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Telemedicine Image Collaboration Enhances Patient Safety


CapSure CloudComputed tomographic (CT) scans are acknowledged as some of the most effective means of early detection for certain forms of illness. In recent years, however, there has been an increased amount of attention paid to the radiation risks inherent in CT scans. Medical research indicates that most patients who require CT scans are not aware of the risk of radiation exposure inherent in the tests. According to a study by Dr. Patrick O'Malley, MD, one of the largest obstacles to providing patients with accurate information regarding the risks of imaging scans boils down to the awareness of the real risks. A study published JAMA Internal Medicine concluded that up to one in three imaging tests in the U.S. are ordered in situations when the expected benefits do not sufficiently exceed the risks, adding that clinicians are not well informed about the risks of medical imaging.

Fortunately, the ongoing digital revolution that has changed so much of society has not neglected medical technology. One major innovation that is saving time and protecting patients is the use of cloud-based data sharing, in particular, for storing medical images.

Medical imaging in the cloud is a leading innovation in the industry that makes the assessment and treatment of medical conditions more efficient and effective. “By storing data in HIPAA compliant servers, medical imaging in the cloud makes it easier, and secure, for different medical facilities to share records”, says Dr. Phil Johnson, Department Chairman of Emergency Medicine at Summit Healthcare. As a result, patients can avoid exposure to potentially harmful radiation due to repeated CT scans. “Furthermore”, continues Johnson, “in emergency situations, it's far more efficient to use a recently captured medical image than it is to take a new one.” In addition to the health benefits, facilities that make use of medical imaging in the cloud can also save themselves and their patients substantial amounts of money. It is estimated that US medical facilities spend roughly 30 billion dollars per year on redundant medical imaging. In many instances, patients have been responsible for storing their own imaging files on CD or even as paper print-outs. Needless to say, this solution obviously is less than ideal, as the physical form of a compact disc makes it prone to damage or loss. The obvious limitations of image print-outs have made them easily the most inefficient method of data transfer.

Johnson continues on the importance of harassing this technology “to put the patient first, treat every patient as you would a close relative, and put the team in place to make that happen. Utilizing technology in the cloud is having a dramatic impact in practice”, he says, “because telemedicine can link anyone with anyone, this new paradigm can provide much better care by saving real dollars, and saving real lives.”  He adds that “to practice in an old paradigm where a consultant at another institution cannot view the digital images with HIPAA compliance puts both the patient and the practitioner at risk”  “I practice in an ER where, with HIPAA compliance, I can show digital images of my patients to any consultant in the world that has access to the internet.”  Within a few minutes of the CT being done on my patient showing they have a true life threatening emergency I tell my patient that the neurosurgeon 200 miles from us has already viewed their images and recommends an immediate transfer for life saving surgery.”  The patient and family look at me with comfort in their eyes knowing they are in good hands that will put them first every time. Dr. Phil Johnson states that after 5 years of using this technology, “I save many lives a year that would not be saved in the old paradigm without this technology and I personally have seen this prevent 3-10 unnecessary transfers a year costing the patient over 40,000 thousand dollars a transfer”. He concludes by saying “I would not consider working in an ER without this technology”.


Efforts to Remove 4 Legal Barriers to Telemedicine


The only thing slower than widespread adoption of telemedicine has been the statutory changes necessary to make the ground more fertile for it. But in just the past six or seven weeks there has been a definite change in attitude among lawmakers and regulators.

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Unraveling the problems requires some new thinking.  First, you must admit that telemedicine holds a great deal of promise in providing access to healthcare and in controlling costs, especially when faced with a shrinking physician population and a rapid increase in the number of senior citizens - the age group consuming 40-50% of all healthcare resources.  Some 10,000 people retire every day in the United States. 

Barrier #1 - Establishing the physician-doctor relationship requires an in-person medical visit.

Unless the doctor-patient relationship exists, it is unprofessional conduct for a physician to prescribe prescription medication.  Not only is this requirement in many states' medical practice acts, but it's also taught to be the standard of care in many medical schools.

Add to that the attitude that "Doctors must be able to touch the patient," you have the argument against technology and remote assessment during an initial visit.  Many doctors believe that in order (for them) to gather the necessary information about a patient's medical condition they must meet in-person.  Although that my be true in some cases, doctors usually conduct a very general exam through conversation, not palpation.  

An initial examination done telemedically is not radically different.  The patient fills out medical history forms; a nurse or lower level practitioner takes the patient's vital signs and logs them along with the patient's complaint. The physician scans the file and enters the room, in this case via videoconference. 

Two weeks ago, the Robert J. Waters Center for Telemedicine and eHealth Law (CTeL) published its proposed "Electronic Examination for Telemedicine Prescribing."  These templates "would ensure that patient safety would be upheld and would provide clarity for telemedicine providers who wrestle with prescribing in states where the use of an electronic 'face-to-face' examination is not specifically identified."  The proposed statutory language would waive the face-to-face exam when "it would not normally be part of a typical face-to-face encounter with the patient for the specific services being provided."

Already, a dozen states allow a bona fide physician-patient relationship to be established through an appropriate electronic exam.  The rest should.

Barrier #2 - Physicians must hold a valid medical license for each state in which they see patients.

To some extent this is a holdover from when state medical boards tested license applicants to make sure they had an adequate fund of knowledge to treat patients. Now the National Board of Medical Examiners administers the USMLE (United State Medical Licensing Examination), and state medical boards just ask for evidence showing that an applicant has passed all three elements of the test.  Obviously, they also have to prove they have a medical degree and have done a residency.  But if they've done that once for a license in their home state, why force them to do it again for telemedicine?  Because each state has different requirements, and they've balked at standardizing them.

Last month, the Federation of State Medical Boards (FSMB) held a meeting for 80 representatives of state medical boards to explore the idea of a streamlined licensing process so as to better accomodate the use of telemedicine.  Those attending the meeting recommended that the FSMB's House of Delegates look into a uniform, expedited interstate medical licensure compact to support license portability.

Some believe the model for license portability should be a compact somewhat similar to the one for nurses.  Twenty-four states are members of the Nursing License Compact (NLC).  A nurse with a permanent residency in one NLC state is eligible to work in other "compact states" without the need for licenses from the other states.

Such a compact for physicians would allow specialists in Reno, for example, to see patients who live in eastern California telemedically without the need for a California medical license. Many rural areas are just across a state border from a major city where healthcare is available, but rendered inconvenient by licensure.

Barrier #3 - The point of medical care depends on the location of the patient.

This barrier is closely related to Barrier #2, but approaches the issue from a different direction.  A comprehensive telemedicine bill introduced in Congress on the last day of the the last Congressional session by California Congressman Mike Thompson would change the point of care to where the doctor is.  The significance of this proposal is that a physician could see patients anywhere in or from the state where he holds a valid license.  Thompson's measure does not create a national telemedicine license because the last thing we need is another level of bureacracy between the doctor and his patient.

The bill must be re-introduced in the new session of Congress, something that Thompson pledges to do.

Barrier #4 - Medicare reimbursement limitations on telemedicine.

These vague limitations were included in the legislation Congress approved in 2001, forcing Medicare to reimburse physicians for telemedicine visits.  To get CMS administrators on board, supporters of the bill had to agree to restrictions aimed at discouraging the adoption of telemedicine within urban areas.  

Even if the patients are in rural areas, a medical practice needs a lawyer to figure out if it can be reimbursed.  As I've mentioned before, CMS believed that left unrestrained doctors would overuse telemedicine and run up giant reimbursements.  Based on this fear, government accountants predicted that telemedicine visits would cost $30 million each year for the first five years the law was in effect.

Never happened!  In the 11 years since reimbursements were approved, the total amount for telemedicine was just over $20 million.

Without a change in attitude, we'll fail to deliver adequate healthcare in the 21st Century to the right patient at the right place at the right time.  It can't be done successfully with the 20th Century model.

More About the Telemedicine Bill Introduced by Rep. Thompson

Thanks to Jonathon Linkous and Gary Capistrant, we now have a better understanding of the comprehensive telemedicine bill, H.R. 6719, introduced by Congressman Mike Thompson.

Linkous is the President of the American Telemedicine Association (ATA) and Capistrant is the Senior Director of Public Policy for the ATA. During a Webcast for ATA members yesterday, they unpacked the bill.  There are two important sections of the comprehensive telemedicine bill which will be reintroduced in the new session of Congress by Thompson sometime in the next couple of weeks.  The first has to do with Medicare and reimbursements which have disincentivized telemedicine for years.

Presently, the law regarding Medicare reimbursements restricts them to physicians seeing patients 25 miles outside metropolitan areas in underserved medical areas.  For a metroplex like Phoenix which stretches through the Salt River Valley and beyond, that means a doctor in Surprise (on the northwest of Phoenix) cannot see Medicare patients telemedically in Queen Creek (on the southeast) and be reimbursed, even though the distance is 75 or 80 miles.  As a result doctors who have satellite offices in the Phoenix area have to split their hours - three days a week at one location, two days at the other.  Telemedicine would not only let them see patients at either location, in-person or telemedically on the same day, but it would also encourage other physicians to open satellite offices in large metropolitan areas, thus expanding the access to healthcare.

Medicare also discourages remote patient monitoring.  Eleven years ago, when the reimbursement legislation was signed into law, the "medical home" was theoretical; now, it appears to be a fait accompli.  The storing and forwarding of medical images is only reimburseable in Alaska and Hawaii.  H.R. 6719 would clear away these restrictions and more.  Instead of saying what will not be reimbursed like the current Medicare law, Thompson's bill would simply state that if Medicare reimburses for an in-person medical treatment, it will reimburse it for telemedicine because it is all healthcare.

I think this part of the bill is a no-brainer.  Other parts make sense, but they will likely face opposition from stakeholders like state medical boards.

The bill seeks to redefine the location of "medical practice."  Currently, the accepted standard by medical boards around the country is that the physician is practicing medicine where the patient is; thus, the physician must have a valid state license there, or otherwise he (or she) is practicing medicine illegally.  The Thompson bill would borrow a concept from the recently approved STEP Act which allows a physician to see any Department of Defense patient anywhere in the country, as long as the doctor holds a valid license in at least one state.  In other words, the medical practice would be where the doctor is located, not the patient.  This change would allow a physician to see patients telemedically wherever they are, no additional state license would be needed.

Here's why this concept poses a problem for state medical boards. Medical board budgets are directly or indirectly related to licensure fees.  In Arizona, for example, the medical board retains 90% of the biannual licensure fee for staffing, for license investigations, and for investigations of complaints against doctors.  Of the some 21,000 licensees, about a third do not practice medicine in the state.  Some may have moved into administration positions. Most live and practice somewhere else, but maintain their Arizona licenses.  If the medical practice location is redefined, multiple licenses become unnecessary and the medical board will undergo a sizeable budget cut.

In other states, licensure fees go into the state's general fund.  Medical boards present a budget to lawmakers and receive an allocation from their legislatures.  They would face a similar budget cut if there was a sudden drop in licensees in other states.

The other problem that a redefinition presents concerns jurisdiction.  A medical board can only investigate complaints against its licensees.  For illustration, if a North Carolina-licensed doctor commits unprofessional conduct with a patient in Tennessee whom he sees telemedically, the Tennessee Board of Medical Examiners would be unable to investigate the case.  The North Carolina Medical Board may never know that one of its licensees has done something harmful to the patient.  If it were notified, investigating the complaint might require unbudgeted expenses and produce unexpected delays, and therefore be too expensive and ineffective.  Of course, this is all hypothetical.  The number of telemedicine-related complaints around the country is very, very small, perhaps because of licensure restrictions.  But who knows how many there might be in the future if Congress redefines the location of a medical practice.

We may know more about the reaction of medical boards to the Thompson bill this spring in Austin, Texas.  The ATA has extended ATA2013, its international meeting, an extra day.  On May 8th, ATA members will meet with lawmakers and medical board representatives from around the country.

Telemedicine Bill Is a Good First Step

Democratic Congressman Mike Thompson of California, a member of the House Ways and Means Subcommittee on Health, has introduced a bill in the U.S. House that may have a chance of passage.  Everyone should understand this is only the first step, albeit a significant one, but there is no guarantee that it will get through the House. (See below for an Update.)

The Telehealth Promotion Act of 2012, officially known as House Resolution 6719, would establish a federal support and payments policy for telemedicine. Since 2001, Medicare has had these foolish abritrary location restrictions that discourage physicians from seeing patients telemedically.  Medicare reimbursements for telemedicine have only been available to physicians who see patients located 25 miles outside a metropolitan area in a medically underserved area.  And a telemedicine process called "store and forward" which relates to medical images is only reimbursed in Alaska and Hawaii.  Neither of these restrictions makes a bit of sense, especially when you understand why Medicare administrators demanded they be included in the law: they thought that physicians would "overuse" telemedicine.  Somehow, they convinced the Government Accounting Office that even with the restrictions reimbursements for telemedicine would run $30million a year the first five years, when in fact research by the Center for Telemedicine and eHealth Law (CTeL) shows the total cost of telemedicine reimbursements from 2001 t0 2012 was only $20million.

Still, the fear of uncontrollable spending haunts any "new" program on Capitol Hill, and it may be tough convincing other lawmakers in the House, especially Republicans, who are sharpening their pencils to cut federal spending in exchange for raising the debt ceiling.  In the two weeks since Representative Thompson introduced the bill on December 30th, I haven't seen any stories about Republicans signing on as co-sponsors. Could that be because the Library of Congress has not received the bill from the Government Printing Office? Perhaps.  I "googled" it and found it on the GPO's Web site.  (If it were a bill that I introduced, I would certainly feature it on my Web site.  If you go to Thompson's Web site, however, there is no mention of it as of the time this post was published - nothing - nada, even though the "Latest News" and "Press Releases" sections have been updated as of January 4th.)

The other aspect of the bill is an extension of what the VA is already doing regarding physician licensing and credentialing.  Let's say a physician is licensed by the Vermont Board of Medical Practice.  He can work at any VA medical center outside Vermont without holding a license from the state medical board where his office is located.  Seeing patients off federal property is a no-no, unless the physician has the license for that state.  Telemedicine allows a veteran to go to a CBOC (Community Based Outpatient Clinic) and see his doctor telemedically, instead of driving in to the medical center in a large urban area.

The proposed legislation would remove the licensure restrictions for federal employee health plans, the Children's Health Insurance Program, and TRICARE as well as the VA.  This is the part of the bill that could run into opposition from state medical boards and/or the Federation of State Medical Boards (FSMB) once its impact on state licensure funding is understood.  But this measure at least doesn't immediately aggravate the FSMB like the proposed draft that Democratic Senator Tom Udall of New Mexico began floating in 2011. He never introduced his plan for a "tandem medical license" because it called for more government spending and another layer of federal bureaucracy; thus, no Republican member signed on.  His own state's medical board opposed it.  The best thing you can say about Udall's bill is that it did draw some attention to telemedicine nationally.

UPDATE:  Since Representative Thompson introduced the bill on the last day of the 112th Congress, it doesn't carry over to the 113th which convened January 3rd.  During a Webcast to ATA members, Jonathan Linkous, President of the American Telemedicine Association (ATA), pointed out that unlike other telemedicine legislation introduced in the past, Thompson's is a comprehensive bill aimed at removing healthcare restrictions.  He called it a "stake in the ground" and "a very important step forward" that Thompson would reintroduce soon.  Gary Capistrant, Senior Director of Public Policy for the ATA who was also on the Webcast, said the idea was to "put some specifics out there" so that other lawamkers would "pick up parts and repackage them" in legislation.

Lesser Known Legal Hurdles for Telemedicine

To say that medical practice law is fractured is an understatement.  So, it's important for physicians to be familiar with their states' Medical Practice Acts.

Even conscientious doctors who make an attempt to understand the laws governing the practice of medicine can make mistakes.  I know of one case in which a physician began doing Internet prescribing because he read the Medical Practice Act in his state and could not find in it a statement that said it was against the law.  For those of you who aren't familiar with Internet prescribing, it's illegal in all states with one exception; in order to prescribe prescription medication, most statutes do not mention the Internet, but do require a physical examination and a complete medical history to establish a doctor-patient relationship.  Rogue pharmacies often use questionnaires for the medical history part, but sidestep the requirement for an examination.  Medical boards have disciplined physicians caught doing Internet prescribing and in some extreme cases the doctors have lost their medical licenses.  More on the doctor-patient relationship in a moment.

Because there are legal pitfalls doctors should be aware of in telemedicine, Alexis Slagle Gilroy and Kristi V. Kung with the law firm of Nelson Mullins Riley & Scarborough LLP in Washington, D.C., have written an excellent article that describes some of the lesser known challenges.  In "Telemedicine Legal Hurdles - An Overview of Lesser Known Challenges," Gilroy and Kung first talk about the familiar legal topics - licensure and credentialing obligations.  Supervision of certain licensed and unlicensed personnel, requirements for establishment of a doctor-patient relationship, and the corporate practice of medicine are rarely addressed, but should be.

The authors note that state medical boards are largely silent on the application of supervision requirements within telemedicine.  Why is this important?  Because doctors are supposed to supervise the performance of certain diagnostic tests.  And there are different supervision thresholds depending on the test and the lower-level healthcare provider. "General Supervision" means the physician has been involved in the overall direction and control, but his or her presence is not required.  "Direct Supervision"means the doctor has to be present and available if needed, but not in the room when the procedure takes place, while "Personal Supervision" means the physician is present in the room during the procedure.  Many Medical Practice Acts make these distinctions in describing the supervision of those lower-level providers involved.  Does the supervising physician's presence by videoconference meet the "direct" or "personal" supervision levels?  Unfortunately, there is no pat answer because the laws vary from state to state.

Gilroy and Kung use Arizona and its unlicensed medical assistants in one example.  The supervision onus is on the physician.  A doctor must directly supervise a medical assistant, but can that be done via videoconferencing when the MA is on the patient end of the telemedicine visit? It depends on the Arizona Medical Board which licenses MDs and the Arizona Board of Osteopathic Examiners which handles DOs.  To date, I know of no such telemedicine complaint case filed with either board that would set a precedent one way or the other.  If needed, a board could formulate a new rule, or the State Legislature could update the statutes.  Here in Arizona, medical assistants are used everywhere, and ignorance is bliss.  Elsewhere, doctor supervision of licensed providers like nurses and physician assistants is not as specific.

For comparison purposes, Nevada requires its medical assistants to be supervised by physicians, but doesn't define the supervision.

As mentioned above, the doctor-patient relationship is important when it comes to prescribing prescription medication.  Arizona and other states require an "in-person," or face-to-face, physical exam first.  Some states have updated their Medical Practice Acts to allow the exam to be done via telemedicine, especially when the patient is in a prison or other institutional setting where it would be inconvenient for the patient to come to the doctor, and that makes sense.  Recently, Georgia's medical board considered a proposed rule that would have required a patient to have a prior visit to a doctor before they could be seen telemedically by a nurse practitioner or physician assistant.  Thankfully, stakeholders argued successfully against it, and it has died a silent death.

Then there is the issue of the Corporate Practice of Medicine that Gilroy and Kung touch on.  Some states have corporate practice doctrines that make medical practices subject to corporate practice prohibitions pertaining to general corporations which are not permitted to practice medicine or to employ physicians.  Where these exist, there may be a legal way around them using a "friendly PC/MSO structure," whatever that is.

Arizona does not have a limitation on who may own a physician practice.  So, there are non-physicians running companies and corporations, other than hospitals, that employ physicians in a medical practice.  What's interesting is the non-physicians are beyond the jurisdiction of the Arizona Medical Board, but the physicians are not.  So, let's say such a business decided that it didn't want to follow state law and provide a patient's medical records to a physician who left the medical practice and who was the patient's doctor.  No legal requirement for the business, but the medical board could hold the physician responsible even though he had no access to the records after leaving the practice run by the non-physician.  Sounds crazy, but it almost happened here.


FCC Chairman: A Telemedicine Convert?

Now that the FCC, after two years of foot-dragging, has finally approved the plan to spend the $400 million appropriated for broadband expansion in rural areas, you might get the idea that the FCC Chairman has been on board from the start.

Julius Genachowski, who became the FCC Chairman in 2009, wrote a blog post for LinkedIn on Monday, titled "Telemedicine to Transform Healthcare for Underserved and Rural Communities."  It's a first-person account of his trip to the Oakland Children's Hospital and Research Center.  He says all the right things, how telemedicine will "completely transform health care infrastructure in our country, improving quality of care for patients, while shaving billions of dollars off patient and healthcare system costs."  While there, he "was pleased to discuss" the FCC's Healthcare Connect Fund which will subsidize 65% of the cost to connect rural health centers and clinics to the Internet.

Perhaps he was responsible for getting the FCC off the dime and doesn't agree with FCC Commissioner Mignon Clyburn who said the cut in the subsidy from 85% to 65% was to "prevent wasteful spending."  I'm prepared to give him the benefit of the doubt, even if he were a recent convert to the benefits that telemedicine can bring to rural communities.  Still, I think the FCC has made it more difficult for connectivity to expand for healthcare by reducing the subsidy.

I don't think broadband Internet connectivity for personal use should be another entitlement warranting a subsidy.  It should remain a privilege, not a right.  Afterall, most people already have smartphones that can surf the Net.  But when it comes to providing access to healthcare that benefits a community in an equitable way, I think the FCC could have and should have kept the subsidy at 85%.  The only facilities that can apply for the subsidy beginning this coming summer are public and non-profit hospitals, rural health clinics, community health centers, health centers serving migrants, community mental health centers, local health departments or agencies and teaching hospitals.

Teleneurology alone can save thousands of dollars in future costs of just one person's healthcare by diagnosing a stroke within the first three hours of the onset of symptoms.  Tissue Plasminogen Activator (tPA), a clot-busting drug, can help preserve a stroke patient's quality of life if started within that window.  According to the American Academy of Neurology, the average American lives an hour away from the nearest neurologist.  Those in rural communities live much farther away than that.  And we're sort of presuming people know who and where their nearest neurologists are. The true benefit of telemedicine is getting the right patient to the right treatment at the right time - sooner rather than later.

FCC Ponies Up for Telemedicine But Marks Down Subsidy

When the FCC finally agreed to start spending the money appropriated for the expansion of broadband, the entire telemedicine industry greeted the news.

Now, however, we're getting to the "small print," and what we're seeing are some important aspects that were overlooked in the initial excitement and what they mean.  The FCC effort is called the "Healthcare Connect Fund." The program will subsidize 65% of broadband costs for participating providers.  Sounds like a good deal, until you consider that the FCC's existing Rural Healthcare pilot program, established by the 1996 Telecommunications Act, provided an 85% subsidy.  So, in order to get broadband support now, rural providers will have to kick in an additional 20% to get what the pilot program provided.

The government has been pushing physicians towards Meaningful Use.  Doctors were first offered financial incentives to buy electronic medical record systems, but a good number of them haven't done it because office expenses like digitizing paper records are not covered and they would end up eating the added costs.  So, Medicare will now begin cutting into reimbursements for doctors who have not gone to electronic medical records.  Government "incentives" are making it more difficult for medical practices.  That's why physicians in urban areas in increasing numbers are selling their practices to hospitals which are creating Accountable Care Organizations.  In effect, the doctors are saying: Let the hospitals deal with the government- I just want to be an employee.  Whether this is the best path for those of us who are patients hasn't been determined yet.

Eric Brown is the president and CEO of the California Telehealth Network (CTN).  In an interview with Government Technology, he says the lower FCC subsidy is an "obvious concern" to members of his organization.  CTN works with stakeholders to establish broadband connectivity for communities which are desperate for access to quality healthcare.  Members of CTN pay about $63 a month for a 1.5 Mpbs T1 Internet connection.  Some providers will find it difficult to come up with the additional 35% that the Healthcare Connect Fund requires.  In dollar terms, these providers may have to pay about $200 a month for the same connectivity as the pilot.

Without connectivity, you can't do telemedicine effectively.  If you pay a lot more for connectivity, you need to make up that added cost somewhere else.  Small rural clinics are already hard-pressed to stay in operation, and the added cost could force them to limit their hours or close.

Of course, the FCC continues to trumpet the Healthcare Connect Fund as "momentous" - that it builds on the successes of the Rural Health Care Program.  Cutting the subsidy, according to FCC Commissioner Mignon Clyburn, will avoid wasteful spending.  This reminds me of the attitude that Medicare officials took around 2001 when Congress approved legislation that allowed reimbursements for physicians who saw patients telemedically.  They saw to it that reimbursements were restricted to medically underserved areas outside metropolitan areas because they were afraid doctors would OVERuse telemedicine. Not only hasn't that happened, but also if it did, wouldn't that mean better access to healthcare for patients?



Rural Telehealth Cliff Averted

No matter how you feel about what has been going on in Washington, the people providing telehealth care at rural health clinics, members of the National Rural Healthcare Association, are breathing sighs of relief today.

Among the pork (e.g. money to subsidize Hollywood movie and TV production), the bill Congress passed and the President signed contained clauses that prevented hundreds of millions of dollars in rural health cuts. The action reinstates critical Medicare reimbursement payments to more than 850 rural hospitals and averted cuts to rural primary physicians and rural ambulance providers.

Other elements that might have been overlooked in the bill were those reinstating the Medicare Dependent Hospital program and the Low-Volume Hospital adjustment. Both expired October 1st.  Had these not been in the measure, many rural facilities that are already fiscally fragile would have had to shut down.

Like a lot of things in the bill, these are all meant to keep things going until Congress decides what and where to cut spending.  The bill delayed the across-the-board sequestration cuts for just two months.  All rural payments were given only a one-year extension, and there are likely to be additional calls for funding cuts in the near term.  I hope that the National Rural Health Association uses the delay to generate data that shows just how valuable rural telehealth is.

The Role of Telemedicine/Telehealth Services in Treating Behavioral Disorders

TelemedicineTelemedicine technology is an amazing resource for efficiently connecting doctors and patients, without physical or geographical constraints. With a full range of remote medical tools now available, such as cameras, peripherals, scopes, and mobile medical carts, telemedicine is becoming an increasingly more useful and accessible solution for providing remote care.

One of the most useful telemedicine technologies available is videoconferencing. Through the use of advanced software and high-quality video and audio devices, physicians are able to see and talk to patients anywhere on the planet as if they were in the same room. This has created a surge in the practice of telepsychiatry and telephyscology for the treatment of behavioral disorders.

But the accessibility of this kind of technology at the consumer level has had an unfortunate side effect in some cases: some doctors or patients are electing to use consumer-grade videoconferencing services such as Skype and Tango in healthcare settings. This can be a big mistake.

Initially, these free services may simply seem like convenient, easy-to-use videoconferencing solutions, but when dealing with such potentially sensitive information as patient records and private medical information, consumer services lack the security and accountability necessary for such applications.

Besides not enabling doctors to comply with HIPAA regulations, these services are much more susceptible to hacking and security breaches than professional-grade technologies – creating a significant risk of losing patient data or of viruses or spyware compromising a physician’s or patient’s entire network. Additionally, you often get what you pay for out of a free service, so connections and image quality can be unreliable or of poor quality.

There is no doubt that videoconferencing is an invaluable telemedicine tool with a wide range of potential applications. But free consumer services are simply inadequate for medical settings. In order to ensure proper security for yourself, your patients and their personal information and medical records, choose safe, high-quality, professional videoconferencing solutions. GlobalMed offers a variety of videoconferencing software and other telemedicine products to meet the needs of any practice. Call 800.886.3692 to learn more about our products and services.

How Serious is the Threat of a Cyber Attack on U.S. Healthcare?

A new paper discussses the vulnerability of the U.S. Healthcare system, and a story in a respected publication assesses the threat of cyber warfare.

David Harries and Dr. Peter Yellowlees authored the "Brief Communication" in the new issue of Telemedicine and eHealth, titled "Cyberterrorism: Is the U.S. Healthcare System Safe?"  Mr. Harries works for Océ North America, a Canon Group Company, and Dr. Yellowlees is a psychiatrist at U-C Davis in California.  Because we're doing a lot with technology in medicine now, we've become fairly dependent on these systems.  And the authors believe that this dependence on data systems that use the Internet makes them a potential target for terrorists.  Should there be an attack on, say, a hospital computer system, bringing it down or revealing confidential patient information acquired from it, this could shake the trust in such systems.  As far as we know, there hasn't been a successful attack on a U.S. healthcare organization.  The authors suggest that with cyber attacks on the increase, it may only be a matter of time before one is launched successfully.  In the article, they discuss "several best practices" healthcare organizations can adopt now for protection.

As to the actual threat of cyber-warfare, The Economist featured an article in its edition last week, titled "Hype and Fear." It points out that "almost all (roughly 98%) of the vulnerabilities in commonly used computer programmes that hackers exploit are in software created in America."  General Keith Alexander, the head of both the Cyber Command and the National Security Agency, says the attacker always has the advantage.  Many potential targets of cyber-terrorists, like power grids, sewage systems, and transportation systems, are less vulnerable than you might think.  Even if a foreign organization launched a weapon like the Stuxnet virus that was used against Iran, experience shows it will have limited success and the vulnerabilities will be repaired quickly.  And that was the best that purportedly two first-rate cyber powers (the U.S. and Israel) could come up with.  To develop a Stuxnet would require large teams of highly-qualified people which may be beyond terrorist groups.  And a large team formed to do bad things attracts the attention of intelligence agencies who are often successful infiltrating them.

Still, there's probably some teenager working round the clock trying to hack his way into a healthcare system for "fun".  As a side note, companies like Microsoft have hired the people who mount cyber attacks on them to frustrate the others who are out there.

Harris and Yellowlees suggest that healthcare organizations develop a "defense in depth" approach as part of an overall risk management strategy.  This involves multiple layers of protection.  They offer six guidelines  to follow:

1. Regular security risk assessments that determine any gaps.

2. Intrusion prevention and detection services that can detect and block cyber attackers.

3. Installation of a data loss prevention solution that checks for leakage of information.

4. Audit logs to track access to sensitive patient data.

5. Performance of regular tests of Web security.

6. Mandates that software for mobile devices, laptops, portable storage and backup tapes be encrypted.

Even with all these measures in place, you may still have to worry about the IT guy who was fired last week and wants to "get even."
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