The Rapid Growth of TeleMedicine: The Challenges Remaining

December 29, 2017 Jeanette Stern

Telemedicine services are rapidly expanding with two key goals: to improve access to care, and manage costs. Recently, systems have been developed, and are working, in ER triage, in workplaces, in skilled nursing and assisted living facilities, and in rural health. Systems have been developed, and are being trialed, with computer-streaming video conferencing, text-based consults, store-and-forward consults, and several others. 

Several challenges remain to the widespread acceptance and use of these services. Legislative restrictions could impede the rapid development and trial of new technologies, as state licensing laws restrict practice across state lines. Two new systems are being developed, however, to address clinical practice issues interstate. Nurses, nurse practitioners, physicians, pharmacists, and physician assistants are all licensed in individual states. Large inter-state compacts are being negotiated, or are due to be implemented soon, that will allow interstate practice without the expensive and unwieldy licensing agreements. 

Several states are looking at legislation that will restrict the practice of telemedicine to only certain types of visits, such as initial visits by video-conferencing only. This legislation comes from the idea that a therapeutic relationship can only be established with a visual meeting, and that possibilities of diversion and fraud is reduced. Controlled substance prescribing is also restricted to in-person only, as it is probable that diversion would increase with controlled substances prescribing over a telemedicine platform. 

There is a bill before the Senate that addresses the licensing issues that impact telemedicine for VA providers. Called the Anywhere to Anywhere Initiative, the bill seeks to allow VA telemedicine services across state lines for their providers who are properly licensed in one jurisdiction. The VA, seeking to improve access to care and decrease wait times, and to rein in costs, especially related to travel for rural and isolated vets, is investing heavily in the new telemedicine technologies. 

The repeal of net neutrality could have a significant impact on the projected growth of telemedicine. With the aim of trying to rein in out-of-control health care costs, adding another layer of restriction and cost to internet access could impact the widespread acceptance and use of these services.

In traditional primary care practice, physical health and mental health services are combined in the holistic health care of a person. The new telemedicine services are firmly dividing mental health and physical health care, with mental health care being further divided into talk therapy, with therapists, and psychiatric care, which includes medication management. This unnatural division of health is a challenge that could lead to fragmentation of care. At this point, patients are making the determination where their health care needs lie, and are going to the proper door, physical or mental health. Putting the diagnosis into a patient's hands, and the expectation that occurs among providers when a patient comes to the visit with a diagnosis already in mind, will likely lead to missed diagnoses and fragmentation of care. 

A further challenge is the technology to access data related to management of chronic illnesses. Some data is critical for chronic care management, such as weight, blood pressure readings, laboratory results, and aspects of a physical exam. While the technology is being developed, at this time the systems still need management or fine-tuning. Clinical practice could be changed by what technology allows us to assess. Standards of care and clinical practice guidelines are written assuming providers can access the data they need to make a complete plan of care. If telemedicine systems only allow providers to access some data, care could be compromised. 

Health insurance companies are making decisions about reimbursement for services state by state, and the challenges that are affecting their decisions remain regulatory and political. They are navigating between federal and state guidelines, and through legislative restrictions specific to a state. They are further involved in the new interstate compacts and licensing issues for providers. These varied and complicated regulatory issues are slowing down the rapid adoption of these services. 

Despite the challenges, the growth of telemedicine is an exciting new development in health care. The goals of the new technology and service model, to improve access to care and decrease costs, will absolutely be met. Regulatory and legislative issues will ensure quality and safety, and technologies will be developed to ensure health care quality remains high. 

For more information about telemedicine services, please contact us.

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