The United States Health Resources and Services Administration defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration” (Human Resources and Services Administration, 2012, para. 1). Telehealth can involve the exchange of information between different providers as well as between patients and providers. Additionally, both patient and provider can use telehealth technologies to derive information from the Internet or other electronic data stores. The main goal of telehealth is to improve patient health outcomes by increasing the accessibility and quality of medical care while decreasing the cost (World Health Organization, 2010).
Telehealth is not new to the medical industry. It has been used as early as the 1960’s to facilitate the exchange of information between psychiatrists and primary care physicians (World Health Organization, 2010). Currently, data exchange using telehealth services can take place over several different mediums including telephone consultations, text messages, and email. Multiple specialty fields provide services via telehealth, including radiology, pathology, and psychology (World Health Organization, 2010). Telemonitoring is the use of information technology and computerized devices to monitor patients remotely (World Health Organization, 2010).
In certain countries, telehealth has been widely used and extensively studied. The United Kingdom has utilized telehealth and studied its effects and has found significant benefits in its use. For example, a recent study in the United Kingdom found that telehealth services decreased patient deaths by 45 percent (Montgomery, 2011). Additionally, the same study found that telehealth cut emergency room visits by 15 percent (Montgomery, 2011).
Telehealth can also reduce the cost of care for both patients and providers. In a recent study in the United States, researchers found that the cost of hospital readmissions is approximately $16 billion per year (Deschenes, July 2012). Telehealth has been shown to reduce hospital readmissions and emergency visits by twenty percent by providing remote analysis and monitoring services, as well as at-home triaging services (Montgomery, 2011).
In addition to saving medical institutions and providers money, telehealth can be a source of new revenue. For example, healthcare providers can seek to contract with employers in order to provide services such as mental health counseling and nutrition counseling via video conferencing sessions (Deschenes, August 2012).
Lastly, telehealth can increase the quality of care by engaging or reengaging patients more effectively (Deschenes, August 2012). According to the magazine Healthcare Finance News, the introduction of performance-based payment incentives highlights the importance of coordinating care across the entire care continuum (Deschenes, August 2012). Telehealth services can provide an efficient way to link the different aspects of a patient’s care while keeping the patient engaged (Deschenes, August 2012)
Patients living in rural areas in the United States would benefit the most from access to telehealth services. This is because there are not many physicians available in rural areas that provide treatment in specialties like mental health, cardiology, and endocrinology. The disorders that these specialists treat are often prevalent in these poorer rural areas. Without access to telehealth services, patients living in these areas will have drive great distances to see these types of specialists or risk going without treatment.
Despite its proven ability to reduce costs in the United Kingdom and the potential benefits that could be realized from its use in underserved areas of the United States, physicians in the United States have remained reluctant to widely adopt this form of service. This is because telehealth remains a largely unregulated form of service delivery in the United States. Laws surrounding the provision of telehealth remain vague. Furthermore, insurance payers have yet to establish payment policies for telehealth services (Roberts J. Waters Center for Telehealth and e-Health Law, 2012). Lastly, as providers use telehealth to practice medicine across state lines, licensure issues have become a cause for concern. (Roberts J. Waters Center for Telehealth and e-Health Law, 2012).
Legal Implications of Telehealth
Because the laws surrounding telehealth are not yet well established, malpractice lawsuits involving treatment via telehealth technologies have been rare. There are only a handful of federal court cases involving the use of telehealth (Natoli, 2009). These cases primarily involve claims of negligence by “physicians prescribing medications to patients across state lines without previously examining the patient.” (Natoli, 2009, para. 12). However, there have been several criminal cases involving telehealth services tried in court.
In the notable case, Hageseth v. Superior Court, the issue of prescribing medication for patients using telehealth to deliver services was examined. On June 11, 2005, a California resident named John McKay purchased fluoxetine from an online pharmacy. The prescription, along with the answers to a short online questionnaire Mr. McKay completed, were sent to Dr. Hageseth for review. Dr. Hageseth was a physician with a license to practice medicine in the state of Colorado. He did not have a license to practice medicine in the state of California. Upon review of the questionnaire, Dr. Hageseth issued the prescription online to a pharmacy in Mississippi, who then mailed the medication to Mr. McKay in California (Hageseth v. Superior Court, 2012). Mr. McKay subsequently committed suicide. The autopsy revealed fluoxetine and alcohol in his system at the time of his death (Hageseth v. Superior Court, 2012). This case will be tried under criminal law, as Dr. Hageseth is accused of breaking California state law by practicing law in the state without a license.
This case brings to light two issues with regard to telehealth. The first issue is that of state licensure. New York State has a very robust system of regulation for approximately 30,000 different professions (New York State Education Department, 2012). In New York State, a mental health counselor must have at least a master’s degree in mental health counseling. Furthermore, the counselor must pass an exam administered by New York State’s State Education Department for mental health counseling. At this point, the counselor can apply for a mental health counselor license. The license allows providers to practice their specialty only in New York State. This is true of most state issued professional licenses. If a New York State licensed professional wishes to practice his or her profession in another state, he or she must pass a corresponding exam administered by the state in which the professional would like to practice. This poses a problem for those professionals who wish to use video conferencing or other forms of telehealth to provide services for patients in different states.
The second issue in this case revolves around the standard of care in prescribing medications to patients. The Center for Medicare and Medicaid Services has identified that the standard of medical care is the same regardless if the care was provided in person or via a telehealth technology (Natoli, 2009). The standard of care in the United States for issuing prescriptions is to first thoroughly examine the patient for whom the prescription will be written. However, a physical examination cannot be performed on a patient that is receiving services via a telehealth technology, such as video conferencing.
We have seen prescriptions written for patients by their physicians without a prior physical examination. For example, it has been common practice for physicians to phone-in an antibiotic via telephone for patients that have been prone to certain infections. However, due to the unethical and in some cases, illegal nature of this practice, it is no longer common. As such, physicians will require patients to revisit the office for a physical examination if a sickness lingers or pain does not improve.
Another legal issue surrounding telehealth is that of payment for telehealth services. The Center for Telehealth and e-Health Law cited the absence of “consistent, comprehensive reimbursement policies” as a roadblock to the widespread use of telehealth (Roberts J. Waters Center for Telehealth and e-Health Law, 2012). The Center for Medicare and Medicaid Services combated this by enacting the Balanced Budget Act of 1997 (Roberts J. Waters Center for Telehealth and e-Health Law, 2012). The Act mandates that the Medicare program pay for telehealth services (Roberts J. Waters Center for Telehealth and e-Health Law, 2012). However, most private insurers have yet to follow suit and do not currently offer consistent payment programs for telehealth services.
Lastly, the legal issue surrounding the electronic storage of telehealth services has not been explored in great length. Questions regarding patient de-identification and privacy, as well as data storage have yet to be answered. For example, should physicians store copies of video consultations or sessions with patients? If so, how long should this data be stored? The archiving of treatment provided through telehealth services would certainly prove useful in negligence cases in which a physician is accused of conduct in which he or she did not engage. However, to which risks are providers leaving themselves open when storing these data? In today’s highly technological world, it is imperative that these issues are discussed and regulations determined.
Ethical Implications of Telehealth
In addition to the legal questions surrounding telehealth that have yet to be answered, there are numerous ethical implications that must be addressed if telehealth is to become a routine form of service delivery.
In order to understand the first ethical concern surrounding telehealth, the meaning of an encounter, as it relates to the medical field, must be defined. Encounters are units of service for which Medicaid provides payment. New York State Medicaid states that encounters must meet certain criteria in order for payment to occur. The first criterion is that services must be medically necessary. For mental health patients, psychiatrists define the medical necessity of specific treatments in the patient treatment plan. The second criterion is that all encounters must be documented according to standards set forth by state and federal governments. In New York State, the Office of Mental Health defines the documentation standard for mental health services. The third criterion is that services must be administered in person. However, in the case of telehealth, the CMS has drafted specific regulations to allow for payment for services that have been provided via a telehealth technology (Roberts J. Waters Center for Telehealth and e-Health Law, 2012).
Despite government support of telehealth as a valid form of service delivery, Dr. Marjorie Landes, a psychiatrist with more than 30 years experience, does not believe video conferencing sessions are an appropriate form of treatment for mental health patients (personal communication, July 20, 2012). Dr. Landes’ main concern is that telehealth does not allow for the physician and patient to form a proper relationship. The physician - patient relationship is vital in the mental health specialty. A proper physician - patient relationship tends to keep patients engaged in their care, while failure to forge a relationship can lead to patient disengagement.
There are two reasons why Dr. Landes does not perceive that a proper physician – patient relationship can be forged when engaging in treatment via video conferencing. The first is that telehealth does not allow for the proper viewing of body language for both patient and doctor. Dr. Landes explained that body language, such as the patient’s hand fidgeting or foot movements can “complete the patient’s story” for the physician. She argues that a complete patient story is necessary in order to properly treat the patient. Furthermore, Dr. Landes argues that slight inflections in voice that can also supply vital information to the doctor can be lost during video conferencing sessions. These losses can be due to any number of reasons, including sound distortion that may occur while sound data is going over networking lines, background noise in the patients home, or poor audio – video equipment in use by the provider or patient.
Another ethical implication that has been addressed by New York State, but not by other states is the responsibility of providers to ensure their credentials are in an area that is easily seen by patients engaging in services via telehealth technologies. New York State has required providers to display their credentials during video sessions. It is also important to educate patients to request to view providers’ credentials if they cannot be seen.
Finally, there are ethical, and in some cases, legal considerations when delivering services via remote monitoring or telemonitoring of chronic conditions such as diabetes and high blood pressure. As described above, telemonitoring involves the use of monitoring equipment to measure a patient’s symptoms or vital signs. However, telemonitoring does not replace human interaction and decision-making. When using telemonitoring technologies, it is imperative that medical teams are in place and have the ability to provide 24-hour support to answer patient questions or respond to a crisis.
Future Implications for Telehealth
With the passage of the Affordable Care Act in 2012 and the apparent cost savings associated with telehealth, the trend towards increasing the availability of telehealth services is gaining momentum. The Center for Medicare and Medicaid Services (CMS), being an early adopter of telehealth technologies, has developed several innovative telehealth programs for the massive number of troops returning from the wars in Afghanistan and Iraq. These troops are coming back home with a host of needs, ranging from rehabilitative services to mental health services (Miliard, 2012). Furthermore, 45% of troops today are from rural locations (Miliard, 2012). CMS understood early on the need for telehealth services and in July of 2012 rolled out the Specialty Care Access Network-Extension for Community Healthcare Outcomes or SCAN-ECHO (Miliard, 2012). SCAN-ECHO seeks to “deploy video conferencing equipment to rural and underserved locations” (Miliard, 2012, para. 12).
Furthermore, the U.S. House of Representatives introduced the Veterans E-Health and Telehealth Act of 2012. The Act would supercede state laws that surround state licensing requirements for providing services via telehealth technologies (Miliard, 2012).
Lastly, in order to increase access to telehealth services for those in rural and underserved locations, the Department of Veterans Affairs removed the co-pay for telehealth consultations in the patient’s home or at a Veterans Affairs medical facility (Terry, 2012).
In the community at large, providers are beginning to see the value in integrating primary care and mental heath care. Satellite mental health offices are springing up in community primary care centers and primary care clinics have been making their way into community outpatient mental health clinics around Rochester, New York and in other cities across the U.S. These providers have begun or will begin using telehealth video conferencing services to consult with each other regarding patient care.
Even with the advances in telehealth technology for mental health, several problems persist that make access difficult. The first is that people living in remote areas often times do not know that telehealth services for mental health are available (Miliard, 2012). Education regarding available telehealth services must remain a focal point for providers. One such initiative is the website MilitaryBenefitsReport.com. The website was started by Wolfgang Ward, who served in the U.S. Military for four years (Military Benefits Report, 2012). The website offers a personalized report that “pinpoints the exact benefits, services, and programs for which each member of the Military community is eligible” (Military Benefits Report, 2012, para. 12).
The second roadblock to access is workforce training. Telehealth services have yet to become mainstream in the United States. Providers will have to be trained and must learn to adapt to this new way of providing services (Miliard, 2012). As of yet, a standard training protocol for e-Health and Telehealth services has not been developed.
Finally, even with the proper access to care and robust training for providers, the stigma surrounding mental health continues to persist. Until we debunk the myths surrounding mental illness, patients may remain reluctant to access care.
Despite these roadblocks, CMS and other payers and providers continue to research and document the benefits of telehealth services. The Information Technology industry continues to develop and evolve telehealth technologies and the patient population continues to embrace the concept of telehealth. As such, one can easily assume that telehealth in the United States is here to stay.
References
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New York State Education Department. Office of the Professions. Accessed August 12, 2012. http://www.op.nysed.gov/prof/mhp/mhcbroch.htm
Roberts J. Waters Center for Telehealth and e-Health Law. “Medicare reimbursement.” Accessed August 4, 2012. http://ctel.org/expertise/reimbursement/medicare-reimbursement/
Terry, K. “VA: Remove copayments for video telehealth consultations.” Information Week, April 13, 2012. http://www.informationweek.com/healthcare/mobile-wireless/va-remove-copayments-for-video-telehealt/232900280
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