So Much Potential

Benefits – and risks – weighed in the expansion of telemedicine

JHC_Nov15_iStock_000035848042_LargeTelemedicine is here; it’s expanding; and it has great potential. But the medical profession and healthcare industry needs to balance its benefits against its risks for patients.

“Telemedicine – the use of technology to deliver care at a distance – is rapidly expanding and holds the potential to improve access for patients, enhance patient-physician collaboration, improve health outcomes, and reduce medical costs,” said Wayne J. Riley, MD, MPH, MBA, MACP, president of the American College of Physicians. “However, the potential benefits of telemedicine must be measured against the risks and challenges associated with its use, including the potential absence of the physical exam, variation in state practice and licensing regulations, and issues surrounding the establishment of the patient-physician relationship.”

Riley made his comments as the ACP published its position paper, “A Guide to the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper,” in the Annals of Internal Medicine on Sept. 8. The American College of Physicians represents approximately 143,000 internists, internal medicine subspecialists and medical students.


The ACP position paper offers 13 policy statements and recommendations for the practice and use of telemedicine in primary care and reimbursement policies associated with telemedicine use.

(1) ACP supports the expanded role of telemedicine as a method of healthcare delivery that may enhance patient-physician collaborations; improve health outcomes; increase access to care and members of a patient’s health care team; and reduce medical costs when used as part of a patient’s longitudinal care.

ACP believes:

  • The most efficient, beneficial telemedicine use occurs between a patient and physician who have an established, ongoing relationship.
  • Telemedicine is a reasonable alternative for patients who lack regular access to medical expertise in their geographic area.
  • Episodic, direct-to-patient telemedicine services should be used only as an intermittent alternative to a patient’s primary care physician when necessary to meet the patient’s immediate acute care needs.

(2) ACP believes a valid patient-physician relationship must be established for a professionally responsible telemedicine service to take place. A telemedicine encounter itself can establish a patient-physician relationship through real time audio/visual technology.

A physician using telemedicine who has no direct prior contact or existing relationship with a patient must:

  • Take appropriate steps to establish a relationship based on the standard of care required for an in-person visit, or
  • Consult with another physician who does have a patient-physician relationship and oversees the patient’s care.

(3) ACP recommends that telehealth activities address the needs of all patients without disenfranchising financially disadvantaged populations or those with low literacy or low technological literacy. Specifically, telehealth activities need to consider:

  • The literacy level of all materials (including written, printed, and spoken words) provided to patients and/or families.
  • Affordability and availability of hardware and Internet access.
  • Ease of use, which includes accessible interface design and language.

(4) ACP supports the ongoing commitment of federal funds to support the broadband infrastructure needed to support telehealth activities.

(5) ACP believes physicians should use their professional judgment as to whether the use of telemedicine is appropriate for a patient. Physicians should not compromise their ethical obligation to deliver clinically appropriate care for the sake of new technology adoption. If an in-person physical exam or other direct face-to-face encounter is essential to privacy or maintaining the continuity of care between the patient’s physician or medical home, telemedicine may not be appropriate.

(6) ACP recommends physicians ensure their use of telemedicine is secure and compliant with federal and state security and privacy regulations.

(7) ACP recommends that telemedicine be held to the same standards of practice as if the physician were seeing the patient in-person. The College believes there is a need to develop evidence-based guidelines and clinical guidance for physicians and other clinicians on how to appropriately use telemedicine to improve patient outcomes.

(8) ACP recommends physicians who use telemedicine should be proactive in protecting themselves against liabilities and ensure their medical liability coverage includes the provision of telemedicine services.

(9) ACP supports the ongoing commitment of federal funds to establish an evidence base on the safety, efficacy, and cost of telemedicine technologies.

(10) ACP supports a streamlined process to obtaining multiple medical licenses that would facilitate the ability of physicians and other clinicians to provide telemedicine services across state lines while allowing states to retain individual licensing and regulatory authority.

(11) ACP supports the ability of hospitals and critical access hospitals to “privilege by proxy” in accordance with the 2011 Centers for Medicare and Medicaid Services final rule allowing a hospital receiving telemedicine services (distant site) to rely on information from hospitals facilitating telemedicine services (originating site) in providing medical credentialing and privileging to medical professionals providing those services.

(12) ACP supports lifting geographic site restrictions that currently limit reimbursement of telemedicine and telehealth services by Medicare to those that originate outside of Metropolitan Statistical Areas (MSAs) or for patients who live in or receive service in a Health Professional Shortage Areas (HPSA).

(13) ACP supports reimbursement for appropriately structured telemedicine communications, whether synchronous or asynchronous and whether solely text-based or supplemented with voice, video, or device feeds in public and private health plans, as this form of communication may be a clinically appropriate comparable service alternative to a face-to-face encounter.

Source: Annals of Internal Medicine, doi:10.7326/M15-0498

The challenges of telemedicine

The integration of telemedicine into the healthcare system is not without challenges, says the American College of Physicians in “A Guide to the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper,” published in the Annals of Internal Medicine on Sept. 8. Those challenges include the following:

  • Most laws and regulations relating to reimbursement and the practice of medicine were drafted before the use of telemedicine by larger markets.
  • State guidelines on the practice of telemedicine, prescribing, and licensing vary.
  • Websites that offer on-demand, episodic care for minor health conditions may disrupt the continuity of care between a patient and his or her physician or medical home, and undermine care coordination.
  • Some hesitation remains among physicians and patients.
  • Legal barriers to the widespread adoption of telemedicine mainly center on medical licensure, credentialing, and privileging that would allow physicians to practice in several locations.

In addition, says ACP, “Concerns exist about depersonalization of the patient–physician relationship, particularly in the primary care setting, and the risk for harm. The physical interaction between a physician and patient and the in-person examination are important components of a patient’s care that allow a physician to gather a comprehensive under- standing of the patient and his or her needs, and build trust and communication.”

Source: Annals of Internal Medicine, doi:10.7326/M15-0498

The hidden economics of telemedicine
In his editorial accompanying the American College of Physicians’ “A Guide to the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper,” published in the Annals of Internal Medicine on Sept. 8, David Asch, MD, MBA, Center for Health Care Innovation, University of Pennsylvania in Philadelphia, made the following comments:

  • “[P]ayers worry that if they reimburse for telemedicine, then every skin blemish that can be photographed risks turning from something that patients used to ignore into a payable insurance claim. Indeed, it is almost certainly true that if you make it easy to access care by telemedicine, telemedicine will promote too much care. However, the same concern could be reframed this way: An advantage of requiring face-to-face visits is that their inconvenience limits their use. Do we really want to ration care by inconvenience, or do we want to find ways to deliver valuable care as conveniently and inexpensively as possible?”
  • “The scalable gains from telemedicine will come from delivering care to populations – sometimes highly specialized care, in totally different ways – often with less physical infrastructure and less of the baggage that accompanies conventional practice. Although the ACP position paper urges parity between telemedicine and face-to-face medicine in how physicians practice and get paid, arguing for parity is a trap if it merely carries forward practice styles and reimbursement requirements from one context to the other. The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face to face, but awakening us to the many things that we thought required face-to-face contact but actually do not.”

Source: Annals of Internal Medicine, doi:10.7326/M15-0498

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