, for example, requires written informed consent, while California and Arizona law permit verbal consent to satisfy the statutory informed consent requirement. Since telehealth is a new and emerging field, patient education is critical to patients' health and providers' ability to practice.

Ideally, patients need to understand details about the expected risks and benefits of telemedicine, available alternatives, and how telemedicine fits into their personal wellness plan.

3. Geographical restrictions on telemedicine services

Although many states are ironing out provisions for health professional licensure requirements, including implementing special telemedicine licenses, border state and consultation exceptions, and interstate reciprocity and endorsements, little research has been done regarding restrictions on limitations for patient location while receiving telehealth services. For instance, can a patient on vacation in another state or country meet with his or her physician for an appointment? If the physician prescribes medication, can the patient fill his or her prescription outside of state lines?

Consideration needs to be placed on not just where the provider is operating from but also where the patient is located at the time of treatment and how treatment is administered.

4. Establishing the provider-patient relationship

Trust is an essential factor in a provider-patient relationship. It has been historically built during face-to-face interactions. States need to consider whether an in-person examination component is necessary or telemedicine can be used instead of an initial in-person patient evaluation.

The face of health care is changing, but prioritizing relationships is at the core of what creates value and better outcomes in health care. When implementing telemedicine programs, it is essential to consider the health of the patient first and design an interaction model that will create the most effective patient-provider relationship.

Overwhelmed? Here's what we know, and where we're going. We know that there are a significant number of rural Americans in the U.S. who have a difficult time accessing and affording health care. We know that many of these Americans are the ones who really need it, given their higher incidence of chronic disease. We know that chronic disease costs a lot and that most rural Americans cannot afford to treat it conventionally. We know that on its face, telemedicine may be one solution to solving the problem of rural health care.

A continued focus on this population of Americans and a renewed sense of urgency will allow for thoughtful state legislation and progressive development. Using Mississippi as a model of telemedicine implementation that is more thorough than many of its counterparts, other states can review their successes and challenges, with specific focus on the issues identified in this piece. For instance, considering where a patient must be located to receive care from providers, as well where they are legally able to fill a prescription from that provider are critical considerations for every state developing and amending telemedicine laws. There are a number of stakeholders involved in the telemedicine field. To ensure comprehensive, thoughtful laws and reforms, state legislature should reach out to local health care providers, nonprofit research centers, state insurance and Medicare/Medicaid departments, private insurance companies, state legislators, and patients to evaluate needs and requirements, and implement suitable legislation.

The adoption of telehealth technologies in rural areas can result in significant cost savings for hospitals and their communities due to transportation cost savings, lost wages savings, hospital cost savings and increased revenues for local labs and pharmacies, according to a white paper by the NTCA-The Rural Broadband Association.

In the white paper, titled “Anticipating Economic Returns on Rural Telehealth,” Rick Schadelbauer, manager, economic research and analysis at the organization, outlines the case to be made for increasing adoption of telehealth in rural areas, and throughout the country, by keeping patients using local health care services rather than traveling to bigger, nearby cities for health care services. Schadelbauer noted that within the United States, there is a distinct health disparity between rural and non-rural Americans, primarily as a result of demographics and limited access to health care.

Telehealth and telemedicine, or the remote delivery of health care services and clinical information using telecommunications technology, holds potential to improve the quality, cost and availability of health care in rural areas. However, telemedicine is not viable without access to robust, reliable broadband service, Schadelbauer wrote. “Rural areas currently lag in broadband deployment, but continue to make impressive gains due in large part to the efforts of small telecommunications providers. Wireless applications require wireline infrastructure in order to be viable options,” he wrote.

The white paper examines the rural health care challenges, telehealth adoption and the potential benefit of telehealth technologies, both non-quantifiable and quantifiable. And the white paper drills down into challenges for rural health, such as reimbursement, cost, patient privacy and licensing.

According to the paper, the non-quantifiable benefits of telehealth are numerous: improved access to specialists, speedier treatment, the comfort of remaining close to home, eliminating the need for long-distance transportation, the ability for health care providers to sharpen their skills, and improved patient outcomes.

The white paper also quantifies several categories of quantifiable benefits of telehealth: transportation cost savings (median cost savings: $5,718 per medical facility, annually); lost wages savings ($3,431 per medical facility, annually); hospital cost savings ($20,841 per medical facility, annually); and increased revenues for local labs ($145,109 per medical facility, annually) and pharmacies ($8,558 per medical facility, annually.)

More specifically, hospitals in rural communities could potentially save more than $81,000 a year on employing doctors, and the white paper presented as one example a hospital that reduced its use of a full-time radiologist from five days a week to one. And, at the same time, hospitals could potentially generate revenue from lab work and pharmacy services that would remain local as a result of telemedicine, according to the white paper. For example, the authors estimated that tens of thousands of dollars could generated by local MRIs, CTs and other lab and pharmacy billings.

“The decision to implement telemedicine is unique to each medical facility, and should take into account not only costs but also non-quantifiable benefits and quantifiable benefits accruing to parties other than the medical facility, such as the patient and local labs and pharmacies located in the communities where telemedicine takes place,” the authors wrote.

As potentially significant as the potential benefits to telehealth—both non-quantifiable and quantifiable—may be, , Schadelbauer wrote that “it is critically important to remember that rural telehealth’s role in addressing the significant health problems inherent to rural areas will depends upon the availability of an underlying, future-proof, fiber-based broadband infrastructure. Further investment in, and expansion of, broadband infrastructure is a critical need not only for rural Americans but also our country as a whole.” Further, he noted, “Absent access to such an infrastructure, the benefits of telemedicine will remain merely theoretical.”

The irony of strict regulation is that while it drives up the quality of care, it also drives up costs, making it unreachable for those without health..

If there’s one dialogue that’s been growing louder across the healthcare landscape, it’s the consumerization of healthcare. Market trends are undeniably steering the healthcare experience into a new paradigm where patients are seizing control. Yet this new direction is not always beneficial for patients or providers.

Just as consumer-driven industries like Uber and Netflix offer quick and seamless digital transactions, many patients want greater convenience and speed from care delivery. Many are also seeking more cost-effective options, thanks to climbing medical debt and high-deductible insurance plans. They’re less willing to tolerate care delays and inefficiencies; many will leave a poor online review after a frustrating appointment.

These are all understandable goals and reactions. But as patients climb into the driver’s seat of healthcare, they’re not always given a roadmap to their intended destination. As they navigate their options, some are running up against four dynamics:

1. Dr. Google

In our fast-paced world, many patients don’t want to wait weeks for an appointment or take time off from work to bring their child to the pediatrician.

Instead they take out their smartphone and look up symptoms to get a quick and theoretical diagnosis. Patients can view photographs of lesions, read checklists of cancer symptoms and lurk on forums where people describe surgery experiences – and encourage each other to self-diagnose.

2. Retail Clinics

Retail clinics like CVS and Walgreens have exploded in popularity – and the market is expected to surpass $8 billion USD by 2028. Patients who feel they’re too busy or too peripatetic to maintain a consistent PCP relationship often prefer the extended hours and easy access of these clinics.

3. Cost Avoidance

Patients are paying higher and higher coinsurances, deductibles and copays – and they’re sick of it.

They’re annoyed by a hospital’s inability to give them an accurate procedure cost in advance; many are stuck with “surprise” invoices after checking into a network hospital and receiving care from an out-of-network doctor.

4. Application Chaos

As applications and portals take over the Internet, many healthcare systems have turned a great idea into patient confusion.

Even patients with moderate care needs may find themselves managing an overwhelming collection of healthcare apps for their OB/GYN practice, dentist, dermatologist, PCP, various hospital online payment portals, lab result repositories and data from their wearables.

As providers are scrambling to transition in-person appointments online, they’re seeing the advantages and unexpected benefits of telemedicine. Here are five ways telemedicine is aiding in the fight against COVID-19.

1. Giving patients a virtual option for regular appointments reduces their risk of unnecessary exposure.

Normal health issues don’t stop for a pandemic. Moving appointments to a virtual setting can help doctors provide follow-up care for at-risk patients remotely, ensuring that patients aren’t accidentally exposed to COVID-19.

It also works the other way: patients who are worried they may be infected but don't need to go to the hospital can check in with their doctor through live video, without worrying about exposing others. It also eliminates the possibility of picking up COVID-19 at the hospital if it turns out they weren’t already infected.

2. Through remote appointments, quarantined healthcare providers can still care for patients.

If a healthcare provider is exposed to COVID-19 and must self-quarantine, or is at a higher risk of serious complications from COVID-19, telemedicine can provide them with a way to continue working.

Clinicians can conduct virtual appointments from home and still provide patients with a high level of care, while relieving some of the strain on the care teams on-location at the hospital.

3. Even in the hospital, clinicians can see patients remotely, conserving valuable Personal Protective Equipment (PPE). 

Using telemedicine within the hospital itself can also prevent clinicians from being exposed to COVID-19. By setting doctors up with video-enabled devices, they can conduct examinations without ever entering a potential COVID-19 patient’s room, saving PPE for nurses and other caregivers who come in contact with patients.

4. Telemedicine can help doctors see patients who would otherwise avoid making appointments.

While there are still many obstacles with how much insurance companies will agree to cover for remote appointments, telemedicine may reduce the cost of some appointments.

This could help attract patients who otherwise could not afford a doctor’s visit. Being able to expand into new demographics and provide them with quality care can help doctors better mitigate the spread of COVID-19.

5. Telemedicine appointments allow for new flexibility, discoveries, and creativity in patient care.

While the COVID-19 pandemic has changed our lives in many negative ways, there is a silver lining: it has illuminated the human capacity for creativity, resourcefulness, and discovery in the midst of tough circumstances.

Clinicians who previously assumed that their services could not be adapted to a telemedicine format are discovering that virtual appointments can give them a valuable insight into patients’ home lives, helping them come up with therapy ideas specifically suited to each patient’s home environment.

Sahana Baker-Malone, a pediatric occupational therapist, told The Mercury News: “We’re getting to participate in their normal life as opposed to bringing them into our clinic, where we see kind of constructed sessions.”

Many healthcare providers have been working to define and implement a telehealth strategy over the past several years. In the initiatives I’ve been involved with, this has generally been a slow march through figuring out the legal, reimbursement, compliance, and physician staffing and compensation implications.

With current events, this timeline has obviously accelerated, with IT and clinical staff being tasked with standing up telehealth programs in weeks, if not days, to deal with COVID-19.

Telehealth is a key tool to limit visitors at a time of overcapacity, to reduce the risk of infection spread, and to manage non-Covid-19 care when clinics are closed.

Below I outline some of the key considerations I have seen in my work with telemedicine, and what that might mean in the near term for health systems scrambling to deploy telehealth functionality as soon as possible.

Here focused on synchronous, clinician to home-based patient communication, although launching other forms of telemedicine (clinician to clinician, virtual ICU, etc.) will have similar concerns.

TECHNOLOGY

For both hardware and software, there is limited time to go through assessments and procurement processes.

Given the time-sensitivity, the focus should be on understanding what is available to be deployed immediately. For hardware, that may mean distributing laptops to ensure clinicians have access to camera and microphone-equipped PCs, or even redistributing hardware from training rooms.

For software, this will entail understanding precisely what applications you currently have available, and what the licensing implications would be to scale up to additional users.

If a new application or additional licenses are necessary, it is important to pull in legal and supply chain as soon as possible to ensure an efficient contracting process.

OPERATING MODEL

The technology for telehealth is relatively easy, but getting clinician, compliance, and revenue cycle leadership buy-in is not. I recommend immediately standing up a taskforce with accountability for decision making and defining policies and procedures.

This group should include your IT, EMR, HIM/privacy, compliance, and physician leadership. They will be tasked with determining who is staffing the telehealth service, what the patient consent process is, patient and clinician support, and how documentation will be entered into your EMR.

Since time is of the essence here, pulling this group together for a couple of long work sessions is likely the most expedient route.

TRAINING AND SUPPORT

You will need to be able to quickly and efficiently train your providers, IT help desk, and scheduling and registration staff. Reception and call center staff will need to know the basics to direct patients to online appointments.

Clinicians will need tip sheets on configuring hardware, installing software, and managing appointments and documentation. Help desk staff will need to understand setup and troubleshooting, including working with “non-standard” devices as clinicians work from home.

You will need basic how-tos for your patients, and coordination with your marketing and web teams to publish information and links to your telehealth service.

LONG-TERM PLANNING

The version of telehealth that you roll out overnight is not likely to be the ideal model.

Once your immediate telehealth service is operational at scale, your focus can turn to the longer-term view. This plan should be focused on patient and provider usability, integration with your existing patient portal and digital front door, and seamless interoperability with your EMR.

Scoping out the new interfaces, services, or UI integration will allow you to plan for and allocate your team over the coming weeks. While the immediate need for Covid-19 screening is urgent, telehealth will continue to be very relevant over the coming months to allow non-Covid-19 business as usual for those with chronic conditions or requiring prescription refills.

We’ve seen enormous changes in the healthcare industry in recent years, mostly relating to the more efficient storage and usage of patient data through blockchain technology and the digitisation of patient files.

In the past two decades, the growing penetration of technology in the industry has yielded new medical devices, automated treatments, and improved diagnostic processes, giving doctors, scientists and patients renewed hope for the treatment of diseases some of which, until now, have been largely untreatable.

Blockchain has enabled the seamless global exchange of patient information in real time with reduced transaction costs and fewer administrative delays, enabling much faster, more secure and more efficient exchanges of health records between medical personnel.

But technology isn’t only transforming the way patient information is handled; it is also revolutionising the way patients receive medical care.

Telemedicine -- the use of information technology to remotely diagnose, treat, or continuously monitor patients - has been hailed the ‘next disruptor’ of the healthcare industry.

In other words, the industry has at last recognised that waiting for hours at a doctor's office to ask a simple question or get a prescription can in some cases be so burdensome and frustrating that it can prevent patients from seeking medical help.

About time, too. If every other aspect of our lives has been digitised -- from job hunting, to online dating, to doing the groceries -- why haven’t we yet digitised the process of receiving medical care?

Often, a doctor’s check-up is so simple that all that is required is a quick verbal check of symptoms and a quick glance into the patient’s eyes.

If this could be done remotely through video technology in less than five minutes, it benefits both the physician -- who can in turn help more patients on average -- and the patient, who needn’t risk becoming even more sick by leaving home and sitting in a crowded waiting room with other ill people.

By empowering caregivers to remotely interact with their patients, telemedicine has the power to completely transform health care delivery, by making it far more affordable and available.

In fact, it has already begun to do this: in 2018, over 7 million patients used some sort of a telemedicine service in the U.S., and that number is only expected to rise over the next few years. Over half of America’s hospitals already use some sort of telemedicine, and there are more than 200 telemedicine networks in the US alone. Inevitably, with anticipated growth comes unprecedented industry investment - and the telemedicine industry is no exception.

There have been huge investments in the global telemedicine market in recent years, so much so that it is anticipated to grow from its current $38.3 billion valuation to an impressive $130.5 billion by 2025.

This encompasses value derived not only from the services provided through telemedicine but the devices and platforms that support service delivery. 

As healthcare companies look for ways to reduce costs and improve patient-centered care, more and more providers -- as well as investors -- are choosing to invest in shares in telehealth.

According to recent studies, 56 percent of healthcare executives say they have already integrated telemedicine - and more specifically, software as a service (SaaS) business models - into organisation, while another 24 percent are currently looking to invest in telemedicine solutions.

The remaining 20 percent are just beginning to become familiar with the opportunities presented by telehealth and telemedicine.

One particular platform - Colorado-based CirrusMD, which gives patients access to a board-certified physician in less than a minute on the app or on the web - has seen the largest investment to date in the telemedicine world, with a further US$15 million in funding having just been granted for the expansion of its telemedicine portfolio.

The money was raised through a series B funding round led by Drive Capital, bringing its total venture capital raised to $26 million altogether.

Founded in 2012 by an emergency physician, the platform is available across 50 states and differs from other telemedicine platforms in that members don’t pay upfront to physicians. Instead, it teams up with integrated delivery networks who pay doctors by the hour to deliver services via its platform.

CirrusMD is far from alone in the telemedicine sphere, mind you. It vies for the attention of patients alongside competitors Heal, Pager, Kry, HealthTap, Snap MD, Mfine, Pager, K Health, and Doctor on Demand, the latter of which just pulled in $50 million to continue expansion of its virtual doctor platform.

Maven - the first telemedicine platform made specifically for women - just launched with $2.2 million in seed funding, and Spruce just raised a further $15 million for its new platform which caters to people with dermatology conditions.

With 25 percent of consumers admitting they would willingly switch their primary care provider for one that offers more telehealth services, and with 75 percent of people saying they would be happy to attend a doctor’s appointment remotely, it's extremely likely that the telehealth and telemedicine industry will grow at an exponential rate in the next few years, paving the way for huge opportunities for those willing to invest in the digital infrastructure that supports it.

Telemedicine is one of the most notable advancements making waves in the digital transformation of healthcare. Telemedicine poses wins for healthcare organizations seeking to improve patient access while controlling costs, as well as healthcare consumers looking for more convenient ways to engage with providers.

With 71 percent of providers reporting the use of telehealthand telemedicine tools, it’s clear that the industry is sold on the benefits of virtualized care. Telemedicine market projectionssuggest that the industry will reach roughly $20 billion by 2025.

The patient and provider benefits of telemedicine are manifold—including reduced readmissions through remote patient monitoring, reduced costs via virtual access to specialists, and improved patient engagement—but barriers to adoption still linger. Here are five key challenges giving healthcare executives pause when it comes to telemedicine adoption and recommendations on how to successfully navigate those hurdles.

1) Understanding what comprises telemedicine. Due to varying state and federal definitions, as well as variance between Medicare, Medicaid, and commercial payer guidelines on what constitutes telemedicine, confusion still exists regarding what services will and won’t be reimbursed. Establishing a keen understanding of what virtual services qualify and how those services are reimbursed for each payer is vital. This will lay the foundation for quantifying the potential revenue impact of adoption.

2) Concerns around the cost to implement. Costs associated with telemedicine program adoption can include a myriad of factors, from video conferencing adoption to remote patient monitoring expansion. To mitigate the potential for expense sprawl, executives should identify key, phase-one telemedicine service offerings. Weigh earnings potential against anticipated program implementation and support costs to justify those telemedicine coverage areas.

3) Added data vulnerability. With healthcare security breaches on the rise, executive teams remain cautious of any patient data exposure risk. Many view virtual care delivery as an additional layer of potential threat. As with other IT implementations, thorough security protocols and routine audits should be put in place to guard against the real-time exposure of protected health information (PHI).

4) Potential for fraud and abuse. Telemedicine agreements can be subject to federal kickback laws, particularly in situations involving referrals for additional services. Providers must remain up-to-date on the regulations governing telemedicine services to ensure regulatory compliance and proper eligibility for reimbursement.

5) Patient awareness of and trust in virtual care offerings. Even with the proper broadband and internet resources in place to support patient adoption of telemedicine, providers may encounter patient reluctance to engage virtually. Healthcare organizations must cultivate trust by educating patients on offerings and what they can anticipate during virtual visits. Providers should also address security concerns with patients.

To ensure that engagement in telemedicine is a long-term trend as opposed to a short-term fad, healthcare providers will have to address and overcome these challenges. By implementing a telemedicine strategy that addresses these challenges head-on, providers can overcome barriers and rise to meet growing consumer demand for more convenient provider engagement options. As more healthcare organizations pivot to embrace new digital health platforms, telemedicine adoption, specifically, is quickly emerging as a key differentiator in an increasingly competitive landscape.

Phase One: Using Simulation Labs to Teach Future Telehealth Providers

For 15 years, I was a home hospice nurse who went out on emergency nighttime visits to patients who were experiencing symptoms that terrified their family. The travel distance added to the anxiety and suffering of family and patients. I always thought that just because a family chooses to live in a rural area, they should not have to accept suffering as “the price they have to pay.”

Since then, I have focused on enabling the provision of healthcare services to patients who choose to live in the beauty of a rural environment.  Using telehealth technology to rapidly view, assess and improve a patient’s situation has been foremost in my program of research.

 I know I do not have to describe the explosion of telehealth during the last 15 years to readers of this blog. In my telehealth experience, I have gone from home hospice organizations, thinking that I was suggesting a cold and unfeeling method of providing end-of-life care, to a Global University interest in me sharing my telehealth expertise as an international Fulbright Specialist.  

In December 2018, I was invited to spend 10 days at the Universidad Mayor (UM) in Chile, South America. The purpose of my visit was to investigate the use of simulation to teach telehealth at the university’s science campuses. The UM is a private university with 11 campuses in Santiago and one in Temuco.  Despite the fact that UM was founded in 1988, only 30 years ago, there are currently 20,000 students enrolled in seven academic programs.  It was clear to me that the reason behind the rapid, yet well-planned, expansion is the attention given to providing students with an education for the future, especially in the areas of healthcare.  The Universidad is intentional and does not let time waste! 

Thanks to a combined effort between UM administrators and Arizona Telemedicine Program initiatives, by January 6, 2019, I was in Santiago.  Chile is a very long country, stretching 2,670 miles but only 217 miles at its widest point. The entire country covers almost 300,000 square miles.  Forty-one percent of the population lives in three large cities, resulting in 10 million people living in rural areas.

I visited two campuses – Alameda and Huechuraba – in Santiago, Chile’s capital, during my first five days in the country.  Both campuses have state-of-the-art simulation mannequins for training. At the Alameda Campus, I observed healthcare simulation training for dental surgery and odontology, the scientific study of the structure and diseases of teeth.  At the Huechuraba campus, I observed medical, nursing and obstetric students all learning together, using the simulation mannequin to give birth as the focus for their collaboration.  

My research program examines human factors that improve the use of telehealth. Effective communication is a critical variable. The technology can be of the best quality possible, but if the communication between the sender and the receiver is not effective, the outcome will not be optimal.  With each new technology addition to our healthcare system, we should expect improvement, not merely substitution for existing processes.

Using the “seven Cs” of effective communication: being courteous, clear, correct, complete, concrete, concise, and considerate, contribute to teaching skills when in person.  However, when instructing remotely, due to limitations of other senses -- smell, 360-degree visualization, and touch – verbal attention to “the seven C’s” of effective communication becomes critical.  Simulation is a great way to allow healthcare providers to learn skills without risk to the patient. This exciting collaboration with the forward-thinking Universidad Mayor will utilize existing simulation technology to teach healthcare providers of the future how to communicate effectively.

Telehealth has emerged as a critical tool in providing health care services. [1] The practice covers a broad range of medical technology and services that collectively define the discipline. Telehealth is especially beneficial for patients who live in rural communities and other remote areas where medical professionals use the Internet to gather and share information as well as monitor the health conditions of patients by using peripheral equipment and software such as video conferencing devices, store-and-forward imaging, and streaming media. The following information details important factors that are shaping this burgeoning field.

The Changing Face of Telehealth Law
Today’s competitive health care marketplace has created an environment where patients demand lower costs, higher service quality, and convenient access to services. [2] Telehealth is an innovative and valuable mechanism that provides patients with efficient access to quality services. Lowering costs and removing barriers to service access, are critical components in promoting patient wellness and population health. Convenience and cost-effectiveness are important commodities in the modern health care marketplace, as patients tend to avoid treatment that is difficult to access or too expensive. As a result, telehealth technology is emerging as a preferred choice among patients and providers. Telehealth has also attracted the attention of US legislators. They utilize this tool for improving the competitiveness of American health care services. This is especially important, seeing as health care represents 17 percent of the nation’s gross domestic product (GDP). In fact, the resource has helped to define the role that lawmakers play in ensuring that patients benefit in a competitive health care market.

Reimbursement for Services Delivered by Telehealth
The laws regarding reimbursements change regularly as more service providers incorporate telehealth technology into their practices. Reimbursement procedures can vary by state, practice, insurer, and service. [3] Care providers need to understand several facts, regulations, and laws to navigate Medicare telehealth reimbursements. They must first scrutinize whether the distance between the facility (the originating site) and the patient is far enough to qualify as a distant site. The location must also qualify as a Health Professional Shortage Area (HPSA) per Medicare guidelines. Additionally, the originating site must fall under Medicare’s classification as a legally authorized private practice, hospital, or critical access hospital (CAH). For instance, the Centers for Medicare and Medicaid Services ranks the Harvard Street Neighborhood Health Center as a top facility in need of physician services based on these criteria. Care providers must also use proper insurance coding to be reimbursed for hosting services that use telehealth technologies. For now, collecting reimbursements for telehealth services remains simpler for practitioners who limit the scope to which they apply the technology.

Telehealth or Telemedicine?
The term ‘telehealth’ is gaining popularity among medical professionals, compared to the original term, ‘telemedicine.’ [4] Some medical professionals use the names interchangeably. However, telemedicine is a term that may apply to the application of any technology in the clinical setting, while telehealth more distinctly describes the delivery of services to patients. Telemedicine is a familiar term, but telehealth more appropriately describes the latest trends in using technology to deliver treatments to patients. Depending on the organization, service providers may use a different definitions of telehealth. Although the basic premise remains similar, the context may change according to factors such as organizational objectives, and the needs of the patient population being served. Medical experts do agree on one point; telehealth is an innovative way of engaging patients, and it is highly beneficial for both providers and patients.

The Road Ahead
There are several areas where telehealth medicine could make a significant impact. It could be used as a tool to remotely monitor patients who have recently been discharged. It may also help treat individuals with behavioral health issues who might normally avoid treatment due to its high cost, or to avoid any perceived public stigma. [5] The largest area where technology could advance medicine is in treating the chronically ill. These patients usually require many visits with several specialists who may practice at different and distant originating sites. To move telehealth forward, organizational leaders must present evidence to peers and patients that the technology offers value. In addition, care providers must work to transition patients from using telehealth services only for minor conditions (for headaches, colds, etc.), to accepting the technology as a viable replacement for costly physician office visits. Advocates for telehealth medicine must also develop quality controls, so that this potentially transformational tool can maximize its problem solving capabilities and its service effectiveness. To harness the benefits of telehealth technology, America’s brightest medical professionals (both experienced and up-and-coming) must make a concerted effort to incorporate the tool into their practices and make it a regular service offering. Today’s medical students — as they enter a world where telehealth is becoming more pervasive — can take part in what might be a monumental change in the way health professionals think about medical treatment.

Telehealth is emerging as a critical component of the healthcare crisis solution. Telehealth holds the promise to significantly impact some of the most challenging problems of our current healthcare system: access to care, cost-effective delivery, and distribution of limited providers. Telehealth can change the current paradigm of care and allow for improved access and improved health outcomes in cost-effective ways.

Telehealth increases access to healthcare:

• Remote patients can more easily obtain clinical services.
• Remote hospitals can provide emergency and intensive care services.

Telehealth improves health outcomes:

• Patients diagnosed and treated earlier often have improved outcomes and less costly treatments.
• Patients with Telehealth supported ICU’s have substantially reduced mortality rates, reduced complications, and reduced hospital stays.

Telehealth reduces healthcare costs:

• Home monitoring programs can reduce high cost hospital visits.
• High cost patient transfers for stroke and other emergencies are reduced.

Telehealth assists in addressing shortages and misdistribution of healthcare providers:

• Specialists can serve more patients using Telehealth technologies.
• Nursing shortages can be addressed using Telehealth technologies.

Telehealth supports clinical education programs:

• Rural clinicians can more easily obtain continuing education.
• Rural clinicians can more easily consult with specialists.

Telehealth improves support for patients and families:

• Patients can stay in their local communities and, when hospitalized away from home, can keep in contact with family and friends.
• Many telehealth applications empower patients to play an active role in their healthcare.

Telehealth helps the environment:

• Reducing extended travel to obtain necessary care reduces the related carbon footprint.

Telehealth improves organizational productivity:

• Employees can avoid absences from work when telehealth services are available on site or when employees can remotely participate in consultations about family members.
• These examples illustrate the some improved outcomes and cost savings being achieved by Telehealth and telehealth programs:
• Home monitoring of chronic diseases is reducing hospital visits by as much as 50% by keeping patients stable through daily monitoring.
• The national average for re-admission to hospitals within 30 days following a heart failure episode is 20%. Telehealth monitoring programs have reduced that level to less than 4%.
• Timely provision of treatments that effectively reverse the consequences of a stroke have risen from 15% to 85% due to the availability of telestroke programs.

Telehealth support to Intensive Care Units (often called eICUs) is reducing mortality rates by 15 – 30% and substantially reducing complications and length of stay.

Telehealth retinopathy screening programs support early identification of serious eye disease and reduce the incidence of blindness in diabetic patients.

CMS has unveiled its first-ever Rural Health Strategy in an effort to improve access to healthcare for the estimated 60 million Americans living in rural areas. The plan includes an emphasis on modernizing and advancing telehealth and telemedicine.

The Centers for Medicare & Medicaid Services unveiled the first-ever program this past week, releasing a five-point, eight-page initiative to improve access to care for the estimated 60 million Americans living in rural and underserved communities.

“For the first time, CMS is organizing and focusing our efforts to apply a rural lens to the vision and work of the agency,” CMS Administrator Seema Verma said in a press release. “The Rural Health Strategy supports CMS’s goal of putting patients first. Through its implementation and our continued stakeholder engagement, this strategy will enhance the positive impacts CMS policies have on beneficiaries who live in rural areas.”

One part of the strategy focuses on using connected care technologies to bring healthcare to those residents.

“Telehealth has been identified as a promising solution to meet some of the needs of rural and underserved areas that lack sufficient health care services, including specialty care, and has been shown to improve access to needed care, increase the quality of care, and reduce costs by reducing readmissions and unnecessary emergency department visits,” the plan states. “To promote the use of telehealth, CMS will seek to reduce some of the barriers to telehealth use that stakeholders identified in the listening sessions, such as reimbursement, cross-state licensure issues, and the administrative and financial burden to implement telemedicine.”

In its strategy, CMS says it will look to modernize and expand telehealth and telemedicine programs, particularly through the Next Generation Accountable Care Organization Model, Frontier Community Health Integration Project Demonstration and Bundled Payments for Care Initiative advanced model.

CMS has long come under criticism for its guidelines on reimbursing healthcare providers for telehealth delivered in rural areas, including restrictions on what services can be reimbursed under Medicare, where those services can be delivered, and even how rural areas are defined.

The agency has been the focus of several lobbying efforts to improve telehealth and telemedicine reimbursement, as well as several bills introduced in Congress. But few of those bills have become law, and healthcare providers still see Medicare reimbursement as one of the biggest barriers to pushing sustainable virtual care into rural America.

Last year, The Healthcare Information and Management Systems Society (HIMSS), American Medical Association (AMA), American Medical Informatics Association (AMIA), Center for Connected Health Policy (CCHP) and Personal Connected Health Alliance (PCHA) all called on CMS to go beyond current proposals to amend the Medicare 2018 physician fee schedule and open the doors to more connected care services.

“HIMSS encourages CMS to embrace a reimbursement system that recognizes the unique characteristics of connected health that enhances the care experience for the patient, providers and caregivers,” former HIMSS President and CEO H. Stephen Lieber and Denise W. Hines, chair of the HIMSS North America Board of Directors and CEO of the eHealth Services Group, wrote.

In that letter, HIMSS called on CMS to support:

Collaborative decision-making involving diverse care-teams. “Decisions are no longer just between a doctor and patient,” the organization wrote. “Connected technologies allow for the incorporation of a patient’s family and trusted advisors, as well as other allied health professionals, in the decision-making process.”
Expanded care locations and always-on monitoring. “When patients are always connected, care (the interpretation of data and decision support) can occur at any time and in any place,” HIMSS said.

A reliance on technology, connectivity and devices. “Connected health involves communication systems using a variety of components; these may be managed by the provider, the patient, or other parties in the care team,” HIMSS said.
And “empowerment tools and trackers that enable patients to become active members of the care continuum outside of the hospital setting and promote long-term engagement which, in turn, leads to a healthier population.”

Recognizing the challenges faced by healthcare providers in sustaining and scaling telehealth, the National Quality Forum (NQF) issued its own report last year, in which it proposed to set a national framework for measuring and supporting success in telehealth and telemedicine.

“Telehealth is a vital resource, especially for people in rural areas seeking help from specialists, such as mental health providers,” Marcia Ward, PhD, director of the Rural Telehealth Research Center at the University of Iowa and co-chair of NQF’s Telehealth Committee, said in a release accompanying the 81-page report. “Telehealth is healthcare. It is critically important that we measure the quality of telehealth and identify areas for improvement just as we do for in-person care.”

CMS’ Rural Health Strategy, developed by the CMS Rural Health Council, formed in 2016, and culled from input gained at 14 public hearings, features five objectives:

• Apply a rural lens to CMS programs and policies;
• Improve access to care through provider engagement and support;
• Advance telehealth and telemedicine;
• Empower patients in rural communities to make decisions about their healthcare; and
• Leverage partnerships to achieve the goals of the strategy.
  The effort was met with words of support from several organizations.

“(The) AHA is pleased CMS put forward thoughtful recommendations to address the unique challenges of providing care to patients in rural communities,” Joanna Hiatt Kim, the American Hospital Association’s vice president of payment and policy, said in a release. “We look forward to working with CMS and Congress to take meaningful action to stabilize access in rural communities, such as creating new alternative payment models, expanding coverage of telemedicine and access to broadband and reducing regulatory burden.”

In a modern twist on bedside manner, doctors are learning to communicate empathy even when their patients are hundreds of miles away.