Telemedicine: An Introduction
Why Telemedicine is moving the healthcare industry into the digital age.
Telemedicine is set to disrupt the traditional healthcare industry in the same vein as Uber and Lyft in the taxicab industry and Airbnb in the hotel industry. Many see Telemedicine as the savior for an industry stuck in the past while others see Telemedicine as a troublemaker that will create a host of problems for an industry that is already one of the most regulated in the United States. Will telemedicine be the long-awaited cure to the disease of inadequate access to high-quality care or will telemedicine just exacerbate legal, ethical and reimbursement issues in the healthcare industry?
As an introductory* piece, this article will proceed in the following manner: 1) defining ‘telemedicine’ and categories of telemedicine technologies; 2) discussing the telemedicine industry and providing examples of telemedicine services; and 3) an overview of how major governing bodies and states are approaching telemedicine.
* This is Part One of a Four Part Article on Telemedicine. Part One is intended to provide a very general overview of telemedicine for readers with little to no knowledge of telemedicine but should still provide some insight to readers with prior knowledge.
Telemedicine (a.k.a. telehealthcare or telehealth) is very difficult to narrow down to an all encompassing definition because telemedicine can apply to a variety of technologies and electronic information used to provide health care from a provider to a patient. Government agencies, States, and non-governmental organizations all have their own definition of telemedicine encompassing varying degrees of activities and technologies making it extremely tough to pin down exactly what services, activities and technologies should be considered ‘telemedicine.’ Given this fact, I have chosen the Federal Health Resources and Services Administration (HRSA) telemedicine definition, albeit, for telehealth as the presumptive definition because it is one of the few definitions that reflects the first thoughts that conjure up in a person’s mind when they first hear the term ‘telemedicine.’ The HRSA defines telehealth as “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Technologies include video conferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”
The states of Minnesota and Nevada have also statutorily defined telemedicine in their statutes and provides a neat example of which services and technologies are included as telemedicine.
Minnesota Telemedicine definition: Minn. Stat. § 62A.617
Minnesota defines telemedicine as “the delivery of health care services or consultations while the patient is at an originating site and the licensed health care provider is at a distant site. A communication between licensed health care providers that consists solely of a telephone conversation, e-mail, or facsimile transmission does not constitute telemedicine consultations or services. A communication between a licensed health care provider and a patient that consists solely of an e-mail or facsimile transmission does not constitute telemedicine consultations or services. Telemedicine may be provided by means of real-time two-way, interactive audio and visual communications, including the application of secure video conferencing or store-and-forward technology to provide or support health care delivery, which facilitate the assessment, diagnosis, consultation, treatment, education, and care management of a patient’s health care.”
Nevada Telemedicine definition: Nev. Rev. Stat. § 629.515.
Nevada defines telemedicine as “the delivery of services from a provider of health care to a patient at a different location through the use of information and audio-visual communication technology, not including standard telephone, facsimile or electronic mail.”
Comparing the two definitions, we can see they have similar restrictions and tend to encompass the same activities. Both state definitions require that the patient and healthcare provider are at two different sites when services are delivered and exclude general means of communication which are readily available to anyone such as the telephone, e-mail and facsimile transmission and instead only count advanced technology such as video-conferencing, interactive audio and visual communications and store-and forward technology used to deliver health services to the patient as telemedicine. Though when it comes to advanced technology, we see a difference because Nevada does not include store-and-forward technology while Minnesota does include it in their definition. For example, a healthcare provider in Minnesota utilizing store-and-forward technology can claim they provide telemedicine services but a healthcare provider in Nevada using store-and-forward technology could not make that claim. This is a good example of the difficulty of defining telemedicine because there are so many technologies and services that can apply that it is possible to make your definition too narrow and miss out on a major service or advanced technology or too broad and include conventional technologies and services. Beyond defining telemedicine, telemedicine can also be considered to encompass four technological categories.
Organizations vary on the categories of telemedicine technologies, with most deciding on three or four. For the purposes of this article, I conclude there are four categories of telemedicine technologies: 1) store-and-forward telemedicine; 2) remote monitoring; 3) interactive telemedicine services; and 4) mobile health (mHealth). Store-and-forward telemedicine is “the transmittal of medical data (such as medical images and bio signals) to a physician or medical specialist for assessment.” Remote monitoring “enables medical professionals to monitor a patient remotely using various technological devices.” For example, through a device a patient could use themselves such as a glucose monitor. Interactive telemedicine services “provide real-time, face-to-face interaction between patient and provider.” Lastly, mHealth covers the provision of health education, health services and health information through a mobile device. Given that telemedicine’s definition is flexible and it encompasses many different technologies, it should be no surprise that the global telemedicine industry is expected to become one of the most valuable industries in the world.
The global telemedicine industry is expected to become worth more than $30 billion dollars by 2020 with North America accounting for about forty percent of the industry’s growth “based on ‘Global Telemedicine Market — Growth, Trends & Forecasts (2015–2020)’, published by Mordor Intelligence.” Telemedicine services are expected to be used by more than thirty million patients in in 2018. The major drivers for telemedicine growth are increasing healthcare costs, an aging population, people suffering from chronic diseases, rise of the software market and increasing technological innovation. The major constraints to growth in the industry are the high costs of technology, legal and reimbursement concerns, poor telemedicine implementation cases, and the lack of adoption among healthcare providers. This small view into the state of telemedicine industry would be incomplete without briefly discussing “Talkspace” and “Doctor On Demand,” two excellent telemedicine services currently available in the marketplace.
Talkspace allows people to receive therapeutic treatment from a licensed therapist directly through their app or website, no need for patients to go directly to the therapist’s office to get treatment. Doctor On Demand allows a patient to get into contact with a board-certified doctor for a video consultation to get medical concerns assessed or answered and even for writing prescriptions. Doctor On Demand can handle non-emergency medical issues (e.g., flue, acne, cold) and will also allow users to have a video consultation with a psychologist. Doctor On Demand boasts a large variety of doctors (primarily physicians) patients can choose from with a provider base of more than a 1,000 doctors. The growth of the telemedicine industry has not gone unnoticed by the major professional associations in the healthcare industry and the states tasked with regulating the practice of medicine within their borders.
Professional Associations* and States
The American Medical Association (AMA), California Dental Association (CDA) and American Dental Association (ADA) have been proactive on this matter with creating model bills for telemedicine and interstate licensure, telemedicine practice guides, research studies on the efficacy of telemedicine, and informational articles for practitioners.
The AMA is actively engaged in telemedicine because telemedicine has the potential to improve healthcare delivery, patient safety, healthcare coordination, and healthcare quality. The AMA has developed a telemedicine and interstate compact licensure model bill’s showing the AMA strongly believes that the explosion of telemedicine will benefit the profession in the long run, but also the hurdles which come along with the adoption of new technology that blurs the traditional geographical and jurisdictional lines of practice.
The CDA and ADA have both been proactive in understanding telemedicine through real-world data and developing guidelines for telemedicine practice. The CDA has also been prepping for “teledentistry” to become another avenue for dentists to provide dental services to patients, further technological adoption and improve access to oral healthcare for low-income communities after California passed the Virtual Dental Home Grant Program (formerly known as Assembly Bill 648). The ADA has taken note of the success of the Virtual Dental Home program in California and passed teledentistry guidelines (“Resolution 45H-2015, Comprehensive ADA Policy Statement on Teledentistry”) in 2015 discussing the modes and forms of teledentistry and the importance of “patient rights, quality of care, and supervision.”
* Advocacy organizations were not included but please check out the American Telemedicine Association (ATA), an advocacy organization focused on promoting telemedicine. ATA has a variety of great resources on the current landscape of telemedicine and extensive practice guidelines. Additionally, you should check out the American Psychological Association (APA) and the American Psychiatric Association (APA) because they are two of the largest professional associations in the mental health field and both have created telemedicine practice guidelines and conducted telemedicine research.
States are also attempting to tackle telemedicine through legislative and regulatory means to define the scope of telemedicine, reimbursement policies, licensure, and other telemedicine related topics. States have been hard at work on defining the scope of telemedicine with forty-four states introducing 200 telemedicine-related legislation in the 2017 legislative session as of April 2017. State are primarily reimbursing telemedicine through their medicaid program and requiring private insurers to cover telemedicine services. States are working on the goal of creating an effective interstate licensure program with the goal of providing doctors a less arduous and time consuming path to get licensed in another state. Nine states grant special licenses to out-of-state physicians to provide telemedicine services to patients in the state once certain conditions are met and eighteen states have adopted the Federation of State Medical Boards (FSMB) Interstate Medical Licensure Compact with the goal of increasing access to healthcare in rural areas through telemedicine by easing the difficulty of obtaining out-of-state licensure.
Thanks for Reading
Thanks for reading the Part One of this Four Part Series on Telemedicine. Please stick around for Parts Two and Three where I shall be discussing the benefits and concerns of telemedicine.
Here is a quick snapshot on the benefits and concerns which will be discussed in further detail in Parts Two and Three.
The primary benefits of telemedicine are lower healthcare costs, improve access to high quality healthcare, improve patient-provider relationship, eliminate issues of stigma, and encourage healthcare practitioners to incorporate advanced technology into their practice. The primary concerns are whether healthcare providers will be reimbursed for providing telemedicine services, whether healthcare providers will incorpate advanced technology into their practice, legal and ethical concerns including licensure, informed consent, data security and privacy, patient-provider relationship, and HIPAA.
- National Conference of State Legislatures (NCSL), Telehealth: Policy Trends and Considerations, Nᴀᴛ’ʟ Cᴏɴꜰ. Sᴛ. Lᴇɢɪꜱʟᴀᴛᴏʀꜱ (2015), http://www.ncsl.org/documents/health/telehealth2015.pdf.
- Health Resources and Services Administration (HRSA), Telehealth, HRSA, https://www.hrsa.gov/ruralhealth/telehealth/ (last reviewed Nov. 2015).
- HealthIT.gov, What is telehealth?, Oꜰꜰ. Nᴀᴛ’ʟ Cᴏᴏʀᴅɪɴᴀᴛᴏʀ ꜰᴏʀ Hᴇᴀʟᴛʜ Iɴꜰᴏ. Tᴇᴄʜ., https://www.healthit.gov/telehealth (last updated Jan. 9, 2017).
- American Medical Association (AMA), Coverage of and payment for telemedicine, Aᴍ. Mᴇᴅ. Aꜱꜱ’ɴ (2015), https://www.ama-assn.org/sites/default/files/media-browser/premium/arc/coverage-of-and-payment-for-telemedicine-issue-brief_0.pdf.
- Bernie Monegain, Telemedicine market to soar past $30B: An increasing aged population and healthcare costs are propelling the market growth, Hᴇᴀʟᴛʜᴄᴀʀᴇ IT Nᴇᴡꜱ (Aug. 04, 2015, 10:58 AM), http://www.healthcareitnews.com/news/telemedicine-poised-grow-big-time.
- Bruce Japsen, ObamaCare, Doctor Shortage To Spur $2 Billion Telehealth Market, Fᴏʀʙᴇꜱ (Dec. 22, 2013, 9:30 AM), https://www.forbes.com/sites/brucejapsen/2013/12/22/%20obamacare-doctor-shortage-to-spur-2-billion-telehealth-market/#9433d3875b1c.
- Mordor Intelligence, Telemedicine Market — Global Trends, Analysis and Forecasts to 2022, Mᴏʀᴅᴏʀ Iɴᴛᴇʟʟɪɢᴇɴᴄᴇ (Feb. 2017), https://www.mordorintelligence.com/industry-reports/global-telemedicine-market-industry.
- How it works, Tᴀʟᴋꜱᴘᴀᴄᴇ, https://www.talkspace.com (last visited Aug. 5, 2017).
- Jill Duffy, 10 Apps That Are Changing Healthcare, PCMᴀɢ (Feb. 11, 2015, 5:14 PM), https://www.pcmag.com/article2/0,2817,2476623,00.asp.
- About Us, Dᴏᴄᴛᴏʀ Oɴ Dᴇᴍᴀɴᴅ, https://www.doctorondemand.com/about-us (last visited Aug. 05, 2017).
- American Medical Association (AMA), Telemedicine & Mobile Apps, Aᴍ. Mᴇᴅ. Aꜱꜱ’ɴ, https://www.ama-assn.org/delivering-care/telemedicine-mobile-apps (last visited Aug. 05, 2017).
- California Dental Association (CDA), Virtual dental home grant bill passes Assembly, Cᴀʟ. Dᴇɴᴛᴀʟ Aꜱꜱ’ɴ (Jun. 02, 2015), https://www.cda.org/news-events/virtual-dental-home-grant-bill-passes-assembly.
- California Dental Association (CDA), What dentists should know about the Virtual Dental Home, Cᴀʟ. Dᴇɴᴛᴀʟ Aꜱꜱ’ɴ (Oct. 28, 2015), https://www.cda.org/news-events/what-dentists-should-know-about-the-virtual-dental-home.
- California Dental Association (CDA), Learn how to implement telehealth dental care, Cᴀʟ. Dᴇɴᴛᴀʟ Aꜱꜱ’ɴ(Feb. 06, 2015), https://www.cda.org/news-events/learn-how-to-implement-telehealth-dental-care.
- Daniela Hernandez, Kaiser Health News, The whole tooth of helping low-income patients with ‘teledentistry’, Pᴜʙ. Bʀᴏᴀᴅ. Sᴛᴀᴛɪᴏɴ NᴇᴡꜱHᴏᴜʀ: Tʜᴇ Rᴜɴᴅᴏᴡɴ, http://www.pbs.org/newshour/rundown/whole-tooth-helping-low-income-patients-teledentistry/.
- Michelle Manchir, Virtual dental homes offer way to get care to the underserved, ADANᴇᴡꜱ (Sept. 06, 2016), http://www.ada.org/en/publications/ada-news/2016-archive/september/virtual-dental-homes-offer.
- House passes guidelines on teledentistry, ADANᴇᴡꜱ (Dec. 07, 2015), http://www.ada.org/en/publications/ada-news/2015-archive/december/house-passes-guidelines-on-teledentistry.
- DENTAL DEMOGRAPHICS FOR CALIFORNIA, Dᴇɴᴛᴀɢʀᴀᴘʜɪᴄꜱ, https://dentagraphics.com/california-infographic/ (last visited Aug. 05, 2017).
- STATE COVERAGE FOR TELEHEALTH SERVICES, NCSL, http://www.ncsl.org/research/health/state-coverage-for-telehealth-services.aspx (last updated Jan. 2016).
- Center for Connected Health Policy, State Telehealth Laws and Reimbursement Policies: A Comprehensive Scan of the 50 States and District of Columbia, Cᴛʀ. ꜰᴏʀ Cᴏɴɴᴇᴄᴛᴇᴅ Hᴇᴀʟᴛʜ Pᴏʟ’ʏ (Apr. 2017), http://www.cchpca.org/sites/default/files/resources/50%20STATE%20PDF%20FILE%20APRIL%202017%20FINAL%20PASSWORD%20PROTECT.pdf.
- Center for Connected Health Policy, State Laws and Reimbursement Policies, Cᴛʀ. ꜰᴏʀ Cᴏɴɴᴇᴄᴛᴇᴅ Hᴇᴀʟᴛʜ Pᴏʟ’ʏ, http://www.cchpca.org/state-laws-and-reimbursement-policies (last visited Aug. 05, 2017).
- The IMLC, IMLCC.ᴏʀɢ, http://www.imlcc.org/ (last visited Aug. 05, 2017).
- Minn. Stat. § 62A.617.
- Nev. Rev. Stat. § 629.515.