Also See: Glossary of Telemedicine
Telemedicine, or “health care at a distance,” is experiencing a boom worldwide, and universities and their affiliated hospitals are key drivers of this growth spurt, experts say.
Telemedicine (sometimes called telehealth) is the use of electronic communications to transfer medical information from one site to another. It involves digital connections such as video conferencing that links patients to specialists, cell-phone reminders about medical appointments, emails to ask doctors routine questions about colds, rashes and earaches, and remote monitoring of surgery patients recovering at home via the internet.
This type of virtual technology is becoming increasingly reliable — and relied upon, particularly in more remote, rural places where health care is lacking, whether in India or Indiana.
It’s an emerging market, one “likely to soar over the next five years,” according to a recent analysis from business consulting firm Frost & Sullivan. “The revolution is finally here” announced a recent Wall Street Journal piece titled “How Telemedicine Is Transforming Health Care.”
“Doctors are linking up with patients by phone, email and webcam. They’re also consulting with each other electronically — sometimes to make split-second decisions on heart attacks and strokes. Patients, meanwhile, are using new devices to relay their blood pressure, heart rate and other vital signs to their doctors so they can manage chronic conditions at home,” wrote the Wall Street Journal’s Melinda Beck.
Mike Baird has seen this explosion firsthand. He’s the CEO of Avizia, a telemedicine technologies firm based in Reston, Va. Set up in 2013, Avizia has experienced “phenomenal growth in the last three years,” he told The Diplomat.
With customers in 37 countries, he sees telehealth “surging everywhere.” But he said that particularly in the U.S., “there is dramatic pressure on the health care industry to provide better quality of care, reach more patients and cut costs.” New technologies, he argues, are often the only way to meet these hydra-headed demands.
Frost & Sullivan attributes the rise in telehealth to a number of factors, including: the Affordable Care Act (i.e. Obamacare, which mandated more insurance coverage); the need to manage chronic health conditions among aging baby boomers; improvements in state and federal reimbursement rates and in physician licensure rules; and the increase in digitally savvy consumers who demand convenient health care.
Likewise, an analysis last November by Foley & Lardner, a national law firm, said that consumer demand “for more affordable and accessible” health care is fueling telehealth growth. It also pointed out that government policy is catching up, citing a study showing that more than 200 pieces of telemedicine legislation were introduced in 42 states in 2015.
“It is expected that the global telemedicine market will expand at a compound annual growth rate of 14.3 percent through 2020, eventually reaching $36.2 billion,” the law firm said, noting that expanding reimbursement coverage, an uptick in international arrangements, momentum at the state level and more retail clinics and employer on-site health center are helping to drive this surge.
Baird of Avizia described this progress on the legislative and regulatory fronts as “providing tailwinds for telehealth in the U.S. We are now up to 32 states that support telehealth reimbursements by private insurance.”
Foley & Lardner partner Nathaniel Lacktman recently wrote that “historically, telemedicine has been focused in the academic medical center and university environment because that’s traditionally the domain of pilot programs and research studies.” Baird points to universities as incubators of telemedicine that are pushing “the innovation curve forward,” both in their neighborhoods and around the world.
Across the country, universities are not only teaching telehealth to medical students and conducting studies, they’ve also been launching — sometimes for many years — telehealth outreach to local partners such as clinics, especially in rural and underserved communities that lack specialists, including pediatricians or even primary care providers.
Among the leaders in this field, Baird cited the Oregon Health & Science University, UCLA, the University of California-San Francisco, the University of Virginia and the Medical University of South Carolina (MUSC).
MUSC, for example, offers telehealth at 80 locations throughout the state and at 26 public school clinics. It provides, among other programs, mental health, maternal fetal services and a neuroscience program that helps dementia patients.
In the Mid-Atlantic region, universities are also using community outreach to advance telehealth.
For example, the University of Virginia, which has provided health services and “traveling clinics” to the state’s rural areas since the 1970s, now has more than 150 community telehealth sites throughout the state, said Dr. Karen Rheuban, a pediatrics professor and medical director of the Office of Telemedicine at the University of Virginia School of Medicine.
Taking a different approach, the University of Maryland Medical System boasts telemedicine outreach to intensive care units in 12 hospitals throughout its network. This “tele-ICU” program provides nighttime, weekend and holiday remote management and 24-7 critical care nursing support, said Dr. Marc Zubrow, the system’s vice president of telemedicine.
Meanwhile, the George Washington University has a rare 24-7 maritime telehealth program that serves commercial and research vessels (such as those working in the Bering Sea), as well as yachts and aircraft.
And Johns Hopkins Medicine in Baltimore, Md., through one of its affiliated hospitals, provides medical oversight and immediate contacts for a two-year-old Howard County telehealth program in eight school health clinics, said Dr. Ingrid Zimmer-Galler, director of the Johns Hopkins Office of Telemedicine and an associate professor of ophthalmology. Hopkins also runs a statewide telehealth program that screens for diabetic retinopathy, a complication of diabetes that frequently goes undetected until the disease is advanced.
Academic centers are drivers of this development because they can provide evidence demonstrating that telehealth works, Zimmer-Galler explained. They can show improved outcomes, for example, and with multiple disciplines in one space, they offer the synergy of cross-cutting research and collegial collaboration. They also often receive grants to fund the projects that encourage further innovation.
In fact, part of the reason why universities have thrived in the telehealth movement is that they have the financial resources to do so. Unlike a provider in a private practice, university physicians and other academic researchers are paid employees. Perhaps even more important, public colleges and universities receive state support and most university research has traditionally been funded by grants — although, in recent years, state and federal funds have been drying up.
Personal Touch, from Afar
A pediatric cardiologist, the University of Virginia’s Rheuban once used telemedicine to help save the life of an infant in China. However, she has also been busy in the public policy sector, serving on boards, getting to know state and federal players and becoming a policy wonk to navigate the burgeoning field. For instance, she has been instrumental in establishing Virginia’s progressive telehealth payment system. To honor her contributions, the university’s telehealth center now bears her name.
At the George Washington University, Dr. Neal Sikka, co-chief of the Telehealth Section at the GWU School of Medicine and Health Sciences, said the school focuses on health problems commonly found in an urban environment. He noted that a weakened patient with a chronic disease and few resources may have as much trouble getting across town to his doctor’s office as an isolated rural individual who needs to drive several hours would. So his team is working on ways to use telehealth to serve an urban population. It’s also exploring novel treatments in post-surgery wound care as well as tele-consults for those in chronic pain, which is critical in an era of opioid overuse.
At the University of Maryland Medical Health System, Zubrow spoke proudly of his remote outreach to intensive care units in the state and said that “telehealth is going to explode locally and nationally.”
“I take some pride that we’re monitoring every ICU bed on the Eastern Shore,” he told us. “It’s effective. It keeps patients locally situated where families can easily visit their loved ones and their physicians can have a life — no phone calls all night.”
The University of Maryland’s telehealth services include home-based remote care that can assess a patient’s status and manage chronic disease. Consults variously specialize in stroke care, high-risk prenatal medicine, psychiatry and genetics counseling. Programs include those for advanced liver disease, neurosurgery follow-up and inflammatory bowel disease
Johns Hopkins has an occupational medicine outreach to 56 work sites in 23 states and recently added a “teledermatology” service to the program. It’s also fielding a telehealth Parkinson’s pilot program that monitors patients at home and is implementing distance psychiatric care and a bio-containment unit with a remote connection to the main Hopkins hospital. The unit is reserved for patients with highly infectious diseases such as Ebola. And, as of last summer, Hopkins now has a centralized Office of Telemedicine, part of its School of Medicine.
The Hopkins School Connection
The crown jewel of the expansive telemedicine network at Johns Hopkins, however, may be a relatively new project that has put CareClix telemedicine carts into eight school health clinics in Howard County, Md. CareClix offers 24-7 access to a certified physician from any smart phone, tablet or computer.
Jointly run by Johns Hopkins and the Howard County Health Department, the program links students to nurses at Johns Hopkins school sites and a team of pediatric emergency room physicians led by Dr. David Monroe, medical director of the Children’s Care Center at Howard County General Hospital and an associate professor of pediatrics at Johns Hopkins.
The Health Department selected the participating schools, all of which are located in underprivileged communities where many children are eligible for free lunch. Parents must officially enroll students in the program and during the initial pilot, Monroe said the focus is on treating minimally complicated medical issues such as sore throat, rash or fever.
Call-ins from a school nurse are handled by physicians in Monroe’s ER, all trained in telehealth. During its first full year, the remote system had 110 virtual visits — 24 percent for fever, 20 percent for asthma, 15 percent for rashes, 5 percent for headaches and a smattering of sore throats, Monroe said. Only about 10 or 15 seriously ill acute patients showed up.
“All of us at the hospital have found it rewarding. The children, nurses and the families are very appreciative. The tech is good. Many of the students have little or no primary care and we [work to connect them] using lists of physicians who will accept them as patients.”
At Ducketts Lane Elementary, one of Howard’s pilot schools, assistant principal Derek Anderson said, “I fully support the program and look forward to seeing it grow.” His admiration is not only from an administrator’s perspective. He witnessed the process firsthand when his daughter Peyton, then 4, used the service last year while at Bollman Bridge Elementary School.
“Peyton had a rash, no fever, and her school nurse called me here to report it, explain it was a minor infection, give me prescription information and say she would call it in. I was able to phone my wife, who’s a federal employee in the District, and pick it up after work,” he said.
The program serves the school population well, Anderson said. “Many are new to the country or the area. Families need assistance negotiating health care and we can now provide that. It’s a great service.”
Not a Cure-All
The nascent field, however, is not without its challenges — among them, licensing problems, spotty Medicare coverage and some customer revolt at the prospect of getting a diagnosis via the internet.
Quality is an overarching concern. Even minor respiratory tract infections, for instance, can be misdiagnosed from afar. Doctors are often anonymous and have no prior relationship with the patient. Accreditation for telehealth doctors, some of whom are based abroad, varies wildly.
Thus, many patients are still more comfortable with traditional face-to-face visits — as are many doctors who grew up with a pen and paper, not iPads and webcams. Interestingly, telemedicine may inadvertently lead to a few turf wars. A 2010 New York Times article noted that when patients received additional monitoring by remote physicians, their on-the-ground doctors and nurses complained that it felt like someone was constantly looking over their shoulder.
Some patients are simply not aware of the telemedicine phenomenon. And insurance reimbursements and legal regulations have yet to catch up.
“Rules defining and regulating telemedicine differ widely from state to state and are constantly evolving. Physicians groups are issuing different guidelines about what care they consider appropriate to deliver in what forum,” the Wall Street Journal article noted.
“Some critics also question whether the quality of care is keeping up with the rapid expansion of telemedicine. And there’s the question of what services physicians should be paid for: Insurance coverage varies from health plan to health plan, and a big federal plan covers only a narrow range of services,” it added.
The American Telemedicine Association reported that 48 state Medicaid programs now have some type of coverage for telemedicine. Medicare, however, has been slow to embrace the trend. It has very narrow and geographically limited (i.e., rural) coverage. However, the Center for Medicare and Medicaid Services is working with Congress to provide payments for telehealth services “in any location.”
In addition, states have adopted so-called “parity laws” that require private insurers to reimburse doctors who provide remote care at roughly the same rates as what they charge for in-person visits.
Still, the entire regulatory system is fractured among the 50 U.S. states, so a doctor licensed in one state cannot provide services to someone in another state — a fact that often renders the concept of long-distance telemedicine moot.
These barriers are lowering a little, with 17 state medical boards having adopted a “compact” to provide physician licenses in each other’s states.
Kathy Wibberly is director of the Mid-Atlantic Telehealth Resource Center at the University of Virginia, which offers information on telehealth programs, collects data such as outcomes and tracks the thicket of laws and regulations affecting states along the Eastern corridor.
Regional trends that Wibberly sees include parity laws that require private insurers to cover telehealth services in Kentucky, Virginia, Maryland, D.C. and Delaware, with such laws being introduced in New Jersey, North Carolina and Pennsylvania. Only West Virginia has “no movement” toward parity, she said. Separately, only Kentucky and Pennsylvania reimburse for remote monitoring.
Overall, Wibberly said that in the region, “there is a movement toward greater reimbursement for telehealth services,” although the field still sees limited reimbursement payments. Mobile health care is increasingly important, if poorly reimbursed, she added, noting that 85 percent of the global population has access to a cell phone.
Despite the challenges, Zimmer-Galler of Johns Hopkins predicted that the industry will continue to move forward at a rapid clip. “Virtual visits are a small percentage of health care today,” and some patients are “unsure” about them, but she said they’re “going to grow exponentially.”
“The younger generation is so connected in their daily lives,” she told us. “If you order your Uber on your phone, and Uber drops you off where you can pick up a coffee, already paid for, on your way to work, well, you are going to think, ‘If I can order my coffee with my phone, why can’t I see my doctor that way?’ And when a child in school can be seen in a telehealth consult, it’s less disruptive for the child and nice for the parents,” Zimmer-Galler said.
Baird of Avizia predicted that “in 10 years, we will see virtual and collaborative care as part of our regular health care interactions.” That can’t come soon enough for the busy CEO. The father of five children ranging in age from 5 to 16, he said managing family health care in the U.S., as it’s currently set up, “isn’t easy.”
Telemedicine is the use of electronic communications to transfer medical information from one site to another. It usually involves a clinical service offering “patient health care at a distance.” The term covers live video conferencing and use of instruments such as a digital stethoscope. It also covers the transmission of still images such as X-rays and remote patient monitoring of vital signs or wounds healing at home, as well as “e-health,” medical education and nursing call centers.
Telehealth, sometimes used interchangeably with “telemedicine,” is a more recent and a broader term. It covers any type of remote health care that uses communications technology, including patient education, disease self-management, web apps, text reminders to patients and notices to families from telehealth clinics in schools.
eHealth is a health care practice supported by electronic processes and communication. It applies to physician offices that have electronic health records.
mHealth or mobile health care is the practice of medicine and public health supported by mobile communication devices such as cell phones, tablet computers and PDAs.
About the Author
Carolyn Cosmos is a contributing writer for The Washington Diplomat.