The term telemedicine refers to the use of information technology to exchange medical data to deliver consultations, procedures, exams or monitoring services over geographic distances. It typically refers to the delivery of clinical services, while the terms telehealth and e-health are often used more broadly to include nonclinical activities, such as research, education and administration. The term e-care is sometimes used as a synonym for telemedicine, but in the federal government it includes technologies to aid in advanced analytics, as well as clinical services.
Though telemedicine has not gained wide adoption in the United States, health care organizations and numerous government agencies tout it as a way to reduce unnecessary hospital visits and to offer specialized services to isolated, homebound or underserved populations.
- What are the main categories of telemedicine?
- Which standards apply to telemedicine?
- What are the challenges of expanding telemedicine in the United States?
- Are rural communities the only beneficiaries of telemedicine?
- How does the U.S. government promote and use telemedicine?
There are three main categories of telemedicine, each of which is being used in some capacity in nearly every medical field.
Remote patient monitoring is a rapidly growing telemedicine technology, and it is championed as a way to save vast sums of money in health care costs. Patients with chronic diseases can be monitored in their homes through the use of devices that collect data about blood sugar levels, blood pressure or other vital signs, and the data can be reviewed instantly by remote caregivers. According to the National Broadband Plan drafted earlier this year by the Federal Communications Commission (FCC), the use of remote patient monitoring technology in conjunction with electronic health records (EHR) could save the health care industry $700 billion over 15 to 20 years.
Store and forward technology stores clinical data, as well as X-rays and other images, and forwards it to other locations for evaluation. The U.S. Department of Veterans Affairs (VA) uses store and forward telehealth for radiology, dermatology and retinal imaging.
Interactive telemedicine lets physicians and patients communicate in real time. Such sessions can be conducted in the patient's home or in a nearby medical facility. Typical activities for these sessions include medical history review, psychiatric evaluations, ophthalmology assessments and other activities that do not require direct physical contact. Psychiatric evaluations, particularly in children and young adults, may actually be more effective with the use of telemedicine; because the physician conducting the interview is not in the same room as the patient, the evaluation process can be less intimidating.
The American Telemedicine Association is working with the National Institute of Standards and Technology's Information Technology Lab to establish guidelines and standards to promote telemedicine. These will include core standards for telemedicine operations, as well as guidelines that apply to such specific fields as pathology, dermatology and mental health. In addition, the FCC in its National Broadband Plan called for the development of standards for exchanging clinical data, as well as health-related administrative and research data.
Several obstacles stand in the way of the more widespread adoption of telemedicine.
For starters, the use of telemedicine technology requires broadband network capabilities, and broadband infrastructure remains elusive for rural clinics and small health care providers. According to the National Broadband Plan, 29% of rural health clinics and 33% of Indian Health Service (IHS) centers lack access to broadband.
Deploying telemedicine technologies can be costly, with significant investments in hardware, software and services -- not to mention networking infrastructure -- often required.
In addition, red tape often confronts providers who wish to use telemedicine. As the Center for Telehealth and E-Health Law notes, states are responsible for their own telemedicine licensure laws. Some have adopted less restrictive policies. Others explicitly require providers to have full medical licensure to see a patient in that state. Other states, in taking no action on interstate telehealth licensure, indirectly force physicians to obtain full licensure.
Within health care organizations, the process of telemedicine credentialing also eats up time and resources, because hospital staff are required to compile and verify this information; the Centers for Medicare & Medicaid Services (CMS) has proposed revisions to telemedicine credentialing rules that would let third parties compile this information.
Finally, providers often do not reap the financial incentives of using telemedicine. Medicare will reimburse for telehealth services performed in a physician's office, rural health clinic, critical access hospital, or federally qualified health center or hospital, but many private insurance companies will not, according to the Center for Telehealth and E-Health Law.
As a result, telemedicine has failed to take off. A joint advisory committee reported to Congress in 2008 that fewer than 1% of U.S. health care sites use e-care technologies. Meanwhile, a 2009 online survey by IDC found that fewer than 5% of consumers had used video conferencing for medical care, and fewer than 8% used a remote patient monitoring device.
Rural and other isolated communities are major beneficiaries of telemedicine, but they are not the only ones. The VA, for example, provides a variety of telehealth services for veterans, which range from "virtual visits" to home health services, to store-and-forward functions.
Health care facilities in any area also could take advantage of telemedicine to tap into the expertise of specialists in other regions. The PeaceHealth Medical Group, a health system in the Pacific Northwest, first implemented telemedicine services to expand outpatient geriatrics, and has since expanded its offering to cover stroke services and pediatric intensive care.
In urban and suburban areas, meanwhile, patients with chronic conditions could benefit from remote patient monitoring technologies, which allow them to be at home while still being under a provider's care. For example, common complications of heart failure, such as weight gain or a change in fluid levels, can be instantly detected, with medications adjusted to prevent the need for a patient to return to the hospital.
The federal government encourages telemedicine initiatives in three ways -- through grants, with Medicare reimbursements and by directly offering services through federal agencies.
- While the VA is the government's biggest provider of remote health care, the Department of Defense, the IHS and the Department of Justice's Bureau of Prisons also provide remote medical services.
- HHS operates a telehealth office within its Health Resources and Services Administration (HRSA). The HRSA promotes public-private partnerships to create telehealth projects and evaluate technology. The office also issues grants, which have funded such initiatives as telehealth resource centers that help rural and underserved communities access telehealth services.
- The Department of Agriculture's Distance Learning and Telemedicine Program offers grants as well.
Meanwhile, the National Broadband Plan recommends further investment in e-care to match what the Health Information and Technology for Economic and Clinical Health, or HITECH, Act outlines for EHR technology. Such investment could range from tax breaks or other incentives for large-scale private pilot programs, to funding for the further development of remote patient monitoring technology that aids in diagnosis or chronic disease management.
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