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Telemedicine
The Doctor Will Email You Now
Technology Is Rapidly Changing Health Care, but Problems Persist
by Jennifer Ginn
Former Wyoming Gov. Jim Geringer has a favorite response to people who say having an appointment with a doctor by webcam is different than going to a doctor’s office.
“If anybody tells you telemedicine is different than the practice of medicine, they don’t know what either one is,” he said.
Telemedicine is when medical professionals use technology—whether email, telephone or webcam—to provide care for patients. It has been around since the late 1950s, when psychiatrists provided therapy to patients by phone.
“It’s not reached its full potential yet, but the expansion of telemedicine has practically skyrocketed the past couple of years,” said Jonathan Linkous, CEO of the American Telemedicine Association, a nonprofit group that promotes improvement in health care delivery through technology. “About a year ago, somewhere around 10 million Americans benefitted somehow from telemedicine.”
“This year, we estimate somewhere between 80,000 and 100,000 Americans will have shown up in emergency rooms with a stroke and that stroke will be assessed and treated using teleneurology. So we’re talking about applications that are really making a difference in people’s lives.”
Telemental Health
Access to medical care is an issue Dr. Sara Gibson, a psychiatrist and medical director of telemedicine for the Northern Arizona Regional Behavioral Health Authority, knows well. The publicly funded agency oversees mental health care for 700,000 residents living in the northern half of Arizona.
Distance, Gibson said, is a tremendous obstacle in the 62,000 square miles the agency covers.
“When I first started doing this, we were looking at one of two options,” she said. “(We could) either bring in sort of a circuit psychiatrist who would travel to the area like for one week a month and see everybody during that week, then move on to other places.
“The other option we were thinking about was putting everybody on a bus and driving them in to see a psychiatrist. Again, it wouldn’t be as frequent as it needs to be. There weren’t any great options.”
Telemedicine has provided services to patients who otherwise wouldn’t be getting help.
Nancy Rowe, director of the authority’s telemedicine program, said providers use 36-inch televisions so patients see their psychiatrist life-size. “It’s a pretty immersive experience,” she said.
“What the patients report is a huge degree of comfort,” Gibson said. “The comment comes up over and over again, ‘I feel like I’m in the same room with you.’ There’s a little bit of anxiety initially, so we try to have somebody sitting with them on the other end.
“There are even some people who feel more comfortable using this technology than an in-person evaluation. They feel like they can open up more and are a little safer from being flooded by the intensity of being in the same room with somebody.”
Telepharmacy
Twelve years ago, the North Dakota Board of Pharmacy did a survey of community pharmacies in the state and discovered something disturbing.
“They discovered … 26 small, rural communities in the state had lost their local pharmacies (and) another dozen
were at risk of losing them,” said Ann Rathke, telepharmacy coordinator for North Dakota State University’s College of Pharmacy. “When you have such a sparse and distributed population, if you lose your local pharmacy services, you can easily end up driving 50-60 miles one way to get a prescription filled.”
The pharmacy board, the university’s college of pharmacy and the North Dakota Pharmacists Association got together to figure out a solution. An administrative rule change opened up the chance to try something new in the country—telepharmacies. Now in its 11th year, the program boasts 79 telepharmacy sites in North Dakota.
Rathke said pharmacy technicians in the remote locations take a patient’s prescription, gather the medicine and begin preparing the prescription. Videoconferencing and an imaging system allow the technician to contact a registered pharmacist, who confirms the prescription and the medication and checks for possible drug interactions. There is a mandatory counseling session between the patient and pharmacist, who then dispenses the medicine.
Rathke said 24 states allow telepharmacies. It has been a great way, she said, to ensure patients can access a pharmacist regardless of where they live and it has added more than $26 million to the state’s rural economy.
“Early on, one of the worries that was expressed by boards of pharmacy with telepharmacy is it would mean that pharmacists would lose their jobs,” she said. “Telepharmacy is not now, nor has it ever, meant to take pharmacists out of the equation. If fact, it’s just the opposite. It’s keeping the pharmacist as a central health care provider.”
Stumbling Blocks
Although telemedicine has increased health care access for millions of Americans, it does not come without challenges.
Linkous said getting Medicare to cover telemedicine is difficult. Federal regulations limit telemedicine payments to areas outside of designated metropolitan statistical areas, which can include entire counties where large cities are located. That cuts out large rural areas, he said, as well as ignores the fact that access to health care in urban areas is sometimes as difficult as in remote locations.
Private insurers also sometimes are hesitant to pay for telemedicine, but that is changing in many states. Eight states in 2013 enacted legislation mandating coverage by either private insurance or Medicaid, according to the American Telemedicine Association.
One of the biggest problems, experts agree, is medical licensure. Each state licenses doctors based on its own requirements and those licenses are nontransferable. Consulting by webcam across state lines can be difficult, Wyoming’s Geringer said.
“A person from Wyoming goes to the Mayo Clinic, they’re seen by a doctor, the doctor diagnoses them and recommends treatment,” he said. “They come back to Wyoming and unless that doctor has passed some sort of reciprocity, that doctor cannot follow up.
“We license by place, not practice. I think a cultural change needs to take place in the doctor-patient relationship. … If we talk about telehealth, really we’re talking about the application of technology, but the practice of medicine has not changed in either case.”
That’s why Geringer, The Council of State Governments and the Federation of State Medical Boards are in discussions to see if a medical licensure compact could help. A compact could be used to improve license portability for doctors and, ultimately, access for patients.
Whatever the solution, Linkous said it needs to happen quickly. With more people joining insurance rolls in January under the Affordable Care Act, telemedicine could help increase the number of doctors who can see those patients.
“Just fix it, just fix it,” Linkous said. “That’s what I’m saying to legislators. Let’s not debate this thing forever. Let’s not come up with 15 different solutions that are going to drag on. … Let’s just fix this darn thing.”
© Brooks Craft/Corbis
© Photo Courtesy of the North Dakota State University’s College of Pharmacy
MEDICAL SCREENING
Telemedicine is becoming more common across the country. Above, Dr. Maurice Cates, an orthopedic surgeon, conducts a live orthopedic consultation remotely by video with a patient (Ronald Jeffries) at Kaiser Permanente’s Capitol Hill Medical Center during an office visit with primary care physician Dr. Isabel Gottron. Telepharmacy has helped many rural residents in North Dakota keep their local pharmacy. Enderlin, N.D., pharmacist Walter Spiese, on screen, is located in LaMoure, 50 miles away from the pharmacy site in Enderlin. Spiese does a final check on the medicine and verifies the prescription with Elaine Diesem, a pharmacy technician. After the final check, the pharmacist releases the drug, even though he is not on site.
