We have the Technology...

I am somewhat perplexed that the adoption of telemedicine remains fairly limited. For purposes of this blog, telemedicine may be defined as the use of digitized audio and video information transmitted to a distant location for making clinical assessments and management decisions. In particular, the use of Telestroke has great potential to treat stroke patients who are potential tPA candidates in a very rapid fashion, thus providing the stroke patient with the best possible chance of a favorable outcome (insert the mantra of “time is brain” here). There is an abundance of scientific evidence that the neurological exam can be performed with equal accuracy in a remote setting compared to an in-person evaluation. In fact, the American Academy of Neurology has a white paper strongly supportive of the adoption of telemedicine. The requisite technology for transmitting and receiving this information is very easily obtained with relatively inexpensive “off-the-shelf” components and existing Internet access. Therefore, there must be other barriers to adopting this technology to explain why there are so few areas where telemedicine actually applies. A few obvious obstacles include:

• Concerns over reimbursement:

No one would be interested in developing and participating in a telemedicine program if there were no fair remuneration for the effort. There are five states (LA, CA, KY, OK, TX) that have actually passed laws mandating the private insurance companies to reimburse a telemedicine patient encounter at the same rate as the face-to-face visit. Medicare does cover telemedicine visits, but only with specific limitations. The requesting facility must be outside of a “metropolitan statistical area.” All of the Medicare-allowed CPT visit types are included (eg, new patient evaluations, office visits). The same code numbers for the visit type gets reported along with the —GT modifier. The non-Metropolitan coverage obviously limits using telemedicine in the exact location that most individuals practice neurology.

• Concerns over credentialing:

Currently, individuals need to get credentialed in every hospital where they want to provide telemedicine services. In addition, they have to be licensed in each state where they apply for these privileges. These considerations certainly limit the scope of how telemedicine is practiced. There is legislation pending that would at least allow the granting of privileges to be a more centralized process, thus avoiding the inconvenience of duplication of effort.

• Concerns over the change how medicine is practiced:

Are there different medical liabilities incurred when providing a telemedicine consultation? What is the relationship between any local neurologists and the remote neurologist? Will patients be accepting of a physician who is not physically present? These are all valid concerns, and solutions will evolve as providing care remotely becomes more and more prevalent.

In short, the obstacles to more widespread telemedicine adoption are mostly bureaucratic and political. There is hope that these problems are recognized and steps are taken to eliminate these hurdles. Once this occurs, there is no doubt that both patients and physicians will benefit. For those still interested in incorporating telemedicine into your current practice, next week I will offer a few practical suggestions on how to proceed.