Archive for October 16, 2012

Will the Affordable Care Act Help Telehealth Flourish?


Nurse Jennifer Witting stands beside newly installed telemedicine equipment at the Aspirus Keweenaw Hospital in Laurium, Mich., on June 20, 2012. Photo courtesy of Flickr Creative Commons.

Opportunity is knocking for telehealth to become a common method of practicing medicine in the U.S.

One-on-one Web-based video chats and other electronic consultation between doctors and patients isn’t new — it’s been used throughout the U.S. in varying degrees for a few years now. But health-care reform, a ballooning  and aging population and a shortage of available family physicians may be a perfect storm that could blow the doors open for telehealth to go mainstream.

As states’ health insurance exchanges — online marketplaces where citizens can compare and purchase insurance plans — begin to debut in advance of the 2014 deadline set forth by the Affordable Care Act (ACA), access to health-care providers should expand for many Americans. Obtaining insurance coverage soon may be easier, but the gap between the number of incoming patients and available primary care doctors is widening.

According to a 2006 report from the American Academy of Family Physicians, the U.S. will have a shortage of at least 39,000 family physicians by 2020 — a figure compiled before the passage of the ACA, which mandates that most Americans purchase health insurance.

Improved fiber-optic lines and faster broadband connectivity have allowed telehealth to supplement face-to-face care, which could help put a dent in the projected shortage of primary care physicians in the U.S.

With the convenience of telehealth, doctors can practice online before and after normal working hours, ultimately serving more people. Whether it’s retired doctors who would still like to practice, physicians who’ve stopped practicing due to family commitments, or doctors who simply want to expand the scope of their business, the technology can help increase the pool of available primary care physicians.

Some industry representatives view telehealth as distinct from telemedicine in that the latter pertains to multiple physicians using electronic communication methods to discuss topics or patients among themselves. Telemedicine has been used for decades.

Experts believe that telehealth may become an essential alternative in order to diagnose and prescribe treatment for common ailments.

Roy Schoenberg, a medical doctor and CEO of American Well Systems, a provider of telehealth technology, believes health-care consultation via the Internet has the potential to move the needle on health-care delivery. And that’s particularly true in light of the 30 million more consumers expected to impact the health-care system in 2014 due to the ACA’s insurance mandate.

“You are not only creating efficiency inside the health-care system, you have the potential of redistributing health care completely,” Schoenberg said. “You are rewriting the map of accessibility to health-care services using technology.”

Glen Stream, president of the American Academy of Family Physicians and a family physician in Spokane, Wash., agreed. He stopped short of calling telehealth a “substitute” for in-person interaction with a patient, but recognized the benefits technology can bring to a medical practice.

For example, Stream said a face-to-face visit likely isn’t necessary for patients he knows well and is familiar with their ongoing medical conditions. A phone call or short video conference could give him all the information he needs in order to make decisions on future treatment.

“The capability [of telehealth] can extend convenience to the patients but also could potentially expand the ability of the practice to take care of folks,” Stream said. “One of the areas where this could be especially helpful is in rural areas.”

Eric Brown, president and CEO of the California Telehealth Network, said telehealth is already bridging a service gap in California, particularly in underserved rural and urban areas that don’t have the physicians to meet the care demands of the patient population.

The California Telehealth Network works with stakeholders to establish broadband connectivity for communities so technology services can be used to improve the quality of health care. The organization has helped establish more than 350 telehealth sites in the state.

Despite the benefits that online remote health care can provide, a number of hurdles still exist before telehealth becomes a widespread practice in the U.S. Licensure of doctors and reimbursement of telehealth services are two issues at the top of the list.

Doctors practicing telehealth need to be compliant with the laws and regulations of the state in which the patient is located. A doctor in Virginia wouldn’t have a problem using telehealth for an in-state patient, but medical facilities near state borders could encounter some legal issues if a patient lives in North Carolina, West Virginia or Maryland.

According to Greg Billings, executive director of the Center for Telehealth and e-Health Law, 12 states currently have a special license that physicians can apply for, or a streamlined licensure process that will allow them to give direct care to patients in other states through telehealth.

Further, a doctor is required to establish a physician-patient relationship in order to prescribe medications. Only 12 states allow an electronic examination to meet the requirements of a face-to-face examination.

Billings said doctors practicing telehealth and prescribing to patients in the 38 states that don’t have an electronic examination law on the books, may be in violation of state law.

Brown added that the issue of practicing teleheath across state lines is a contentious subject among some of the California Telehealth Network’s members. Predictably in-state doctors would lose business from patients who choose another to get their medical care from doctors in another state.

“If you are California-licensed and credentialed doctor, you’re not really happy that all of a sudden providers [could] go out of the state to get their needs met,” Brown said. “I think it’s inevitable and I think the marketplace will ultimately prevail if it’s allowed to.”

On a national level, U.S. Sen. Tom Udall, D-N.M., is considering legislation to make it easier for doctors to practice telehealth. Government Health IT reported in February that the proposed legislation would streamline the portability of licensure across state lines. As of September, a bill had not been introduced.

When contacted by Government Technology, Jake McCook, Udall’s deputy press secretary, indicated that the senator’s staff still is working on the bill and that it would eventually be introduced.

Payment for telehealth services presents an additional roadblock to telehealth expansion. Only 15 states have legislation requiring health insurance providers to recognize claims for services rendered through telehealth.

Michigan and Maryland are the two newest states to enact such a law. California passed a similar law in 2011.

Brown called the issue of reimbursement “the most formidable” of the obstacles preventing telehealth from taking root in the U.S. Billings agreed and explained that the reimbursement legislation some states are passing doesn’t require insurance companies to do anything new.

In the 15 states that have authorized reimbursement of telehealth services, if an insurance policy covers an in-person medical visit and the physician feels they can treat the policyholder using telehealth, then an insurance company can’t deny payment of that electronic visit.

“I think more and more states are going to do that,” Billings said. “Michigan cropped up organically, with a member of the [state] legislature grabbing onto it. We are taking a look at it as well — to make sure that all the other states are educated on this issue and can conceivably move forward on it.”

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HHS opens innovators program to public voting

For the first time, the public can vote on their favorite innovation from among the finalists of the HHSinnovates Program, Health and Human Services Secretary Kathleen Sebelius announced this past Friday.

Launched in the spring of 2010 as part of HHS’s open government efforts, HHSinnovates is meant to recognize innovative projects from HHS employees aimed at helping solve thorny healthcare challenges.

“The HHSinnovates Program recognizes and rewards good ideas and facilitates the exchange of innovations throughout the Department and beyond,” said Secretary Sebelius. “Innovative ideas and practices aren’t restricted to the private sector: government workers are developing new ideas and facilitating connections to improve the way government works and improve the health of all Americans.”

[See also: HHS aims to cut medical errors.]

Twice a year, HHS employees are invited to submit their innovations, and the top picks are posted for secure, online voting by the entire HHS community. Six finalists are chosen and publicly announced. The Secretary then selects her top picks.

Now, for the first time, the public will pick the “People’s Choice” winner. In the program’s fifth round, the public is invited to choose from among six finalists. They come from 60 total submissions from across HHS, officials say, noting that each embodies an innovative spirit, and is scalable and replicable:

The 100K Pathogen Genome Project. This collaborative project, originating from the Food and Drug Administration, academia, and industry partners, aims to sequence the genetic codes (genome) of 100,000 strains of important food pathogens (tiny organisms that cause food-borne illnesses – bacteria, viruses and others) and make them available in a free and public database at the National Institute of Health’s (NIH) National Center for Biotechnology Information.  Open access to sequences allows researchers to develop tests that can identify bacteria present in a food within a matter of hours or days, significantly faster than the two weeks it now takes to grow and analyze bacterial cultures conventionallyNational Institute of Allergy and Infectious Diseases (NIAID) Exchange. NIH’s NIAID developed an internal supply exchange for their institute called “NIAID Exchange” to help increase the speed and efficiency of government.  They developed a user-friendly Web resource where staff can advertise existing government-owned scientific and office equipment and supplies they no longer need and search for available items advertised by other staff members.  The NIAID program has saved over $30,000 since its release to the institute last January.Online Food Handler Training Project. The Albuquerque Area Indian Health Service (IHS) led the development of an online food handler certification program that trains an average of 3,500 food handlers a year in class room food handler trainings, while compensating for a 20 percent reduction in staff.  This novel training program, which was developed in collaboration with local partners, incorporates the principles of adult learning and story-telling in a way that is culturally sensitive and resonates with tribal customers.  The training is available to the public on the IHS website, and numerous people from across the country has registered and initiated the training.Development and Use of Coal Dust Explosibility Meter. The Centers for Disease Control and Prevention’s National Institute of Occupational Safety and Health in association with industry and commercial partners developed a coal dust meter that gives users real-time feedback on environmental conditions – a significant improvement over the lengthy measurement procedure currently employed.  This tool, which gives immediate results, represents an improved means for underground coal miners and coal mine operators to assess the relative hazard of dust accumulations in their mines.  To date, more than 200 of these devices have been sold and are being deployed in mines across the United States.National Health Service Corps Jobs Center. Many underserved communities remain underserved because it is very difficult to recruit physicians to high-need areas; in some instances it can take up to two years and $60,000.  To help improve this process, the Health Resources and Services Administration’s National Health Service Corps established the NHSC Jobs Center, an online employment site connecting thousands of job-seeking medical professionals, doctors, nurses, dentists, and mental health providers in primary care disciplines to thousands of employers in underserved communities throughout the United States and U.S. territories.National Institute of Health Research Portfolio Online Reporting Tools. The National Institute of Health developed a Research Health Portfolio Online Reporting Tool (RePORT) that serves as a one-stop shop to provide the public with an interactive suite of tools to search NIH-funded research and the work of its investigators.  By providing the scientific community with better tools to explore the portfolio of NIH-funded research, RePORT furthers progress to foster fundamental creative discoveries, innovative research strategies, and their applications.

[See also: HHS aims to spur software apps development.]

Public voting is open until Sept. 14, 2012. Winners will be announced on Sept. 24. To learn more, visit the HHSinnovates website.

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ONC drops pursuit of NwHIN governance

The Office of the National Coordinator for Health IT has dropped pursuit of a regulation for establishing “rules of the road” for the nationwide health information network (NwHIN) based on feedback it has received.

Commenters from industry and the public made it clear that federal regulation could slow development of health information exchange just as those activities are starting to emerge and pick up steam, “perhaps more than is widely appreciated,” according to Dr. Farzad Mostashari, national coordinator for health IT.

ONC issued a request for information (RFI) in May to collect public comment on a possible approach for rulemaking to spell out “conditions of trusted exchange,” including safeguards and technical and business practices. ONC wanted to receive broad input before issuing a proposed rule, he said.

ONC also considered establishing a voluntary accreditation and certification process through which to approve organizations as being legitimate participants in NwHIN, somewhat similar to the procedures for certifying electronic health records for meaningful use functions.

“Based on what we heard and our analysis of alternatives, we’ve decided not to continue with the formal rulemaking process at this time, and instead implement an approach that provides a means for defining and implementing nationwide trusted exchange with higher agility, and lower likelihood of regret,” he wrote in a Sept. 7 blog.

NwHIN is a set of comprehensive standards, services and policies that enable healthcare organizations to share information securely through the Internet.

ONC’s goal is that information follows the patient where and when it is needed, across organizational, vendor, and geographic boundaries.

But the current state of information exchange and care coordination is far from this ideal. In addition to technical challenges with interoperability, “the absence of common ‘rules of the road’ may be hindering the development of a trusted marketplace for information exchange services,” Mostashari said.

However, voluntary governance bodies are now forming both for directed and query-based exchange. ONC wants to encourage the exchange activities that are gaining steam, “and not to hobble them,” he said, especially with the expectations for standards-based exchange in stage 2 of meaningful use.

“And let me assure you that if systemic problems or market break-downs emerge that might require regulatory action, we will again seek input from the public and our stakeholders, including the Health IT Policy and Standards committees,” Mostashari warned.

Participation in the NwHIN Exchange previously was limited to federal health agencies and primarily large healthcare organizations that contract with them or are federal grantees. Agreement on how to assure conditions for trusted exchange will enable many more organizations to participate.

Among the actions that ONC will press for to promote trusted exchange are:

• Identify and shine a light on good practices that support secure and interoperable exchange and provide a guide for evolving governance models

• Learn from and engage with groups in governance and oversight roles for exchange partners in order to foster models within and across communities

• Continue to use existing authorities and convening powers to create consensus and provide guidance and tools around specific barriers to interoperability and exchange

• Evaluate how and what consumer protections can be appropriately applied to health information exchange through existing regulations

• Monitor and learn from the wide range of activities that are occurring.

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Cellphone Radiation Debate Heats Up

It has been a busy week for cellphone regulation.

On Monday, Aug. 6, U.S. Rep. Dennis Kucinich introduced a bill that would put warning labels on all cellphones and create a national research program to study cellphone radiation. On Tuesday, the U.S. Government Accountability Office (GAO) issued a report asking the FCC to revise its standards on cellphone radiation limits. And Thursday, the city of San Francisco met with the wireless industry in a court case that could determine whether the city will be allowed to force cellphone retailers to warn customers about potential cellular radiation risks.

There have been conflicting opinions on whether cellphone radiation is harmful to people since cellphones were first invented. According to the GAO, there is no evidence that cellphones cause cancer in humans, but the agency is asking the FCC to retool its policy on the issue based on modern research data and current technology, because the old standards are from 1996. The change may be tighter regulation or it could even increase the amount of radiation allowed – the GAO is simply asking for the FCC to take a second look at cellphones and update the law accordingly.

In 1996, the FCC set the maximum exposure limit on radio waves to 1.6 watts per kilogram, averaged over one gram of tissue. Cited in a 2006 GAO report, the IEEE suggested that 2.0 watts per kilogram, averaged over 10 grams of tissue, “represents a scientific consensus on RF energy exposure limits.” These limits are generally considered by experts to be a fiftieth of the level required to harm humans. However, the World Health Organization (WHO) classifies cellphone use as “possibly carcinogenic to humans,” and puts cellphone use in the same hazard category as drinking alcohol, being near coal burnt indoors, and contracting malaria.

Consumer groups tend to err on the side of the safety, agreeing with the WHO’s stance that it’s not yet clear whether cellphones are harmful or not.

A court case starting Thursday in the U.S. Appeals Court will decide how much power the city of San Francisco has over private businesses selling cell phones. Initiated by a piece of legislation approved in 2010 by then-mayor Gavin Newsom and the San Francisco Board of Supervisors, the law would require retailers selling cellphones to display posters that warn of potential risks caused by cellphone use, affix stickers to cellphone packages with specific absorption rate (SAR) levels for the devices as defined by the FCC, and offer a fact sheet that outlines potential risks and methods for reducing exposure.

The cellphone industry is being represented by The Wireless Association (CTIA), which is suing the city on the grounds that the city’s requests violate First Amendment rights. “The government can’t compel a private party to express an opinion that it disagrees with,” said Andrew McBride, an attorney representing CTIA’s case, reported Cnet.com. McBride also added that the information the city is asking retailers to share is only opinion, not fact.

San Francisco Deputy City Attorney Vince Chhabria will argue that warnings are needed because research on the topic is inconclusive. “This (GAO) report confirms what was already obvious,” he said. “New information keeps coming up about the relationship between cell phone use and health risks, such as cancer. And we think the public is better served if they’re given the opportunity to take a closer look at this new information.”

It’s no coincidence that San Francisco’s cellphone debate, the GAO’s request for the FCC to rethink cell radiation limits, and Rep. Kucinich’s bill come at a time when the FCC had announced they were planning to retool regulations. In June, the FCC issued a notice of inquiry that examined whether the agency’s methods and standards needed updating since the last major standard was instated 15 years ago.

The idea that old regulations can be dangerous is the crux of Rep. Kucinich’s bill calling for cellphone warning labels and the creation of a national research program to study cellphone radiation. The Cell Phone Right to Know Act would create a new set of regulations that would also require the Environmental Protection Agency to update the standards for SAR values, which indicate the amount of radio energy absorbed by a human body.

“It took decades for scientists to be able to say for sure that smoking caused cancer. During those decades, the false impression created by industry supporters was that there was no connection between smoking and cancer, a deception which cost many lives. While we wait for scientists to sort out the health effects of cell phone radiation, we must allow consumers to have enough information to choose a phone with less radiation,” Kucinich said in a statement. “As long as cell phone users may be at increased risk of cancer or reproductive problems, Americans must have the right to know the radiation levels of cell phones.”

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What the platforms tell us about parties’ stance on health IT

It’s a joke without a punch line: Both Republican and Democratic national party platforms make sparse mention of health IT.

To be certain, there’s plenty of focus on the broader healthcare issues. The GOP platform, in fact, dedicates its first two sections to ‘Saving Medicare for future generations’ and ‘Strengthening Medicaid in the states’, while the Democrats also address the issue early on with a section about healthcare as part of ‘The middle class bargain’ and another on ‘Social Security and Medicaid.’

[Survey analysis: Romneycare vs. Obamacare, do Americans care?]

As for any particulars of health IT, well, that’s another matter. Quite literally, each party offers up a single sentence on its intentions for health IT.

From page 33 of the 2012 Republican Platform PDF:
We support technology enhancements for health records and data systems while affirming patient privacy and ownership of health information.

Now, should that strike you as oddly vague, just wait.

“If anyone was disappointed in the scant attention given to health IT in the Republican Party Platform, then the Democratic Party Platform should give them pause,” said Brian Ahier, health IT evangelist at Mid-Columbia Medical Center, author of the Healthcare, Technology, and Government 2.0 blog, and city councilor in The Dalles, Ore. “Health IT is barely mentioned at all, and only in the context of broader technology initiatives.”

Indeed, in the 2012 Democratic National Party Platform health IT is on page 41 of the PDF:
We will ensure that America has a 21st century digital infrastructure – robust wired and wireless broadband capability, a smarter electrical grid, and upgraded information technology infrastructure in key sectors such as health care and education.

Reactions to the perhaps pithy stances of both parties stance have been mixed.

“I regret that the platforms are largely silent on HIT,” former four-term Vermont Governor Jim Douglas wrote in an email exchange with Government Health IT. Douglas is now a member of the Bipartisan Policy Center’s Governor’s Council and executive-in-residence at Middlebury College. “Perhaps it’s not a sexy topic, but it’s essential to our efforts to improve the quality of care and contain costs.”

So, why such vague references to health IT? Shouldn’t the national party platforms include a greater vision of and intent for the technologies forging the underpinnings of next-gen healthcare in America? Or is what the parties outlined enough for the majority of American voters?

“At this point in time I think maybe it is enough,” said Iowa State Representative Linda Upmeyer (R), a career nurse practitioner who has proposed health IT legislation since being elected 10 years ago. “I hope what it means is that this is really in an early state, but there’s a commitment to move health IT forward, that they’re listening and trying to continually improve so that the government doesn’t get this wrong.”

While some will argue that the November elections might test the bipartisan nature of health IT, at least for now Ahier, Douglas and Upmeyer view the party platforms as evidence that bipartisanship remains intact.

“It would seem that both parties agree that when health IT is used effectively it can help address the challenges confronting our healthcare system,” Ahier said. Douglas added that “the current administration continues to move the ball down the field through grants to the states, incentives to providers and implementation of the meaningful use standards,” he said. “I’m confident that the bipartisan support will continue because both parties understand the value of HIT.”

Which leads back to the beginning, where both parties support health IT, but are short on detail about exactly how – which may be because neither party can say for sure precisely what committing to health IT will really mean for the future.

[See also: Political strategists on how candidates should shape healthcare messages in election.]

“It’s always important to have something that keeps policymakers pushing health IT to the forefront, but we policymakers, be it inside the beltway or inside the golden dome in Iowa, don’t have the solutions or all the answers. So we can commit to investing in health IT and rely on the people really doing it to help determine what the next steps are,” Upmeyer, the Iowa rep said. “I don’t really want congressmen or senators or legislators deciding for them.”

Neither does Steven Waldren, MD, director of the Center for Health IT at the American Academy of Family Physicians.

“I’d much rather health IT not be a political football and remain behind the scenes a little because there’s no political urgency such that either side is going to try to politicize it and move forward. Instead, they recognize it’s an important issue,” Waldren said. “The two platforms have different philosophies but at least it’s not being debated at the level of lies, made up truths, or spinning things out of context.”

Although, there might be a solid punch line or two to emerge from that manner of rhetoric.

For more of our politics coverage, visit Political Malpractice: Healthcare in the 2012 Election.

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