Telehealth: Frequently Asked Questions WHAT IS TELEHEALTH? Telehealth is the use of electronic information and telecommunications technology to support: THE DELIVERY OF HEALTH CARE PATIENT AND PROFESSIONAL HEALTH EDUCATION PUBLIC HEALTH HEALTH ADMINISTRATION HOW IS TELEHEALTH DELIVERED? Telehealth is primarily delivered in four ways: VIDEOCONFERENCING (Synchronous): Live two way interaction between a patient/client and a health professional. Examples include telepsychiatry, telepractice (speech therapy), and tele-stroke. STORE AND FORWARD (Asynchronous): Transmission of pre-recorded digital information (images, pictures, video) through a HIPAA-secure electronic communications system to a health professional who uses the information to evaluate the case or render a service. Examples include tele-radiology, tele-dermatology, and diabetic retinopathy screening. REMOTE PATIENT MONITORING: Collection and wireless transmission of health and medical data ontact Information (e.g., blood pressure, glucose, weight, pulse, blood oxygen, peak flow) from an individual at one location to a health care provider or call center in a different location for use in patient care. Use cases include chronic disease management, patient engagement/education, and prevention of hospital readmissions within 30 days of discharge. MOBILE HEALTH (mhealth): Health care, education and public health practice supported by mobile apps and mobile communications devices such as cell phones and tablets. Applications can range from targeted text messages that promote healthy behavior (e.g., medication and appointment reminders) to wide-scale alerts about disease outbreaks to gamification of health to encourage healthy behaviors and practices (e.g., exercise, nutrition, tooth-brushing).
WHAT ARE THE DIFFERENT MODELS OF TELEHEALTH? Telehealth has been in existence for over 25 years, and models of telehealth have changed over time. Telehealth models fit into three broad categories: HUB AND SPOKE When telehealth first began, the model was predominantly hub and spoke and primarily involved specialty care consults between large tertiary care centers and smaller rural hospitals. The tertiary care center would be considered a hub. Specialists at the hub site would provide consultation to patients at one or more small rural hospitals called spokes. Examples of services provided using this model include tele-stroke, tele-burn, and tele-cardiology. NETWORK OF NETWORKS Over time, technology improved, bandwidth increased, and costs decreased. Health care systems also began to shift their priorities around health reform, with a focus on reducing costs, providing better care, and ultimately improving health outcomes. Coordination of care and the ability to manage chronic and life style diseases became a necessity. As a result, the promise of telehealth expanded its reach to include community health centers, private practices, school based health clinics, and other facilities (both traditional and nontraditional). Health care facilities began to connect to each other, creating a network of networks. For example, students in school based health clinics connected via telehealth to receive primary care from a clinician at a pediatric practice; patients at community health center connected to a psychiatrist in hospital; etc. FULLY DISTRIBUTED NETWORK Telehealth is in the midst of yet another transformation called the Direct to Consumer evolution. We are seeing telehealth expand its reach to wherever the patient may be, whether that is at their home or school or even while on vacation. Instead of requiring a patient to go to a location to receive health care services, those services are now going to the patient. This model is often referred to as virtual care or care anywhere.
IS TELEHEALTH CONSIDERED A SAFE WAY TO PROVIDE QUALITY HEALTH CARE? Telehealth is a tool for delivering health care and not a separate service in and of itself. Therefore, the safety and quality of care provided through telehealth is dependent on the clinical judgment, adherence to clinical practice standards and education/training of the clinician. CLINICAL JUDGMENT Developing and being able to apply good clinical judgment is essential for all health professionals. Clinical judgment comes from a combination of critical thinking skills, training, and experience. If a patient were to come into a clinician s office and his/her stethoscope were malfunctioning, one would expect the clinician not to use it as a tool for rendering a clinical assessment. Similarly, if a patient were being seen via telehealth and for whatever reason, the clinician is unable to see or hear the patient clearly; one would expect the clinician not to proceed with the telehealth encounter until the problem is resolved. If the issue cannot be resolved, then the clinician would need to ask the patient to make an inoffice visit. Ultimately, the health professional must make the determination regarding whether telehealth is or isn t appropriate for the service being rendered. STANDARDS AND GUIDELINES Over the years, there have been a number of standards, guidelines and best practices that have been developed to ensure the responsible use of telehealth technologies in patient care. In some instances, telehealth has actually become the standard of care. Examples of existing standards include: The Federation of State Medical Boards Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine American Telemedicine Association Telemedicine Practice Guidelines for: o Live, On Demand Primary and Urgent Care o Telepathology o TeleICU Operations o Core Operational Guidelines o Telemental Health and Video-Based Online Mental Health Services o Store and Forward and Live-Interactive Teledermatology o Videoconferencing-Based Telepresenting o Diabetic Retinopathy o Telerehabilitation o And more! American Psychological Association Guidelines for the Practice of Telepsychology American Academy of Ambulatory Care Nursing Telehealth Nursing Practice Scope & Standards of Practice
TRAINING, ACCREDITATION AND CERTIFICATION Training programs currently exist, both in the classroom, on-site and online. The American Telemedicine Association has a list of accredited training programs and also has an accreditation for online patient consultation. In addition, a variety of both online and classroom Certificate programs exist for telehealth coordinators, telemedicine clinical presenters, telestroke presenters and others. As telehealth continues to expand, more and more such programs will emerge. For example, the Center for Credentialing & Education developed a Board Certified-TeleMental Health (BC-TMH) Provider credential. WHAT ARE THE BENEFITS OF USING TELEHEALTH? There exists a large body of literature regarding the evidence for telehealth feasibility, quality, safety and cost-effectiveness. EVIDENCE BASE There are several places to find the body of literature on telehealth. These include: The Institute of Medicine publication The Role of Telehealth in an Evolving Health Care Environment. A recent (2016) technical brief prepared for the Agency for Healthcare Research and Quality entitled Telehealth: Mapping the Evidence for Patient Outcomes for Systematic Reviews that identified 1,494 citations about telehealth and found a number of areas where the evidence base is very strong and other areas where further research is still needed. The Center for Connected Health Policy (National Telehealth Policy Resource Center) Research Catalogues summarizing peer reviewed research in a number of telehealth-related areas. The Northeast Telehealth Resource Centers Resource Library. Here you will find a searchable database of publications related to clinical guidelines, outcomes research by specialty area and more. CASE STUDIES The American Telemedicine Association (ATA), Health Information and Management Systems Society (HIMSS) and Personal Connected Health Alliance have all been actively collecting and making available case studies to show how telehealth saves time, saves money, improves patient outcomes and otherwise demonstrates the value of telehealth. These case studies may be found at: Telemedicine Case Studies (ATA) mhealth Case Studies (HIMSS) Personal Connected Health Alliance Case Studies ASSESSMENT AND EVALUATION The National Quality Forum has developed a Framework to Support Measure Development for Telehealth as a way to assist researchers and analysts to advance quality measurement for telehealth. For more information about telehealth, visit www.telehealthresourcecenter.org Developed by the Mid-Atlantic Telehealth Resource Center (www.matrc.org) Updated: February 2018
TELEHEALTH POLICY ISSUES www.telehealthresourcecenter.org September 2017 The ubiquitous adoption of telehealth continues to lag despite improved technology and increasing amounts of evidence of its ability to effectively provide health services. In the last few years, telehealth has received attention as a means to achieving the goals of the Triple Aim: increased efficiency, better health outcomes and better care. However, existing policy barriers on both federal and state levels contribute to the limited use of telehealth. Below are some of the major barriers that currently exist. REIMBURSEMENT Telehealth reimbursement policy varies greatly on the federal and state levels. Restrictions in the Medicare program include limitations on where telehealth services may take place, both geographically and facility-wise, the limited number of providers who may bill for services delivered via telehealth, a limited list of services that can be billed, and restricting, for the most part, to only allowing live video to be reimbursed. Each state dictates what their telehealth policies are which creates a patchwork quilt of telehealth laws and regulations across the nation, in both the private and public sectors. Over the last few years, states have also begun to pass legislation to either encourage or mandate private payers to reimburse for telehealth delivered services. These policies also vary across states and some contain their own limitations, depending on how the laws have been crafted. Additionally, the laws may also be written in such a way where there may be parity in coverage of services, but not necessarily parity in payment amount. In other words, a state law may require an insurer to pay for services if they are delivered via telehealth if those same services were covered if delivered in-person, but the law may not require the insurer to necessarily pay the same amount for that service in both cases. LICENSING/REGULATORY BOARDS Licensing is under the purview of states to control and regulate. The majority of states require a license from the state in order to provide services though a few exceptions exists in a handful of states. Various national groups have worked to ease some of these issues. The Nurses Licensing Compact allows a nurse with a license in a compact member state to practice in another compact member state without having to obtain another state license. The Federation of State Medical Boards offered their own type of solution for physicians by creating model language for an Interstate Medical Licensure Compact that would allow member states to create an expedited process to obtain a license in a member states. There is also a Psychologist Compact as well. In addition to the licensing issue, regulatory boards also hold key control over other aspects that impact telehealth policy. Increasingly, regulatory boards are looking to develop regulations, policies, or guidelines on how providers they regulate utilize telehealth in their practices. Some of these guidelines have mirrored what licensees would need to do if they had provided the services inperson, others have included additional requirements. CREDENTIALING/PRIVILEGING CMS approved regulations to allow hospitals and critical access hospitals (CAH) to credential by proxy which allows a clinic (the originating site) to contract with another hospital, CAH or telemedicine entity (the distant site) to provide services via telehealth and credential those providers by relying on the credentialing work done by the distant site, if certain conditions are met. This creates a faster, more cost effective method for clinics and hospitals to access needed specialty care. The Joint Commission created parallel guidelines to the federal regulations. Both are optional to use and a clinic or hospital may still utilize a full credentialing process.
HIPAA/PRIVACY/SECURITY The technology alone cannot make one HIPAA compliant. Human action is required in order to meet the necessary level of compliance that is required. HIPAA does not have specific requirements related to telehealth. Therefore, a telehealth provider must meet the same requirements of HIPAA as would be needed if the services were delivered in-person. However, to meet those requirements an entity may need to take different or additional steps that may not have been necessary if the service was delivered in-person. For example, a tech support person who would not be exposed to protected health information if a practice was strictly in-person may be in a different situation where telehealth is involved because that tech support person may be required to enter an exam room to help with the equipment. Additionally, states may have their own privacy and security laws with which providers must be familiar. HIPAA is a baseline to protecting health information and some states may actually have a higher bar a provider must meet in order to be compliant. Additionally, states may have specific internet vendor laws that may not be directed at health services, but nonetheless impact them because they are services sold via the Internet. If a provider is offering services in another state, it would be prudent to look into the state laws covering these areas. For more information, contact your Telehealth Resource Center at www.telehealthresourcecenter.org or the Center for Connected Health Policy (www.cchpca.org). The National Consortium of Telehealth Resource Centers (NCTRC) is an affiliation of the 14 Telehealth Resource Centers funded individually through a cooperative agreement from the Health Resources & Services Administration, Office for the Advancement of Telehealth under grant number G22RH24743. The goal of the NCTRC is to work collaboratively to provide accurate, consistent information on telehealth while efficiently using federal funds. MALPRACTICE There have been few cases that involve telehealth and many have revolved around teleradiology. The low number of cases, however, is likely due to the low adoption of telehealth. Additionally, there have been a few negligence cases that involve the non-use of telehealth. Theoretically, telehealth malpractice cases are likely to increase the more it is widely used. However, one thing related to malpractice that providers should be aware of and which has become an issue to some providers is malpractice coverage. Not all carriers will cover for malpractice involving telehealth delivered services and not all coverage a provider has will be viable in another state. Additionally, some carriers will provide malpractice coverage, but may charge high premiums. Very little policy has been related to addressing these issues. Providers should ensure that their malpractice insurance does cover telehealth delivered services and that it is viable in any other states they wish to practice in. A provider may find he or she will need to purchase additional insurance. PRESCRIBING A relationship entirely built via telehealth may not be considered a valid means of establishing a relationship, limiting the ability of a provider to do so. The Ryan Haight Act dictates how telehealth (telemedicine is the term used in the Act) may be used to prescribed controlled substances. The Act provides specific scenarios on how the interaction between patient and provider must take place. States have control over how everything else is prescribed when telehealth is used and as mentioned in earlier sections, the policies vary across states. Some states have very specific rules for the use of telehealth in prescribing while others are vaguer or silent. Some of the rules center on whether telehealth is adequate to establish a patientprovider relationship which, again, vary across the states. This question of telehealth and prescribing has gained increasing attention in the last few years and will likely continue to be an area where states continue to develop their policies.