Billing for Professional Telehealth Services During the Public Health Emergency

SPECIAL EDITION 

Tuesday, March 31, 2020 

Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. When billing professional claims for non-traditional telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with the Place of Service (POS) equal to what it would have been in the absence of a PHE, along with a modifier 95, indicating that the service rendered was actually performed via telehealth. As a reminder, CMS is not requiring the “CR” modifier on telehealth services. However, consistent with current rules for traditional telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:

• Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology, use GQ modifier
• Furnished for diagnosis and treatment of an acute stroke, use G0 modifier

Traditional Medicare telehealth services professional claims should reflect the designated POS code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. There is no change to the facility/non-facility payment differential applied based on POS. Claims submitted with POS code 02 will continue to pay at the facility rate.

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-31-mlnc-se

CMS Issues New Telemedicine Guidelines and Approves Seven New Procedures in Move to Further Encourage Telehealth Initiatives

As the Medicare program expands telemedicine services, the opportunity may arise for sub-specialist pathologists to offer consultation services across state lines

More use of telemedicine across state borders has long been predicted as a way to improve access to care—particularly for patients in rural areas—as well as to give physicians and patients access to talented sub-specialists. Within the anatomic pathology profession, however, there are probably as many pathologists who view telemedicine across states lines to be a threat as there are pathologists who see it as an opportunity to raise the quality of care.

For its part, the Centers for Medicaid and Medicare Services (CMS) is taking a step forward in supporting the wider use of telemedicine. It is issuing new rules that expand reimbursement for remote patient services, a move that one day could benefit pathologists who provide sub-specialty pathology consultations with referring physicians across state lines.

CMS Added Seven Procedures to Its New Telehealth List

When final payment rules governing how Medicare will pay healthcare providers and suppliers in 2015 were released last October, CMS added seven procedures to the telehealth list of covered services, including annual wellness visits, psychotherapy services, and prolonged services in the office.

The American Telemedicine Association (ATA), which has long advocated for widespread use of telemedicine, praised the CMS for opening the door to greater access to telemedicine.

“It’s been a long time coming, but this ruling making signals a clear and bold step in the right direction for Medicare,” Jonathan Linkous, CEO of ATA, said in a statement. “This allows providers to use telemedicine technology to improve the cost and quality of healthcare delivery.”

What This Means for Pathologists

As the use of telemedicine becomes more common, states will be pressured to revise physician licensure laws to make it easier for out-of-state physicians to provide telemedicine services to in-state patients. For the medical laboratory profession, this might eventually make it possible for pathologists to one day be able to remotely monitor chronic patients using patient self-test devices that upload lab test results in real-time to their clinical laboratories.

For now, remote patient monitoring will continue to be available only to some Medicare patients. As Politico points out, CMS stopped short of dropping the provision requiring patients to be in a rural location to receive billable telemedicine services.

“We do not have authority to implement many of these revisions under the current statute,” Politico quoted CMS as stating. “The CMS Innovation Center is responsible for developing and testing new payment and service delivery models to lower costs and improve quality for Medicare, Medicaid, and CHIP beneficiaries. As part of that authority, the CMS Innovation Center can consider potential new payment and service delivery models to test changes to Medicare’s telehealth payment policies.”

In all, Medicare payments to telehealth are 0.8% higher in 2015.

Chronic-care Management Receives New Code: Causes Confusion

The CMS also added a new Current Procedural Terminology (CPT) code for chronic care management services. However, this change may not be as significant as first thought, because, as the ATA explained in a statement, “CMS has once again not allowed payment for data collection.”

In an iMedicalApps.com article, Perry Payne, M.D., J.D., M.P.P., Assistant Research Professor in the Department of Health Policy at the George Washington University School of Public Health and Health Services (GW), and an adjunct at Howard Law, addressed the initial confusion over the Medicare rule allowing for payment for chronic-care management.

“Some media outlets and organizations that support telemedicine are reporting that CMS is paying for remote monitoring of chronic care management patients because of a new rule that offers providers reimbursement for non-visit based services for chronic care management patients,” Payne wrote. “However, this change is not focused on telehealth or digital health services as it can include many other activities.”

Health Plans Support Telemedicine

Greater CMS reimbursement for telemedicine likely will be the impetus needed for more private payers to jump on the telemedicine bandwagon. For now, Aetna, Highmark, and Cigna are among the private insurers reimbursing for telemedicine and telehealth services, Healthcare IT News reported.

Highmark has been an early adopter of telemedicine. The private payer first offered primary care visits through Teladoc to beneficiaries in 2012. In January 2015, Highmark became the first health insurer in the country to offer teledermatology as a covered benefit.

“We need to make sure our members get the right care in the right setting, and telemedicine is a key tool to help make that setting more patient-centered,” said Donald R. Fischer, M.D., MBA, Highmark Senior Vice President and Chief Medical Officer, in a company statement. “Telemedicine is a resource that is critical to transforming the delivery of healthcare. It ensures faster access to high-quality healthcare while also helping to control costs.”

Texas Erects Barriers to Telemedicine

Telemedicine, however, still remains controversial. In April, the Texas Medical Board voted to rein in the practice of telemedicine in Texas by requiring physicians to conduct in-person visits with patients before providing diagnoses or prescribing drugs by phone or video, the Houston Chronicle reported. The only exception would be if a patient is at a healthcare facility such as a hospital, clinic, or pharmacy, and has another healthcare professional with them. Mental health visits are excluded from the rules.

“What the board is trying to do is really to keep patients safe,” Douglas W. Curran, M.D., a family physician and Vice Chair of the Texas Medical Association Board of Trustees, told the Houston Chronicle. “They want patients to be seen and evaluated so that patients can get the very best car possible. And I happen to agree with that.”

Opportunities for Pathologists

What pathologist will want to note is that CMS is taking another forward step in supporting the expanded use of telemedicine. That will put pressure on states to revise their physician licensure laws to make it easier for out-of-state physicians to provide telemedicine services to in-state patients. As that happens, this trend may open the door for more pathologists to provide sub-specialty pathology consultations with referring physicians across state lines and do patient consults as well (that are reimbursable to the consulting pathologists).

Read more: CMS Issues New Telemedicine Guidelines and Approves Seven New Procedures in Move to Further Encourage Telehealth Initiatives | Dark Daily http://www.darkdaily.com/cms-issues-new-telemedicine-guidelines-and-approves-seven-new-procedures-in-move-to-further-encourage-telehealth-initiatives-608#ixzz3ceYthMR9

Study Finds Pediatric Telemedicine Improves Patient Outcomes

Following a comprehensive study of 1,000 pediatric telemedicine consultations available throughout Latin America, researchers at Children’s Hospital of Pittsburgh discovered physicians there were highly satisfied with the services and believed they had improved patient outcomes.

The study, covered in Healthcare IT News, showcased Children’s multi-center experience in telemedicine at three hospitals in Colombia and one in Mexico from July 2011 to June 2013.

Children’s physicians provided 1,040 consultations for 476 patients, with a real-time intervention taking place in 23% of those encounters. In 6% of the tele-consultations, a different diagnosis was suggested based on the interpretation of cardiac or imaging studies.

Relevant patient data was provided in a secure database and telemedicine hardware was used for real-time consultations.

We’re told that a CICU physician from Children’s participated in all encounters.

Based on anonymous surveys of physicians participating at the international centers, 96% of respondents reported being satisfied or highly satisfied with the telemedicine service, while 58% rated the promptness and time dedicated by the tele-intensivists as very high. Physicians reported that they sometimes changed their clinical practice in relation to the telemedicine encounters, with changes in surgical management noted most frequently.

“Now we know that the physicians we assist internationally consider this technology to be useful for patient outcomes and education. We will continue to expand access to the world’s best healthcare for children around the world,” said lead investigator Ricardo A. Muñoz, M.D.

The study is available for review here.

http://mhealthwatch.com/study-finds-pediatric-telemedicine-improves-patient-outcomes-23702/

Telemedicine may ease chronic pain

Telecare may ease chronic pain

A telemedicine program using automated phone calls or the Internet to monitor symptoms and tailor drug treatment might help patients with chronic pain improve their condition, a new study found.

Researchers at Indiana University School of Medicine randomly assigned 250 patients with chronic musculoskeletal pain to receive either telecare or standard care from their primary care doctor at a Veterans Administration medical center. Patients in the telecare group reported their pain levels through an interactive voice-recorded call or online, and their answers guided adjustments to their medications, based on an algorithm.

After one year, the telecare patients were nearly twice as likely to report a 30 percent improvement in their pain compared with those who received standard care, and they were more likely to report feeling satisfied with their treatment. Those who received standard care were almost twice as likely to report feeling worse pain after six months compared with the telecare group.

BOTTOM LINE: A program using phone calls or the Internet to monitor symptoms and tailor care might help patients with chronic pain improve their condition.

CAUTIONS: Participants consisted of veterans from a single medical center so the findings may not apply to a wider group. The study relied on self-reports of pain, which may not be accurate.

WHERE TO FIND IT: Journal of the American Medical Association, July 16

http://www.bostonglobe.com/lifestyle/health-wellness/2014/07/20/telemedicine-may-ease-chronic-pain/IENXEzLQJnfkzwY1ZXXw4L/story.html

Mercy Virtual Care Center In Works, Will Benefit Western Arkansas

Image courtesy of Mercy / A $50 million Mercy Virtual Care Center in Chesterfield, Mo., is under construction. A virtual groundbreaking was held Tuesday, May 13, 2014, at Mercy Fort Smith for the center that will benefit the Mercy system.

Mercy Fort Smith and its regional satellite community hospitals will benefit from a new $50 million Virtual Care Center, the first of its kind in the nation, being built near St. Louis.

A virtual groundbreaking by video was held Tuesday at Mercy Fort Smith’s Hennessy Center with a graphic artist’s digital rendering of the four-story, 120,000-square-foot building at Chesterfield rising up before Mercy president and CEO Lynn Britton and Mercy staff on a big-screen projection.

The new facility will serve as the command center for all of Mercy’s telemedicine programs, a growing list that includes the nation’s largest single-hub electronic ICU, SafeWatch eICU, and 75 other services like pediatric telecardiology, nurse-on-call, telestroke and home monitoring.

“Telemedicine will have a significant impact by letting virtual physicians and nurses be the first point of triage and care for patients in the hospital, emergency room, or even at home,” Dr. Tom Hale, executive medical director of Mercy’s telehealth service, stated in a news release.

Dr. Cole Goodman, Mercy Clinic president, said a shortage of physicians is “not just a Fort Smith problem.”

Only one in 10 doctors practice in rural areas, while nearly one in four Americans live in these areas, the release states. Mercy patients in Fort Smith, and at satellite Mercy community hospitals in Booneville, Ozark, Paris and Waldron will be able to take advantage of the virtual care system with nearly 300 highly specialized medical professionals providing care.

Ryan Gehrig, Mercy Fort Smith president, said the “comfort level” among patients with virtual care technology has increased along with the improved performance of Mercy’s network. Cameras and monitors allow physicians to even examine retinas if needed. Mercy estimates the new virtual care center will manage more than 3 million telehealth visits in the next five years.

Hale noted in the release that Mercy’s virtual care “frees up physicians while also attending to patients faster than before.” Before pediatric telemedicine, it sometimes required a week or more to get results of an echocardiogram (images of the heart). A virtual pediatric cardiology team cuts that down to 24 hours or less.

The new virtual care center in Chesterfield is expected to be complete and open in 2015. From 2007 to 2012 the telemedicine monitoring market more than doubled, growing from a $4.2 billion to $10 billion a year operation, the release states.

Likewise, Mercy Fort Smith’s patient numbers increased by an average of 31 patients a day in May compared to the same time last year, Gehrig said. The hospital is full and Gehrig attributed the increase, in part at least, to Arkansas’ “private option expanding health care participation,” he said.

http://swtimes.com/business/mercy-virtual-care-center-works-will-benefit-western-arkansas

Lawmakers look to expand, regulate telemedicine in Florida, but House Senate bills far apart

MIAMI — The calls may come in the middle of the night and from hospitals more than an hour away. Someone is having a stroke and is en route an emergency room in the Florida Keys, but there aren't any neurologists on call.

Within 15 minutes, a University of Miami neurologist pops onto a computer screen and can order an IV drug that should be given within three hours. It's that sort of potentially life-saving technology that some lawmakers say will drive down health care costs, while also addressing serious doctor shortages around the state.

A Senate bill would increase the use of telemedicine in Florida and establish requirements for health providers who treat patients remotely. A companion bill is also making its way through the House, but that bill doesn't require doctors to have a Florida license — only that they be licensed in their home state and registered in Florida.

"If we didn't have an access problem we wouldn't be here today ... everyone would rather see the doctor face to face, but when your mother is having a stroke in rural Florida and the choice is having a doctor via telehealth versus having no doctor," said Rep. Cary Pigman, an emergency room physician who supports the bill.

The Senate bill requires doctors providing telemedicine services to patients within the state to be licensed in Florida or meet an alternative requirement. For example, an insurer using a doctor that's in-network in another state would also be allowed to treat a Florida patient. The bill recently passed a Senate committee, but has two more stops before it's heard on the floor. Dozens of other states have passed legislation supporting telemedicine.

The Senate bill also would require Medicaid to reimburse for telemedicine services and allow doctors to negotiate payment rates with insurers. The House bill doesn't address payments.

"If you're a patient in Florida and you have a specific heart defect and the guru is a doctor in Philadelphia, you should be able to consult with her," said Republican Sen. Aaron Bean, who is championing the bill.

But critics worry that requirements for doctors in other states could compromise patient care. Some say that doctors practicing telemedicine in Florida should be licensed here.

"It may be the wave of the future, but I still think we need to concentrate on the patients and the bottom line is these (out of state) doctors are not licensed in Florida so they don't have the same accountability," said Sen. Dorothy Hukill, who voted against the bill.

Bean said they will be held accountable through the insurance company or the doctor's network they practice within.

Rep. Gayle Harrell, voted for the bill, but noted it still has problems.

"I also need to know what my recourse action should be should some malpractice incident take place," she said.

She also wants to see a website created where people can find information about the out-of-state doctors who may be treating them. After all, she noted, patients can't walk into the office of an out-of-state doctor and see medical degrees on the wall.

The Florida Chamber and several other groups, including ones representing nurse practitioners, physician assistants, nurses and pharmacists all support the bill.

But the powerful Florida Medical Association is strongly opposed, worrying it doesn't require treatment by a licensed Florida physician or mandate a review of the patient's medical history. The organization said such technology holds great promise, but does not support the bill in its current form.

"This will revert Florida back to the days of the Wild West where anyone with a bottle of whiskey, a pocket knife and Skype can practice medicine. That's what happens to the bill in its current form, said David Custin, a lobbyist for the group.

Several hospitals around the state have had success with telemedicine in recent years, helping patients in rural areas connect to specialists or getting multiple consultations conducted simultaneously for acute emergency cases. University of Miami neurologist Dr. Gustavo Ortiz has done more than 600 consultations since their program's inception in 2009.

Telemedicine saves money by reducing hospital and ER admissions and doesn't require medical transportation, supporters say.

Dr. Kim Landry, an emergency room physician and EMS medical director for four counties in the Panhandle, began a pilot program where 911 responders connect patients remotely to an ER doctor for a quick evaluation.

"Eight out of 10 times, they don't require transport to the hospital, so in a lot of cases, it's made life easier for a lot of sick patients," said Landry, who found those results after testing the program in nursing homes.

During a recent consultation, University of Miami dermatologist Dr. Anne Burdick asked an assistant at a Fort Pierce county health clinic to zoom the camera in on some scaly, white patches on a 10-year-old boy's legs. The boy is often kept indoors and complains of constant itching at night. Burdick, who diagnosed him with eczema, modified his prescriptions and added a monthly bleach bath to reduce bacteria. The boy was one of five pediatric patients seen remotely from her Miami office that day.

Burdick, who estimates 40 percent of her practice includes telemedicine patients, also does medical consultations for two cruise lines, the Indian Health Service and a weekly program for school children.

"For some areas in the state, it's going to be impossible to get specialists to that area and so telemedicine is really the best option, " said Burdick. "The bill will be a really good step forward for Florida."

http://www.dailyjournal.net/view/story/de83d3480a7e46b48960943b1abb6b03/FL--Telemedicine/#.U0PoOPldWSo

Cole Memorial offers telemedicine for pediatric emergencies

Photo courtesy of Cole Memorial

Cole telemedicine

From left, Cole Memorial Hospital maternity department employee Ashley Cowburn, RN, along with pediatrician Dr. Marlene Wust-Smith, examine Sophia Cizek, 4, with her father, Scott, and Steve Weidner, RN, in the hospital’s emergency department pediatric telemedicine examination room.

COUDERSPORT — Cole Memorial Hospital in Coudersport has launched pediatric telemedicine in the emergency department and maternity unit, thanks to the Optimizing Utilization and Rural Emergency Access for Children (OUTREACH) program through the University of Pittsburgh Medical Center.

Hospital officials said when a child requires emergency health care, pediatricians and emergency medicine providers at Cole Memorial will be able to consult with clinical specialists at Children’s Hospital of UPMC via the new state-of-the-art telemedicine technology.

“The telemedicine unit is portable so it can be used in the emergency department or in the newborn nursery at the hospital, allowing our providers to collaborate with pediatric specialists in Pittsburgh,” said Ann Slotta, RN, director of maternal/child and inpatient behavioral health services at Cole Memorial.

Telemedicine offers two-way audio/video conferencing applications to provide high-level clinical consultations between a Cole Memorial provider and a specialist at a distance.

Cole Memorial director of emergency services Shannon Work, RN, said 18 percent of the patients that visit the hospital’s emergency department are age 18 and under. 

Hospital officials said so far, the benefits of Cole Memorial’s pediatric emergency telemedicine service include patients and their family travel less to receive specialized care; the need for hospital admissions may be reduced; when higher-level care or a special procedure is required, transfers may be made immediately; expert care is available 24/7; and provides patients, their family members, hospital providers and staff with an increase in satisfaction with the outcomes.

“The first pediatric tele-emergency patient visit ... allowed our patient to be evaluated by an emergency room provider at the Children’s Hospital of Pittsburgh, who agreed with me that he was stable for discharge to his own home,” said Dr. Marlene Wust-Smith, a pediatrician. “Our patient was relieved to not have to travel four and a half hours to Pittsburgh, and I was reassured that his presenting complaint did not require further work-up.” 

In addition, the following tele-medicine services are available at Cole Memorial with expert clinical partners such as: Rheumatology with the Geisinger Health System in Danville and cardiology and neurology with UPMC Hamot Heart and Vascular Institute in Erie. 

For more information, visit the website www.colememorial.org.

http://www.bradfordera.com/news/article_b7eb4d68-b921-11e3-8d27-0019bb2963f4.html

Revisiting how Christensen’s “disruption innovation” in healthcare means decentralization

By: Jonah Comstock | Mar 26, 2014   

The term “disruptive innovation” has become so much of a buzz word, it’s not uncommon to hear it applied to just about any radical shift in care. But for Harvard Business School professor Clayton Christensen, who invented the term, it has a very particular meaning. Most innovations are “sustaining innovations” — they make an existing product better and cheaper for its existing customers, and allow producers to sell it at a better margin. Disruptive innovations actually drive costs down, but ultimately end up more profitable because they open up the market to customers that didn’t exist before.

At Better Health Boston, a one-day event for healthcare industry stakeholders hosted by McKesson Corporation, Christensen talked about how the idea of disruptive innovation really applies to healthcare — and what the healthcare system needs to do to go forward.

As an example of a disruptive innovation cycle, Christensen talked about the computer business, specifically the move from $2 million mainframes to $200,000 minicomputers to $2,000 personal computers, and finally to $200 smartphones. He pointed out two things: each innovation brought computing technology to a larger segment of the population, and none of the market leaders in any part of the chain was able to stay a market leader in the next part (with the possible exception of Apple).

“[Makers of minicomputers] got no signal that the personal computer mattered to their customers, because it didn’t matter to their customers,” he said. “We started using a PC for simple things and then the tech got better and better and better, until we could solve all our problems with a personal comupter and we didn’t have to buy a mainframe anymore. And the leaders in that space got killed. … It’s not that the market leaders didn’t see it coming. It’s that it made no economic sense.” 

In healthcare, the market already includes all the possible consumers. The way disruptive innovation will happen, he believes, is in the form of decentralization. Rather than just innovating diminishing returns on better and better hospital-based treatment mechanisms, innovation will consist in taking equal or even inferior versions of technology that exists in hospitals and moving it outward — to clinics, retail clinics, and, eventually, the home.

The way that technology enables that shift outward in care is by doing what Christensen calls “commoditizing experience.” As the scope of medical knowledge has increased, doctors have already made a shift from intuitive care, where educated guesses and trial and error came to bear in treating patients, to evidence-based medicine, where doctors devise treatment plans based on what’s worked best historically in patients with the most similar symptoms.

The shift from evidence-based medicine to personalized medicine, where the doctor uses detailed data about a particular patient to devise a highly specific treatment plan, will be the same kind of shift. Each gradation makes diagnosis and treatment easier to teach, allowing more parts of care to scale out from physician specialists to nurse practitioners to patients and families.

Decentralization will also solve what Christensen considers a fundamental business problem for hospitals.

“In a typical hospital, overheads account for 85 to 90 percent of total costs because of the complexity of offering a ‘one size fits none’ offering,” he said. “It turns out there are three different business models inside a hospital, and those three business models are incompatible.”

The diagnostic function of a hospital functions similarly to a consulting firm, he explained, and works best with a fee for service business model. The acute care and surgery functions of a hospital are a process business, like manufacturing or education, and should have an outcomes-based business model. Finally, chronic disease management and patient community-building are facilitated networks, like telecom companies or insurance companies, and they want a membership-based payment model. Decentralization of care would enable each of those businesses to operate more efficiently, with less overhead.

Christensen thinks actual disruptive innovation in healthcare hasn’t really begun yet. But technologies on the horizon — from home health sensors, to telemedicine, to increasingly sophisticated population health management, could start to move that needle.

http://mobihealthnews.com/31470/revisiting-how-christensens-disruption-innovation-in-healthcare-means-decentralization/

Telemedicine: Doctor Visits via Video Calls

By Olga Kharif February 27, 2014

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(Corrects reference to the technology used by Lindsay Kolowich in the sixth paragraph.)

One night last fall, Beth Ferrin’s 9-year-old son came home with a swollen throat and fever. It was after dinner, so she flipped open her laptop and dialed into LiveHealth Online, a service offered by her insurer, WellPoint (WLP), that connects patients with doctors via video calls. Fifteen minutes later, Ferrin says, “we were on with a doctor.”

After a quick diagnosis of an infection (the doctor, Ferrin says, treated it as strep, though couldn’t diagnose that without a test), a prescription for an antibiotic was called in to a pharmacy near Ferrin’s home in Bellbrook, Ohio. “By 10 p.m., I was back home,” she says. “It was quick and easy.” Her other options would have been to see a doctor in the morning or risk a long wait at an urgent care facility. The video call was faster and cheaper—it cost $40 instead of the $100 a pediatrician would charge, she says.

Hundreds of employers of all sizes are contracting directly or through their insurers with telehealth providers to cut medical costs and give workers 24-hour access to doctors and nurse practitioners. WellPoint teamed up with Boston-based American Well to offer telemed services to 3.5 million of its health-plan subscribers last year and intends to extend the service to another 32.5 million over the next 12 to 18 months. UnitedHealth Group (UNH) began a pilot program in January, providing 310,000 subscribers in Nevada with virtual doctors’ visits.

Telemedicine has been spurred in part by the Affordable Care Act, which is funneling more patients into a system plagued by physician shortages. By 2020 the U.S. will have 91,500 fewer doctors than needed, says the Association of American Medical Colleges. Telehealth providers say they help make up for this shortfall by aiding doctors in delivering services more efficiently. WellPoint says users of LiveHealth Online saved an average $71 per visit and most of them saved two to three hours of time.

The widespread use of camera-equipped devices has made remote medical connections easier, and high-definition video often provides enough detail for medical professionals to make diagnoses. “Sometimes if it’s a rash, we can see the rash,” says Katherine Sandstrom, a nurse practitioner in Portland, Ore., who sees a few patients via video each week through health-services provider ZoomCare.

Lindsay Kolowich, a 23-year-old marketer in Boston, recently consulted a doctor through American Well. She wanted to check on how her foot was healing after recent surgery. Her surgeon was far away and only available midday, so she opted for a teleconsult that didn’t require time off from work. “It saved me four or five hours,” Kolowich says. “I had to show him where it hurt and how flexible my foot was, and he gave me easy directions on what to do,” she says.

Telecare works well for treating common conditions such as colds, flu, pink eye, and sprains, providers say. The larger telemedicine companies contract with doctors with an average 15 years’ experience who are certified to practice in the states from which patients call.

The American Telemedicine Association is developing an accreditation program for telehealth providers. A bill introduced in Congress last year by Representatives Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio) would create federal telecare standards.

“I don’t think we know how it works, the risks and benefits at the moment,” says James Perrin, president of the American Academy of Pediatrics. When asked about the throat infection of Ferrin’s son, Richard Rosenfeld, chairman of otolaryngology at SUNY Downstate Medical Center in Brooklyn, N.Y., said: “The only way to diagnose strep is with a test. Best practices say you can’t just throw an antibiotic at somebody.” He says there’s only so much a doctor can tell without an examination performed in-person and telemedicine visits could result in unnecessary medication.

Telehealth companies say they track their doctors’ prescribing practices to ensure they’re in line with the prescription levels of in-clinic doctors. “Reaching out to your primary physician is the best way to be treated,” says Timothy Howard, senior medical director for telemed provider Teladoc. “But if that physician is not available, we would like to be that next level.” Many doctors who provide telehealth services often advise patients to follow up with their doctors.

Most users pay about $40 a visit and receive the services through their insurers. A small number have signed on directly, paying as little as $10 a month for a subscription. About 20 states require private insurers to reimburse doctors for services provided remotely. At least 10 additional states might enact similar laws this year, says Jonathan Linkous, chief executive officer of the American Telemedicine Association.

Telehealth companies are reporting double-digit revenue growth and attracting high-profile investors. MDLive raised $23.6 million in January. Its investors include former Apple (AAPL) CEO John Sculley. “Our service is expected to increase 10 times in the number of patient visits this year,” Sculley says.

“It’s going to be just like urgent care was in the U.S.—it’s now completely acceptable,” MDLive CEO Randy Parker says. “Within the next few years, no consumer will even remember not being able to connect to their providers through telehealth.”

The bottom line: Investors are putting money into telehealth services, used to treat common ailments.

Kharif is a reporter for Bloomberg News and Bloomberg Businessweek in Portland, Ore.

http://www.businessweek.com/printer/articles/186457-telemedicine-doctor-visits-via-video-calls

Telemedicine Bolsters ICU Care In Rural Maryland Hospitals

By Rita Rubin

FEB 12, 2014

This story was produced in collaboration with 

An intensive care unit nurse in a small-town hospital on Maryland’s scenic Eastern Shore suspected that a patient had necrotizing fasciitis, the so-called “flesh-eating” disease.

The condition is rare. Even experienced intensive care doctors seldom see it, and, since it was nighttime, no such physician was in the ICU. Pinning down the diagnosis was critical—and in this case Berlin, Md.’s Atlantic General Hospital had back-up.

Doctor Marc T. Zubrow, medical director at the University of Maryland Medical System's eCare, says he can use a bank of monitors to care for up to 100 patients in eight different hospitals all over the state of Maryland. Patients can be visually monitored and their lab tests and medical information are contained on the screens (Photo by Barbara Haddock Taylor/Baltimore Sun).

A critical care doctor 125 miles away was monitoring the patient’s health via voice, video and high-speed data lines constantly streaming information about vital signs, medications, test results and X-rays, a telemedicine service known as Maryland eCare. The physician quickly verified that the patient had the deadly infection and arranged immediate transfer to another hospital with a surgeon who could remove the infected tissue.

Atlantic General is one of Maryland eCare’s six original community hospital clients, which have a total of 72 ICU beds. By the end of the year, the program will go live in three more Eastern Shore hospitals, adding 18 more ICU beds.

Studies have shown that patients do better and leave sooner from ICUs managed by intensivists, another term for critical care doctors. But intensivists are in short supply nationwide, and small community hospitals like Atlantic General have a difficult time recruiting and retaining them, let alone paying their salaries. Connecting intensivists to small ICUs via telemedicine, proponents say, is the next best thing to hiring them.

Telemedicine, the exchange of medical information between sites via electronic communications, is being used not only by ICUs but also by other hospital departments, home health agencies and private doctors’ offices. But skeptics suggest that small ICUs might be able to improve care with less expensive measures. Telemedicine now costs hospitals roughly $40,000 to $50,000 a year for each covered bed. Initially, adaptation of telemedicine in ICUs nationwide was rapid, but a new study suggests it is slowing.

One of Maryland eCare’s 20 intensivists monitors ICU patients from 7 p.m. to 7 a.m. weeknights and for 24 hours on Saturdays and Sundays.  They’re stationed at computers in Maryland eCare’s COR—Central Operations Room—which last year moved from the Christiana Care Health System in Wilmington, Del., to the University of Maryland Medical Center in Baltimore. On weekdays, when the hospitals’ critical care doctors are at work, eCare critical care nurses staff the COR computers.

Physicians and nurses at the University of Maryland can monitor ICU patients using voice, video and high-speed data lines that constantly stream information about their vital signs using a telemedicine service known as Maryland eCare (Photo by Barbara Haddock Taylor/Baltimore Sun).

Critical care specialist Atif Zeeshan and another intensivist work in Atlantic General’s ICU from 7 a.m. to 7 p.m. on alternating weeks, and they’re on call 24/7. Zeehan said he was at first leery of telemedicine. Four years after his eight-bed ICU hooked up with Maryland eCare, Zeehan is a believer. “There have been cases where lives were saved with eCare intervention,” he says. 

Maryland eCare was established with a $3 million grant from CareFirst BlueCross BlueShield, which helped cover capital expenses, such as computer and video connections. Participating hospitals pay Maryland eCare an annual fee for each ICU bed. Other eCare clients are Peninsula Regional Medical Center in Salisbury, Union Hospital in Elkton, Meritus Medical Center in Hagerstown, Calvert Memorial Hospital in Prince Frederick and MedStar St. Mary’s Hospital in Leonardtown.

Zeeshan’s initial skepticism isn’t unusual. “Nobody wants to be dictated to,” acknowledges Marc Zubrow, a critical care and lung specialist and eCare Maryland’s medical director. “An absolutely huge part of my job,” says Zubrow, is to “convince the local medical community that this will not negatively impact patient care and might possibly improve patient care.”

Hospital representatives routinely visit the Baltimore COR, and Zubrow and members of his team regularly visit the community hospitals and “get very close with the local bedside people.”

And sometimes to patients’ families.  Zubrow shared an eCare doctor’s notes about an interaction with a patient’s daughter (stripped of information that could identify the patient). The woman, who’d flown in to be at her critically ill mother’s bedside, arrived  around 3 a.m. and spent a few minutes video-chatting with the eCare intensivist on duty.

“I told her that nothing we do medically is going to improve her mother’s condition or meaningfully prolong her life,” according to the doctor’s notes. “I urged her to allow us to focus on treating her mother’s pain and suffering…I offered my support and told her I would speak with her again at any point tonight.”

Community hospitals say telemedicine helps critically ill patients be treated close to home and family. Even with extra oversight, however, these hospitals are still not equipped to care for all critically ill patients, so telemedicine intensivists help them decide which patients should be transferred.

Telemedicine has helped improve the care of ICU patients says registered nurse Anne Lockhart, who directs the unit at Calvert Memorial. Lockhart says that includes a reduction in the number of patients contracting pneumonia as a result of being on a ventilator.

Since implementing telemedicine, “we dramatically reduced our ICU mortality rate,” says Ed Grogan, vice president of information services and chief information officer at Calvert Memorial.

But Jeremy Kahn is skeptical. An associate professor of critical care, medicine and health policy at the University of Pittsburgh, he says assessing telemedicine’s effectiveness in the ICU is tricky. Comparing mortality rates before and after implementation of telemedicine doesn’t account for the fact that “outcomes in the ICU get better over time, no matter what,” Kahn says.

A better comparison would be to other, less-expensive, measures, such as using more non-physician providers—physician assistants and nurse practitioners—at ICU patients’ bedsides, Kahn said.

While Maryland eCare is adding hospitals, Kahn says adoption of telemedicine in ICUs nationwide is slowing. In a study published online in October by Critical Care Medicine, Kahn and his colleagues found that the number of U.S. hospitals using telemedicine in ICUs increased from 16, or 0.4 percent, in 2003, to 213, or 4.6 percent, in 2010, with usage doubling in the first four years but dropping to average growth of 8.1 percent in the last four.

 “In an era of cost constraints, I feel we need to be simultaneously exploring cheaper ways to get the same outcome,” Kahn says. “That’s not to say we should not explore telemedicine.”

http://www.kaiserhealthnews.org/Stories/2014/February/12/Some-Maryland-hospitals-use-intensivists-to-improve-healthcare.aspx

USDA awards millions for telemedicine

Posted on Feb 05, 2014

By Bernie Monegain, Editor

Ozarks Medical Center in Missouri and Flagstaff Medical Center in Arizona are just two hospitals in 25 states across the country that will receive federal funding for telemedicine projects. Agriculture Secretary Tom Vilsack announced nearly $16 million in USDA grants would be disbursed for distant learning and telemedicine services.
The USDA's Distance Learning and Telemedicine Loan and Grant program provides funding to rural hospitals, clinics, schools and libraries for equipment and technical assistance for telemedicine and distance learning. Grant recipients must demonstrate that they serve rural America, prove there is an economic need and provide at least 15 percent in matching funds.


Since 2009, USDA has invested almost $150 million in the Distance Learning and Telemedicine program. The investments complement other USDA efforts to improve rural communications. In FY 2013, USDA provided $305 million in loans for broadband infrastructure. These loans will result in new or upgraded broadband service for about 120,000 rural households, businesses and community institutions once the projects are completed.



Hospitals receiving telemedicine grants are:

Alaska
Chugachmiut: $180,656
Funds will be used to re-establish a telemedicine network between Native village sites in the Chugach region and offices in Seward and Anchorage. Clinics in the villages of Tatitlek, Chenega, Port Graham and Nanwalek will be linked with Anchorage and the North Star Clinic.

Alaska Native Tribal Health Consortium: $114,842
Funds will be used to purchase video teleconferencing equipment systems for virtual sessions between patients and health care providers. It is projected that nearly 3,200 people will benefit in the first year alone. The Alaska Native Tribal Health Consortium includes nine organizations that deliver innovative telehealth solutions throughout the  Alaska Federal Health Care system.

Arizona
Flagstaff Medical  Center: $129,412
Funds will be used to purchase digital electronics and software for a telemedicine system linking the Flagstaff medical center with clinics in Coconino, Apache, Mohave and Navajo Counties. This system will connect local caregivers and their patients with specialists at Flagstaff.

Kentucky
Norton Healthcare Foundation: $259,607
Funds will be used to expand the Norton Rural Medicine Initiative. The equipment will allow Norton physicians and other medical specialists in Louisville to consult medical staff and their patients at Breckinridge Health and Westlake Regional Hospitals in Kentucky; and Scott Memorial Hospital in Indiana. With the telemedicine network, patients no longer will have to travel for pulmonary, cardiology, neurology, infectious disease and critical care.

Maine
Community Health & Counseling Services: $103,235
Funds will be used to purchase in-home patient monitors, medication dispensers and screening monitors for Community Health and Counseling Services, which serves patients in Piscataquis and Washington counties with congestive heart failure, medication compliance issues, patients who need speech pathology to address swallowing disorders. The project is expected to reduce preventable hospital visits and emergency room visits, saving time and money.

Missouri
Ozarks Medical Center: $274,638
Funds will be used to buy equipment to expand medical services to Ozarks Medical Center's four hospitals and nine clinics. Services will include tele-stroke, tele-psychiatry, tele-speech therapy and tele-dermatology.

Harrison County Community Hospital District: $500,000
Funds will be used to purchase software and equipment for Harrison County’s teleradiology system. A Radiology Information System will be purchased to connect end-user workstations at clinics in Princeton, Cainsville and Bethany. The project will also fund a new telemedicine unit for the hospital's outpatient clinic. The hospital will be able to improve operations in several departments, including emergency, respiratory therapy
and cardiac rehabilitation.

Mercy Health: $382,748
Funds will be used to purchase equipment and devices for exam rooms in 11 sites in Missouri, Arkansas and Oklahoma. Physicians and other medical specialists at Mercy Hospital in St. Louis will use the audio/video equipment for face-to-face consultations, observation and diagnosis, and treatment planning.

Mississippi
University of Mississippi Medical Center: $378,360
Funds will help a consortium of rural hospitals in Mississippi acquire high-definition video teleconferencing units for their emergency rooms, and mobile units for ambulatory care at each hospital. The University of Mississippi Medical Center will make specialists and medical personnel available through the video network to respond interactively to live emergencies from any of the participating sites.

North Carolina
Grandfather Home for Children: $393,368
Funds will be used to install video teleconferencing equipment. Grandfather Home is a facility in Banner Elk, N.C., for abused and neglected children. Video conferencing will provide critical therapeutic services for children and a direct line of communication between children and their foster parents.

New Hampshire
Mary Hitchcock Memorial Hospital: $498,356
Funds will be used to purchase equipment and software to expand the telemedicine network at the Mary Hitchcock Memorial Hospital to new sites in New Hampshire and Vermont. After this expansion is deployed, the system is projected to provide medical expertise for more than 5,000 rural residents.

Mary Hitchcock Memorial Hospital: $500,000
Funds will be used to purchase telemedical carts and related equipment for 18 rural sites. The participating sites include rural acute care hospitals, ambulatory care sites, rehabilitation sites and behavioral health centers in
Woodsville, Littleton, Greenfield, Colebrook, New London, Whitefield, Lancaster and Groveton.

South Carolina
Hampton Regional Medical Center: $249,162
Funds will be used to purchase a variety of video teleconferencing equipment and digital exam devices for the medical center and nine end-user sites. Roper St. Francis Hospital in Charleston will serve as a hub site for medical specialists and video system management. The video teleconferencing platform will allow face-to-face consultations between patients and physicians and between local health care providers and medical staff at the hub site.

Washington
Kadlec Regional Medical Center: $329,269
Funds will be used to purchase telemedicine equipment for a consortium of 12 health care organizations serving 19 sites at rural clinics along the Columbia River in Eastern Oregon and Washington. The Medical Center and participating hospitals will offer a comprehensive array of services and consultations.

West Virginia
Davis Memorial Hospital: $74,189
Funds will be used to establish telemedicine consultations between physicians at Davis Memorial Hospital and the Cortland Acres (Tucker County), Pendleton Manor (Pendleton County) and Mansfield Place (Barbour County) nursing homes. Physicians will be equipped with iPads and video-enabling software to increase their availability to observe and provide diagnosis for residents and patients.
Also USDA gave several awards that combined funding for both distance learning and telemedicine.

Missouri
Citizens Memorial Hospital District, $175,989
Funds will be used to provide telemedicine equipment for a partnership led by Citizens Memorial Hospital. The hospital and its hub partners will provide telemedicine services to rural clinics in Pleasant Hope, Rockville, El Dorado Springs, Stockton, Greenfield, Buffalo, Montrose, Wheatland, Hermitage, Humansville, Appleton City and Deepwater.

Montana
Kalispell Regional Medical Center, $363,326
Funds will be used to help Kalispell Regional Medical Center provide 24/7 telemedicine consultation services in its nine
county area. The equipment will create a telemedicine service among the Western Montana Tele-neurology Network, Kalispell Regional Medical Center and critical access hospitals in the region.

New York
Jefferson-Lewis-Hamilton-Herkimer-Oneida Board of Cooperative Educational Services, $487,267
Funds will be used to purchase video teleconferencing units for 37 schools in the Jefferson Lewis Hamilton Herkimer Oneida jurisdiction, 15 of which have never been connected to a distance learning system before. LeMoyne College in Syracuse, Clarkson University in Potsdam, Jefferson Community College in Watertown, and the Syracuse University School of Medicine will be part of the teleconference network.

Oklahoma
Board of Regents of the University of Oklahoma Health Sciences Center, $500,000
Funds will be used to purchase state-of-the-art digital equipment and software for a telemedicine initiative hosted by the University of Oklahoma Health Science Center. The initiative will use video teleconferencing to offer geriatric services to Choctaw Nation clinical sites -- including Stilwell Community Hospital -- and Choctaw clinics in Hugo, Broken Bow, Stigler, Idabel, Talihina and Atoka, and general services to health care facilities in Fort Cobb, Grandfield and Tipton.

South Carolina
South Carolina Department of Juvenile Justice, $196,809
Funds will be used to provide video teleconferencing systems for the South Carolina Department of Juvenile Justice. The equipment will give students a better chance of obtaining work skills and higher education opportunities

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