Telehealth

 VI. Key Issues: Financing and Delivery >> A. Health Spending >> Health Cost Containment  >> Improve Administration >> Health IT >> Telehealth (last updated 5.15.22)

 

Telemedicine

  • Former Senators Join Forces to Advance Telemedicine. “In their post-Senate careers, the three former lawmakers have relocated to K Street, home to lobbyists, and are working on behalf of the Alliance for Connected Care, a nonprofit collection of health care providers, insurers, pharmacies, technology firms and telecommunications companies, to pursue legislative and regulatory changes to let more Americans essentially get much of their health care remotely… All three former lawmakers said they became interested in the potential of digital technology to deliver health care when they were representing states with pockets of poverty, where access to health care can be difficult for geographic and economic reasons.” (New York Times, 5.20.14)
  • Pediatric eHealth Interventions: Common Challenges During Development, Implementation, and Dissemination. “The challenges associated with eHealth interventions and their proposed solutions are multifaceted and cut across a number of areas from eHealth program development through dissemination. Collaboration with a range of individuals (e.g., multidisciplinary colleagues, commercial entities, primary stakeholders) is the key to eHealth intervention success. To ensure adequate resources for design, development, and planning for sustainability, a number of public and private sources of funding are available. A study design that addresses ethical concerns and security issues is critical to ensure scientific integrity and intervention dissemination. Table Isummarizes key issues to consider during eHealth intervention development, testing, and dissemination.” (Journal of Pediatric Psychology. 2014;39(6):612-62)
  • The Cleveland Clinic: Coming to a Kiosk Near You? Health System to Offer New Telehealth Options. “The Cleveland Clinic has signed a letter of intent to partner with HealthSpot, a provider of telehealth services based in Ohio, to provide care to patients via walk-in kiosks located in non-traditional health care settings, like workplaces, universities, and retail stories. The kiosks are private, eight-by-five foot spaces outfitted with medical devices, videoconferencing capabilities, and medical devices. They allow Cleveland Clinic providers to see patients through the kiosks, and each kiosk is staffed by a medical assistant. The clinic will integrate patient data from the kiosks into its electronic health record system.” (The Advisory Board Company, 5.22.14)
  • Telecare Collaborative Management of Chronic Pain in Primary Care: A Randomized Clinical Trial. “The Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was a randomized trial comparing a telephone-delivered collaborative care management intervention vs usual care in 250 patients with chronic (≥3 months) musculoskeletal pain of at least moderate intensity (Brief Pain Inventory [BPI] score ≥5). Patients were enrolled from 5 primary care clinics in a single Veterans Affairs medical center from June 2010 through May 2012, with 12-month follow-up completed by June 2013… Telecare collaborative management increased the proportion of primary care patients with improved chronic musculoskeletal pain. This was accomplished by optimizing nonopioid analgesic medications using a stepped care algorithm and monitoring.”JAMA. 2014;312(3):240-248
  • New Push for TeleHealth in ACOs. “NAACOS has co-signed a letter to HHS urging CMS to grant a waiver to permit all ACOs to use and bill for TeleHealth services. HHS clearly has the authority but so far has been unwilling to exercise it.” (National Association of ACOs, 6.6.14)
  • Telehealth Services Comments Letter: NAACOS has signed on to an Alliance for Connected Care letter to the House Energy and Commerce Chairman and the Energy and Commerce Subcommittee on Health Chairman addressing improvements to the availability and use of telehealth services. (National Association of ACOs, 6.16.14)
  • Does Telehealth Diminish Physician-Patient Relationships? “Nonvisit care of patients is becoming a necessity in primary care, noted Dr. Scherger, who practices part-time and was a pioneer of secure email consultations. Moreover, he pointed out, the Internet has created new ways to deliver chronic and preventive care and treat minor acute problems, and those modes will be used. ‘You’ve got this new platform of communication and care that is going to be delivered, whether it’s by a continuity provider or by somebody else.’” (Medscape Medical News, 7.25.14)
  • What Will You Do With All That Telemedicine Data? “(T)he growing prevalence of monitoring devices is starting to make many doctors nervous as they contemplate how they will deal with all the data they may receive. And if you work in an environment where reimbursement will increasingly be based on outcomes—a hospital, a practice owned by a hospital system, an accountable care organization (ACO), or a patient-centered medical home (PCMH)—this dilemma may affect you sooner than you may think… Many physicians fear that once remote patient monitoring becomes the standard of care, they will be deluged with patient data that they will then need to evaluate and, in some cases, act on in a timely fashion, when there already aren’t enough hours in the day.” (Medscape Business of Medicine, 12.18.14)
  • Patients Consent to Physicians Crowdsourcing for Diagnosis. “The increasing number of apps and online services that allow physicians to use crowdsourcing to make a diagnosis highlights the need for a debate on how to allow for patient privacy and consent, according to results from a new survey. When asked whether they would give permission to have their picture posted online, about 80% of respondents agreed to posting to improve their own medical care, about 80% agreed to posting to educate other doctors, and about 80% agreed to posting to advance scientific knowledge.” (Medscape Medical News, 5.1.15)
  • Regulators Can’t Seem To Tamp Down Telemedicine, And That’s A Big Sign Of Change. “Over the past decade, patients began paying far more of the doctor bill out of their own pocket, and suddenly they became more of a consumer. The best example of the emerging new influence of the health care patient as consumer is the phoenix-like rise of telemedicine. Despite endless efforts over decades to make it die from a thousand regulatory cuts, people want to be able to consult physicians—and nurses—via ubiquitous communication technology like teleconferencing and email. Large employers have been interested in this for a long time, but only recently removed enough regulatory hurdles to systematically offer it for employees at a national level. According to a new study by the Employer Benefits Research Institute (EBRI), 96% of surveyed large employers plan to offer telemedicine for employees in states that allow it. More than half (56%) offer telemedicine benefits for behavioral health… According to Annette Guarisco Fildes, president and CEO of the ERISA Industry Council (ERIC), the key advocacy arm for employer benefits policy in Washington, D.C., employers seek out telemedicine because it improves access to care.” (Forbes, 4.16.18)

Virtual Medical Visits

  • Virtual Visits Benefit Physicians as Well as Patients. “Virtual patient visits — via videoconferencing on a personal computer, laptop, tablet, or smartphone — as well as remote visits via old-fashioned telephone, secure email, and even texting, are controversial to many physicians, who may regard a hands-on office visit as being the sine qua non of good patient care. That’s changing fast. In August, a Deloitte report predicted that the number of telehealth visits in the United States and Canada could soar to 75 million in 2014, representing 25% of the addressable market. The study noted that of the 600 million annual visits to primary care practices in North America, approximately half were for problems that could be solved by remote rather than in-office visits. To meet exploding patient demand, especially for videoconferencing, virtual physician networks are springing up across the country. They are being sponsored by insurers, health plans, employers, hospitals, and physician groups, often funded by millions of dollars in venture capital, and there appears to be no shortage of physicians who seek to join them. Here’s why.” (Medscape Business of Medicine, 9.25.14)
  • ACP Supports Expanding Telemedicine in Primary Care. “Telemedicine can broaden access to care, improve outcomes, and reduce care costs, but risks and benefits must be carefully evaluated for both patients and physicians, say authors of a new position paper from the American College of Physicians (ACP). The paper, published online September 8 in the Annals of Internal Medicine, offers more than a dozen recommendations — and the rationale behind them — for successful telemedicine, which the ACP says should be held to the same standards of practice as in-person medicine.” (Medscape Medical News, 9.8.15)

Telehealth under Medicare

  • Medicare Increases Telehealth Coverage… a Bit. “The Centers for Medicare & Medicaid Services (CMS) proposes to increase incrementally the telehealth services that Medicare will cover, including wellness visits and some behavioral health services. However, CMS continues to restrict telehealth coverage to rural areas and offers a very circumscribed definition of the telehealth technology that can serve as the basis for coverage… Years ago, Dr. Bashshur recalled, CMS refused to cover telehealth at all, and it is still taking a very restrictive approach because it is afraid of the potential for overuse. On the basis of his own research, Dr. Bashshur has estimated that CMS paid only $12 million for telehealth last year.” (Medscape Medical News, 7.16.14)
  • Current Law Restricts Millions of Americans’ Access to Telehealth Services. “Several of the nation’s largest pharmacies and health-care companies are urging lawmakers to expand the types of telehealth services that can be covered by government insurance programs, arguing that an outdated federal law is limiting the number of Americans who can access telemedicine. Under current law, only telemedicine services offered through rural hospitals and clinics are covered by Medicare, according to a section of the Social Security Act that regulates how Medicare reimburses for telemedicine.” (Washington Post, 10.19.14)
  • Medicare Advances Virtual Check-ins in Pay Rule. “CMS is using the code G2012 for brief interactions via ‘communication technology-based service’ by a physician or other qualified healthcare professional. This check-in visit should not originate from a related E/M service provided within the previous 7 days, nor should it lead to an E/M service or procedure within the next 24 hours or at the soonest available appointment. CMS described the creation of the payment for a check-in visit as the agency’s recognition of how patients and physicians have different expectations about the practice of medicine over a distance than they did in recent decades. ‘From the ubiquity of synchronous, audio/video applications to the increased use of patient-facing health portals, a broader range of services can be furnished by health care professionals via communication technology as compared to 20 years ago,’ CMS wrote. In this initial rollout of the check-in visit, CMS opted not to limit how many times this code can be used by the same practitioner with the same patient.” (Medscape 11.6.18)

Telehealth at the VA

  • Veterans’ Use of VA Telehealth Services Increased Significantly in Fiscal Year 2019. “In FY2019, VA delivered more than 2.6 million episodes of telehealth care, representing a 17% increase in overall telehealth visits over the previous fiscal year. Additionally, Veterans’ use of VA Video Connect for secure video appointments with a VA health care provider increased 235%, with more than 99,000 Veterans using the app in their homes rather than visiting a VA facility. ‘VA is committed to offering Veterans the health care they deserve, whenever and wherever they need it,’ said VA Secretary Robert Wilkie in a VA news release detailing VA Telehealth’s FY2019 report. ‘We want every Veteran to have a choice to schedule an in-person, telephone or video visit with their providers, depending on their preferences for health care delivery.’ Health Data Management published an article about VA Telehealth’s FY2019 report. Read it here.” (US Department of Veterans Affairs, 11.27.19)

Patient Portals

  • Patient Portals Do Not Improve Hospital Outcomes. “Overall, researchers noted no significant difference between patients using the portal and those who did not in 30-day readmissions, inpatient mortality and 30-day mortality. ‘Use of the patient portal in the inpatient setting may not improve hospital outcomes,’ concluded first author Adrian Dumitrascu, with Mayo Clinic. ‘Future research should examine the association of portal use with more immediate inpatient health outcomes such as patient experience, patient engagement, medication reconciliation, and prevention of adverse events.’” (Clinical-Innovation, 1.8.18)
  • Most US Patients Not Using Patient Portals. “Overall, 63 percent of survey participants reported not using a patient portal during the past year, and 60 percent reported not having been offered access to a portal. Nonusers were more likely to be men, aged 65 or older, to be unemployed, live in a rural location, have public insurance through Medicaid, have a high school diploma or less education and to lack a regular doctor. Similar characteristics, as well as being non-white, were seen among people who said they weren’t offered access to a patient portal… Among the reasons participants gave for not using online portals, 25 percent mentioned issues with internet access, 32 percent said they had no online medical record, 70 percent said they preferred to speak directly to the doctor, and 22 percent were concerned about privacy issues.” (Medscape, 1.5.19)

Health Care Apps

  • Physicians Warm to Digital Communications With Patients. “Forty percent of physicians say they believe the use of digital technologies to communicate with patients can improve outcomes, and the same percentage say they have increased their use of digital tools in patient care during the past year, according to a recent Manhattan Research survey. These digital technologies include everything from the use of patient portals and emailing and texting with patients to the prescribing of mobile health apps for self-tracking and remote patient monitoring, Monique Levy, vice president of research at Manhattan Research, told Medscape Medical News.” (Medscape Medical News, 6.12.14)
  • Smartphone Applications for Patients’ Health and Fitness. Article introduces evidence that smart phone apps can better help patients reach their health and fitness goals,  describes what features to look for in an app, gives an overview of popular health and fitness apps, and offers app recommendations. Current limitations of apps, and future research are also discussed. (The American Journal of Medicine, 2016)
  • Study Names Top Apps for Patients to Manage Illnesses. “Top clinically rated apps for patients to manage their conditions include those for cancer, diabetes, hypertension, and asthma, according to IQVIA. The number of healthcare apps has increased from 165,000 in 2015 to 315,000 in 2017, with 200 apps debuting each day on the Apple Store and Google Play. Most of them still belong in the ‘wellness’ category, catering to individuals who want to track their jogging, food intake, and sleep, for example. However, the percentage of apps focused on health conditions and patient care has increased from 27% to 40% in 2 years’ time. Forty-one apps with at least 10 million downloads each account for almost half of the download volume. Eighty-five percent of all healthcare apps have fewer than 5000 downloads.” (Medscape, 11.7.17)
  • More Mobile Medical Apps Have FDA Approval. “Over 165,000 mobile health apps are estimated to be on the market. Despite their popularity, few physicians recommend them to patients because they question their reliability and suspect many of being little more than digital snake oil. One survey suggests that only 15% of doctors encourage patients to use health apps. The same cannot be said of mobile apps for physicians, which are used by many clinicians to accomplish a variety of clinical and practice management tasks. Eighty-six percent of healthcare professionals say that mobile apps will improve their efficiency in providing patient care, and 59% use smartphones to access medical research. Despite the popularity of these apps, clinicians still face the challenge of separating the wheat from the chaff. The guidelines on mobile medical apps issued by the US Food and Drug Administration (FDA) can help them make an informed choice.” (Medscape, 11.8.17)
  • Mobile Apps Help Patients Cope with Pain. “The BWH pain app has been upgraded three times. It is now available for iPhone and android devices; to date, about 600 people have used it for 6 months or longer… Research suggests that those who are more disabled tend to use the app more frequently. There is some indication that such individuals gain coping skills and that their levels of pain, depression, and anxiety are reduced. ‘There is some evidence, but it’s not overwhelmingly strong, and there are major individual differences,’ said Jamison. He noted that large controlled trials are needed… Jamison believes computers will play an even bigger role in the future. He foresees that in 25 years, devices will be able to measure mood just by voice or face recognition. He is also convinced that face-to-face consultations will become all but obsolete. Diagnostics and treatments will be completed through telemedicine and teletherapy, he said.” (Medscape Medical News, 11.15.18)

Telemedicine Impact on Costs

  • Telehealth Visits Raise Costs Due to More Use, Study Shows. “Telehealth companies have touted virtual visits as a way to lower costs by averting more expensive office visits and emergency department (ED) visits. But a new study from the RAND Corporation published in this month’s Health Affairs shows that, at least for people with acute respiratory illnesses, telehealth raises costs by increasing the utilization of healthcare services… As a result, the researchers said, the savings from substitution in lower per-episode costs were outweighed by the increase in spending from new utilization. They estimated there was a net $45 per person (95% CI: $10, $79) increase in acute respiratory infection spending among the cohort that used telehealth. The authors noted that their findings on telehealth costs are similar to those of studies of retail clinics, where about 60% of visits represent new utilization.” (Medscape Medical News, 3.6.17)
  • Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending. “The use of direct-to-consumer telehealth, in which a patient has access to a physician via telephone or videoconferencing, is growing rapidly. A key attraction of this type of telehealth for health plans and employers is the potential savings involved in replacing physician office and emergency department visits with less expensive virtual visits. However, increased convenience may tap into unmet demand for health care, and new utilization may increase overall health care spending. We used commercial claims data on over 300,000 patients from three years (2011–13) to explore patterns of utilization and spending for acute respiratory illnesses. We estimated that 12 percent of direct-to-consumer telehealth visits replaced visits to other providers, and 88 percent represented new utilization. Net annual spending on acute respiratory illness increased $45 per telehealth user. Direct-to-consumer telehealth may increase access by making care more convenient for certain patients, but it may also increase utilization and health care spending.” (Health Affairs, March 2017)

TeleMental Health

Effectiveness

  • Cognitive Therapy Works Even by Telephone, Computer. “Cognitive behavioral therapy (CBT) for anxiety and depression, whether self-guided, provided via telephone or computer, or provided face to face, was better than no care in a primary care setting and was also better than treatment as usual (TAU), according to a meta-analysis published online September 22 in Family Practice.” (Medscape Medical News, 10.9.14)
  • Simpler Depression Therapies? “Psychological treatments for depression in primary care patients are increasingly available and being studied around the world, but their efficacy is still unclear… The researchers found evidence that psychological treatments are effective in depressed primary care patients but that, of the approaches studied, substantial evidence suggests that interventions that are less resource intensive, such as guided self-help cognitive-behavioral therapy (CBT), no or minimal- contact CBT, remote therapist-led CBT, or problem-solving therapy, might have effects similar to more intense in-person treatments. These results are of great interest and suggest that we should be considering combining less resource-intensive forms of psychological therapy with our other interventions for depression.” (Medscape Psychiatry, 5.1.15)
  • Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder. “Telephone-delivered CBT consisted of as many as 11 sessions (9 were required) focused on recognition of anxiety symptoms, relaxation, cognitive restructuring, the use of coping statements, problem solving, worry control, behavioral activation, exposure therapy, and relapse prevention, with optional chapters on sleep and pain. Telephone-delivered NST consisted of 10 sessions focused on providing a supportive atmosphere in which participants could share and discuss their feelings and did not provide any direct suggestions for coping… In this trial, telephone-delivered CBT was superior to telephone-delivered NST in reducing worry, GAD symptoms, and depressive symptoms in older adults with GAD.” (JAMA Psychiatry, October, 2015)
  • Is Telemental Health Effective – How Does It Measure Up? “The research into telemental health has consistently shown it to be an effective delivery system for mental health services. A 2013 review of the literature found that telemental health is as effective and comparable to in-person care.3  More specifically, the use and effectiveness in telemental health has been demonstrated in:
    • diagnosis and assessment (good inter-rater reliability)
    • many populations (adult, child, geriatric, and ethnic)
    • most mental health disorders
    • a variety of settings including ER’s, home health, private practice, agencies and schools
    • providing access to geographically distant clients
    • improved client satisfaction

A 2017 review of the current literature supports these earlier findings and recognizes telemental health such as online counseling as an effective solution for service delivery and is especially advantageous for geographically isolated communities.” (TheraPlatform Blog, 1.3.19)

  • Internet-Based Cognitive and Behavioral Therapies for PTSD in Adults. “Therapist-delivered, trauma-focused, psychological therapies are the accepted first-line treatments for posttraumatic stress disorder (PTSD). However, they are not easily available or accessible for many patients. Delivering cognitive and behavioral therapy on the Internet (I-CBT) is an acceptable alternative, but is it effective? A team of investigators from Cardiff University, Wales, has performed a Cochrane review to assess the effects of I-CBT for PTSD in adults. The researchers found 10 studies with 720 participants and concluded that although there were some beneficial effects of I-CBT for PTSD, the overall quality of evidence was very low owing to the small number of included trials.” (Medscape Psychiatry, 5.9.19)

Mental Health Apps

  • Mobile Health App Effective for Serious Mental Illness. “Patients with serious mental illness were more open to starting treatment using a mobile health (mHealth) app than to attending traditional sessions at a clinic in a randomized controlled trial. In addition, patients who used the mHealth app experienced reductions in symptoms comparable to those experienced by their peers who attended group therapy sessions. ‘It is now time to try and integrate this approach into real-world practice,’ Dror Ben-Zeev, PhD, professor of psychiatry and behavioral sciences and director of the mHealth for Mental Health Program at the University of Washington in Seattle, told Medscape Medical News. The study was published online May 25 in Psychiatric Services.” (Medscape Medical News, 6.1.18) 
  • Mental Health Apps: Boon or Bust? “The use of mental health apps is dramatically expanding, but while they are promising tools, many are ineffective in reducing symptoms, do not offer evidence-based approaches, and potentially compromise patients’ privacy, new research suggests. Investigators reviewed over 70 studies of mental health apps using two leading frameworks to analyze information such as price, updates, developer information, safety, and the evidence base behind the interventions included in the app. They found that common strengths of available apps included symptom-tracking features, psychoeducational components, and higher user engagement. Common weaknesses include insufficient privacy settings and little integration of empirically supported treatments, outside of scientifically developed apps… ‘Overall, we found that finding effective apps that are easy to use, evidence-based, and that protect personal information is very challenging, and we think that this is best done in tandem with some sort of health professional,’ he said.” (Medscape Medical News, 3.25.19)

Development of TeleMental Health 

  • Coalition for Technology in Behavioral Science Formed (Summer, 2014). CTiBS is an inter-disciplinary group dedicated to fostering the legal and ethical use of evidence-based technology in behavioral health care and is open to members of all disciplines who share an interest in technology in improving the human experience. “Please review the many areas of technological research, development and consultation that we support; review our mission; avail yourself of our extensive and searchable bibliography; and read about the latest writings about the intersection of technology and behavioral health in our blog.”
  • Telepsychologist Competencies for Psychologists Practicing in Ohio. Webinar provides an overview of competencies and best practices in implementing telemental health. (Ohio Psychological Association, October, 2014)
  • Antea Group Launches Online Cognitive Behavioral Therapy Benefit. “When Antea Group realized employees often could not access mental health services from their EAP or medical plan on a timely basis, they added Learn to Live, an online cognitive behavioral program available 24/7 to their benefits program… ‘Our broker brought Learn to Live to our attention, and we totally fell in love with it because it was 24/7 which is really appealing to our employees who are always on the go,’ she says. Learn to Live provides online CBT to address psychological problems such as social anxiety, depression, stress and worry. Employees complete an online questionnaire and based on the results, they are directed to one of three eight-module programs. The goal is that by the end of the program, participants have the tools and resources to deal with the specific challenge they are facing… The online CBT program was just rolled out in January so it is still early days, but she says already 16 people have completed the program.” (Employee Benefit Advisor, 3.18.16
  • Reinventing Employee Behavioral Health: How Innovative Technology and Management Practices are Enabling New Access to Care.(CastLight, 6.15). “How new computer, videoconferencing, and analytics technologies are improving access and helping to manage costs for employers and employees.”
  • Telehealth Updates for 2018. “For Calendar Year 2018 (CY2018), CMS has added the following psychology-specific services to the Medicare telehealth list:
    • CPT codes 90839 and 90840: Psychotherapy for crisis (first 60 minutes) and Psychotherapy for crisis (each additional 30 minutes).
    • CPT code 90785: Interactive complexity.
    • CPT codes 96160 and 96161: Administration of patient-focused health risk assessment instrument and Administration of caregiver-focused health risk assessment instrument.

    The addition of the Psychotherapy for crisis codes to the telehealth list came with CMS stating that payment for these services via telehealth is explicitly conditioned upon the remotely located practitioner having the ability to mobilize resources (i.e. communicate with and inform staff) at the originating site to diffuse the crisis and restore safety, when applicable. Also, effective for CY2018, CMS has eliminated the requirement to report modifier GT (telehealth service provided via interactive audio and video telecommunications systems) on professional claims for telehealth services. Instead, psychologists should use the telehealth Place of Service (POS) Code 02, which became effective in 2017, and which certifies that the service meets the telehealth requirements. By eliminating the GT modifier reporting requirement, CMS is hoping to make it easier to bill for these services by reducing administrative burden for practitioners.” (APA Services, 3.8.18)

TeleMental Health Guidelines

Legal and Professional Issues in Telehealth Delivery

  • Online Psychotherapy Gains Fans And Raises Privacy Concerns. “Some studies suggest that therapy online can be as effective as it is face to face. ‘We have a lot of promising data suggesting that technology can be a very good means of providing treatment,’ says Lynn Bufka, a clinical psychologist who helps develop health care policy for the American Psychological Association… Family therapists, mental health counselors and clinical social workers are licensed to practice by individual state boards. But it’s unclear whether a practitioner who lives in one state can or should treat someone who lives elsewhere. ‘We’d like to see a little more mobility and flexibility with that, because certainly for licensed psychologists the standards are pretty similar across state lines,’ Bufka says. Perhaps, she adds, therapists could get a special certification that would allow them to practice in multiple states or countries.” (National Public Radio, 6.30.14)
  • FSMB Compact Could Ease MultiState Licensing. “The Federation of State Medical Boards (FSMB) has unveiled a draft interstate compact for physician licensure that, it said, should make it easier to practice telemedicine across the country. The compact, which the FSMB expects to finalize in the next month or two, offers a ‘streamlined alternative pathway’ for physicians who want to practice in multiple states, according to a federation news release. Under current state medical board policies, physicians must be licensed in the state where a patient is located to diagnose or treat that patient, a stance that the FSMB recently reaffirmed in its model policy for telemedicine. As a result, physicians who consult remotely with patients in other states must be licensed in those states. That can create barriers to telehealth consultations, especially for on-call physicians who are not licensed in every state where patients may contact them online. The FSMB’s interstate compact would allow physicians to apply once and receive licensure in all states that are party to the compact.” (Medscape Medical News, 8.5.14)
  • Teladoc Files Antitrust Suit Against Medical Board. “In just over a month, a new state rule is set to kick in that could undercut the business model of Dallas-based Teladoc, a rapidly growing telemedicine company that connects patients and doctors over the telephone and internet. With the clock ticking, the company is brandishing every weapon in its arsenal, deploying teams of lobbyists and lawyers to fight a Texas Medical Board rule change that it says is more about stifling competition than protecting patient health. The board’s rule, set to start June 3, would prevent doctors from treating people over the phone — making a diagnosis or prescribing medicine — unless another medical professional was physically present to examine the patient.” (Texas Tribune, 4.30.15)
  • Telepsychology: Compliance Alert from Ohio State Psychology Board. (Ohio Psychological Association 7.22.15). “Psychologists and other mental health professionals are being actively and increasingly recruited by national companies to provide online services. The Board’s Telepsychology Rules include specific requirements and direction regarding the practice of Telepsychology within the state of Ohio. However, when online services involve residents outside of Ohio, numerous challenges and considerations become apparent. Deliberation, competence, and caution are necessary.”
  • Telemedicine Runs Into Crony Doctoring. “Yet while telemedicine can connect a patient in rural Idaho with top specialists in New York, it often runs into a brick wall at state lines. Instead of welcoming the benefits of telemedicine, state governments and entrenched interests use licensing laws to make it difficult for out-of-state experts to offer remote care… Using its power under the Commerce Clause of the Constitution, Congress could pass legislation to define where a physician practices medicine to be the location of the physician, rather than the location of the patient, as states currently do. Physicians would need only one license, that of their home state, and would work under its particular rules and regulations. This would allow licensed physicians to treat patients in all 50 states. It would greatly expand access to quality medical care by freeing millions of patients to seek services from specialists around the country without the immense travel costs involved. With one simple change that would not cost taxpayers a dime, Congress could create a national market for health care, and allow the telemedicine revolution to increase access to quality health care while lowering its cost.” (Wall Street Journal, 7.22.16)

Ethical Issues in Telehealth Service Delivery

  • Abortion by Mail Allows Better Access But Political Questions Remain. “At a time when access to abortion is being restricted on many fronts, advocates say being able to terminate a pregnancy through telemedicine and mail-order drugs would provide a welcome new option for women. Opponents of abortion find the concept dangerous and deeply disturbing. The idea builds on a trend that is helping women obtain birth control more easily. A growing number of smartphone apps and websites now make it possible to get prescription contraceptives without visiting a doctor’s office first. The pills Marie and the other women received through the study are not allowed for sale in pharmacies and are usually available only at hospitals and abortion clinics… The service is not available in the United States, and the Food and Drug Administration warns against buying the drugs over the internet.” (Kaiser Health News, 11.15.16)

Remote Monitoring of Patient Status/Adherence

  • Patients Self-Monitor With Wearable Diagnostics. “In a scene that does not usually take place at a medical conference, models showed off wearable diagnostic and tracking devices here at the Health 2.0 Annual Fall Conference. The technology included otoscopes attached to smart phones and monitors that fit inside pendants, bras, socks, and wrist watches. A model demonstrated a headset that monitors brainwaves to accompany an armband that tracks heart rates (Evoke Neuroscience), jewel-like sensors that update the wearer on exposure to sunlight (Netanol), and a monitor that inserts under the skin to continuously report on glucose (Medtronic)…Despite marketing directly to consumers, the entrepreneurs still envision a role for physicians.“ (Medscape Medical News, 9.25.14)
  • Fifteen Game-Changing Wireless Devices to Improve Patient Care. “Cardiac electrophysiologist David Lee Scher, MD, clinical associate professor of medicine at Penn State University, director of a digital health consulting firm, avid blogger on mobile health issues, and chairman of the Healthcare Information and Management Systems Society (HIMSS) Mobile Health Roadmap Task Force, points to 15 potential game changers in mobile health technology that hold the promise of revolutionizing patient care in hospitals, in nursing homes, and at home.” (Medscape, 10.23.14)
  • The Tyranny of the Should. “In the UK, it appears the NHS will have a ‘huge rollout‘ of wearable technology as part of a ‘revolution in self care.’ … Could all this data collected about our behaviour be used to ration or even deny care? I’m not the only one who is asking that question. In a great article by Hamza Shaban examining the impact of sensors collecting data about our health on the pricing of health insurance, one sentence stands out, ‘Imagine a pricing scheme that would punish sleep-deprived single parents or the dietary habits of the working poor.’ A world where our health insurance premiums decline when we behave within the guidelines, and rise when we deviate from the guidelines… Today, the National Institutes of Health announced it’s searching for a wearable or otherwise discreet device capable of measuring blood alcohol level in real time. There is a fine line between ‘Digital Nudges’ and ‘The Tyranny of the Should’ – and it’s not clear to me that we’re having the right conversations in the right places.” (Juneja, Maneesh, 3.2.15)
  • Digital Healthcare Services in 2016 (and Beyond). “Tap into these eight industry leading trends in digital healthcare services for 2016… While payers have had patient health analytics software for a few years already, in 2016, we can expect patient scoring and health analysis to make its way into the hands of the clinicians and patients. Software tools for visualizing a patient’s complete range of health metrics, along with clinically validated algorithms for scoring a holistic view of patient health will make their debut. These will provide clinicians with at-a-glance analytics of a patient’s overall health, allowing doctors to spot patterns and red flags by comparing a person’s health data against targeted health ranges, based on factors like age and gender.” (Mobi Health News, 1.5.16)
  • Just What the Doctor Ordered: Connectivity in Medical Devices. “Last month, Qualcomm Life and Novartis said they were teaming up to develop an Internet-connected Breezhaler to treat chronic obstructive pulmonary disease, or COPD. It will detect and report usage and other information. The data will go to a patient’s smartphone via a Novartis mobile app, which sends the data to the Internet cloud.’By enabling near-real-time data capture from the patient and the connected Breezhaler device, patients can monitor their own adherence to the medication they take, which is vital to their health outcomes,’ said David Epstein, head of Novartis Pharmaceuticals. So far, however, the connected medical market has been slow to develop, with a raft of questions holding back adoption. They include concerns about regulation, security, privacy, liability and reimbursement… To date, the top proponent of remote patient monitoring has been the U.S. Veterans Administration. ‘They have been the early adopters in the United States,’ Camlek said. Others are moving more slowly. Novartis isn’t planning to release the connected inhaler until 2019.” (Los Angeles Times, 2.21.16)
  • Care Plans: The Future. “The ‘Magic Mirror’ on the wall is not just a fantasy anymore. Using facial recognition and mood sensing, blood pressure and heart rate sensing through skin pigmentation, and other technology, we can imbue the ordinary bathroom mirror with interactive qualities to help monitor our health.” (GoInvolution, March 2016)
  • Care Plans: A Path to Driving Better Outcomes. “In 2016, expect the basics of digital adherence — self-reporting, tracking refills and chronic disease outcomes, etc. — will receive a boost from the use of sensors to collect confirming data, whether it’s via breath analysis, urine sampling, or another non-invasive method.” (Involution Studios, March, 2016)
  • Evolutionary Pressures on the Electronic Health Record. “In this world of patient portals and electronic tablets, it should be possible to collect from individuals key information about their environment and unique stressors—at home or in the workplace—in the medical record. What is the story of the individual? The most sophisticated computerized algorithms, if limited to medical data, may underestimate a patient’s risk (eg, through ignorance about neighborhood dangers contributing to sedentary behavior and poor nutrition) or recommend suboptimal treatment (eg, escalating asthma medications for symptoms triggered by second-hand smoke). Recognizing this void, the National Academy of Medicine has called for systematic integration of social determinants of health into the EHR. Advances in this area could provide clinical teams with information to more holistically approach patients’ needs.” (JAMA, 8.15.16)
  • Feasibility of Reidentifying Individuals in Large National Physical Activity Data Sets From Which Protected Health Information Has Been Removed With Use of Machine Learning. “Policymakers1,2 have been concerned about the possibility of identifying individuals or their actions based on activity data, whereas device manufacturers and exercise-focused social networks believe that sharing deidentified physical activity data poses no privacy risks.3–5 Because it was recently reported that location information from activity trackers could be used to identify the location of military sites,18 these groups have begun to restrict which location data are shared. However, device manufacturers continue to share deidentified physical activity data with individuals’ employers, advertisers, and health care organizations.10 Thus, it is vital to be able to quantify the privacy risks from sharing such data. Our results suggest that partially aggregated PAM data with geographic and protected health information removed can be reidentified using machine learning… policymakers should consider developing regulations to restrict the sharing of activity data by device manufacturers.” (JAMA Network, 12.21.18)
  • Linking Financial Incentives with Wearable Devices.“A new partnership between UnitedHealthcare, Minnetonka, Minnesota, and Qualcomm Inc., San Diego, offers financial incentives for step activities to employees enrolled in its wellness program. The program, UnitedHealthcare Motion, provides customized wearable devices by Trio Motion, Freeport, Pennsylvania, to employees in the program at no additional charge and enables those employees to earn up to $1,460 each year by meeting certain daily step goals… Data from the trackers are sent to the UnitedHealthcare Motion app powered by Life’s 2net mobile platform.” (Club Industry, 3.15.16)

Impact on Health Outcomes

  • Impact of Remote Patient Monitoring on Clinical Outcomes.“Difference-in-difference point estimation revealed no statistically significant impact of remote patient monitoring on any of six reported clinical outcomes, including body mass index (−0.73; 95% CI: −1.84, 0.38), weight (−1.29; −3.06, 0.48), waist circumference (−2.41; −5.16, 0.34), body fat percentage (0.11; −1.56, 1.34), systolic blood pressure (−2.62; −5.31, 0.06), and diastolic blood pressure (−0.99; −2.73, 0.74). Studies were highly heterogeneous in their design, device type, and outcomes. Interventions based on health behavior models and personalized coaching were most successful. We found substantial gaps in the evidence base that should be considered before implementation of remote patient monitoring in the clinical setting.” (Nature, 1.15.18)

Artificial Intelligence

  • Using Facial Recognition and AI to Confirm Medication Adherence. “The developers of AiCure’s technology have likened it to a personal trainer in a gym working directly with a client to achieve their goals. It involves facial recognition and motion-sensors in a mobile device. It records patients taking their medication and transmits that data back to a clinician through a HIPAA-compliant secure network, who can then confirm that patients took their medication. It can also flag up adverse events or potential barriers and work with patients to overcome them. It is designed to support Directly Observed Therapy… The move comes as Barton Health became the first health system to prescribe ingestible sensors, initially for patients with hypertension. emocha, a DreamIt Health company from Baltimore, also enlists video from mobile phones to confirm when patients have taken their medication.” (MedCity News, 1.12.16)
  • How Artificial Intelligence Could Help Diagnose Mental Disorders. “In 2015, a team of researchers developed an AI model that correctly predicted which members of a group of young people would develop psychosis—a major feature of schizophrenia—by analyzing transcripts of their speech. This model focused on tell-tale verbal tics of psychosis: short sentences, confusing, frequent use of words like ‘this,’ ‘that,’ and ‘a,’ as well as a muddled sense of meaning from one sentence to the next. Now, Jim Schwoebel, an engineer and CEO of NeuroLex Diagnostics, wants to build on that work to make a tool for primary-care doctors to screen their patients for schizophrenia. NeuroLex’s product would take a recording from a patient during the appointment via a smartphone or other device (Schwoebel has a prototype Amazon Alexa app) mounted out of sight on a nearby wall.” (Atlantic, 8.23.16)
  • A Manifesto for Augmented Mental Health: The End of Psychotherapy as We Know it. “While mental health disorders are on the rise, so is the demand for mental health care services. But, the current healthcare system can not keep up. Mental health disorders cost $467 billion annually to the US economy. On top of that, behavioral health issues are a key predictor of high costs… In the Augmented Mental Health era, patients receive personalized care and support around the clock, families are automatically notified when their loved ones are at risk and therapists base their diagnosis on objective data… Technology will enable around the clock monitoring of a person’s mental state, and as a result, the provision of real-time patient support too… Timely identification of an outset of a mental health illness will help to act quickly and take preventative measures. And this will be done through an unobtrusive process to help patients maintain a healthy mental state.” (Eleftheriou, George, 7.5.18)

Analysis

  • Internet of Things (IoT): Privacy and Security in a Connected World. “Such a massive volume of granular data allows those with access to the data to perform analyses that would not be possible with less rich data sets. According to a participant, ‘researchers are beginning to show that existing smartphone sensors can be used to infer a user’s mood; stress levels; personality type; bipolar disorder; demographics (e.g., gender, marital status, job status, age); smoking habits; overall well-being; progression of Parkinson’s disease; sleep patterns; happiness; levels of exercise; and types of physical activity or movement.’ This participant noted that such inferences could be used to provide beneficial services to consumers, but also could be misused. Relatedly, another participant referred to the IoT as enabling the collection of ‘sensitive behavior patterns, which could be used in unauthorized ways or by unauthorized individuals.’ Some panelists cited to general privacy risks associated with these granular information-collection practices, including the concern that the trend towards abundant collection of data creates a ‘non-targeted dragnet collection from devices in the environment.’ Others noted that companies might use this data to make credit, insurance, and employment decisions… although a consumer may today use a fitness tracker solely for wellness-related purposes, the data gathered by the device could be used in the future to price health or life insurance or to infer the user’s suitability for credit or employment.“ (Federal Trade Commission, January, 2016)

Telehealth Resources

  • Smartphone Applications for Patients’ Health and Fitness. Article introduces evidence that smart phone apps can better help patients reach their health and fitness goals,  describes what features to look for in an app, gives an overview of popular health and fitness apps, and offers app recommendations. Current limitations of apps, and future research are also discussed. (The American Journal of Medicine, 2016)
  • Care Plans: A Path to Driving Better Outcomes. “Healthcare payers are transitioning from a volume-based to value-based payment model, meaning that medical professionals will only get paid for the success of care, rather than for conducting the care itself. This shift requires quality metrics to assess outcomes, which can only be achieved through consistently delivered care plans and comprehensive health data tracking. When the feedback loop of an intervention engine is achieved, effectiveness of standardized interventions can be understood to accurately provide reimbursement and improve national healthcare as a whole.” (Involution Studios, March, 2016)