Telemedicine practitioners can feel isolated. They are often among a handful of people in their immediate practice or hospital who are using telemedicine to perfect care, improve outcomes, and make their lives easier. 

The truth, however, is that healthcare providers using telemedicine are part of a large, growing, and thriving community. When we started working in this field almost two decades ago, telemedicine was rare. Now, however, the most committed, innovative healthcare providers all use telemedicine in one form or another. 

Telemedicine is actually thriving. Here are 5 reasons why: 

• Politics are catching up. As this article details, parity laws are going into effect in several states. Also, the Telehealth Modernizaion Act -- to establish a clear definition of telehealth -- is on its way to going through. "Telehealth is a major contributing factor to increased health care quality, convenience, and lower costs," said Reps. Doris Matsui (D-Calif.) and Bill Johnson (R-Ohio)
• Telemedicine is reaching critical mass. Research and Markets is predicting 18.5 % growth in global telemedicine in the next 4 years. 
• New providers are more familiar with technology. For some of the same reasons as we highlighted in our discussion of concierge medicine, and as this article discusses, new providers are adopting practices like telemedicine at higher rates.
• Providers are using smartphones in their practice. According to Verizon, "38% of physicians with smartphones use medical apps on a daily basis, and that number is expected to increase to 50% this year. Two-thirds of healthcare providers said that implementing or improving their use of mobile technologies is a high or mid-level priority during the next 12 months."

We're thrilled to know that providers are connecting better, people are collaborating, and patient care is improving as telemedicine becomes more widespread.

If you're looking into the options, get our Quick Guide to Telemedicine here:

Image courtesy of thomaslevinson on flickr.com, used under Creative Commons rights. 

"Health-care reform, a ballooning and aging population and a shortage of available family physicians may be a perfect storm that could blow the doors open for telehealth to go mainstream."

-- Brian Heaton, GovTech 

Despite recent fiascos in our nation's capitol, the Affordable Care Act is taking root. And regardless of where you fall politically, there is one thing that is clear: the ACA may really boost telemedicine. We've been keeping our eye on the regulatory side of things, so here is our rundown... 

6 reasons the Affordable Care Act makes telemedicine (even more) crucial:

1. High demand. It's estimated that the healthcare system will see an influx of more than 30 million newly insured patients. Those patients' needs may be best met with a combination of telemedicine and conventional solutions. 
2. Provider shortage. The ACA's provisions increase demand while not addressing the provider shortage (particularly of primary care doctors), making telemedicine-based visits are care coordination crucial. 
3. Better reimbursement and funding. The bill provides several explicit provisions increasing funding and easing reimbursements for telehealth.  
4. Need for medical home and meaningful use. It's not enough to use EMRs, as we all know -- it has to be meaningful use.
5. Shared cost and outcomes-driven models. A focus on outcomes (rather than treatments) and a shared cost model means that the care coordination, collaboration, and savings that telemedicine can provide will be crucial for hospital systems and providers. As Dr. Brian Rosenfeld, Chief Medical Officer at Philips Healthcare, said, "Telehealth offers the opportunity to provide the access, quality and cost that will be necessary to increase prevention and leverage our current workforce."
6. Technology is less of a barrier. Although this factor isn't directly related to the ACA, it is a trend happening at the same time. Every year, technology -- broadband, collaboration platforms, cameras, computers -- get a little more widespread and a little easier to use. For instance, every doctor has the tools for using iClickCare in their office, and most have it in their pocket.

New compensation structures start with the best of intentions: keep costs down and patients healthy. But healthcare providers can become a casualty on the road to lower costs.

So, is your pay system causing provider burnout? The short answer is: probably.

Exhibit 1: Pay for volume.
Volume-related incentives were the compensation fad of the last decade. However, since provider burnout is exacerbated by feeling disconnected to patients and not having enough time to spend with them, this short-sighted policy contributes to many frustrated providers. As Dr. Robert Centor said at the Medscape Roundtable, "Too often the current finances of medicine force physicians to spend inadequate time with patients… I would argue that our payment system, especially for outpatient internists and family physicians, is a leading cause of burnout." 

Exhibit 2: Pay for performance.
A recent New York Times article shows how the Affordable Care Act is prompting hospitals to link provider pay with performance (measured by patient outcomes, cost containment, and patient satisfaction.) It sounds like a plan that makes sense, but physicians tend to resent this time of micro-level intervention in how they care for patients. And some point out that they're held responsible for things they can't influence (like whether a hospital floor is clean.) In fact, experts say that this plan of "carrots for doctors" is unlikely to work, even outside of physician considerations. 

What works?
There is no doubt that healthcare has to be more accountable and costs need to come down. But when it comes to designing a compensation plan that works, healthcare provider needs have to be front and center. The big problem with igorning provider needs and stressing them out? Well, it doesn't work. Patient satisfaction starts with happy healthcare providers. And research shows that doctors with lower incomes, more debt, and less savings tend to be more burned out than their peers. So if your compensation structure is burning out your providers, it's very possible that you're gouging patient outcomes and even elevating costs at the same time.

Compensation is a headache, but coding doesn't have to be. Get our free guide to ICD-10:  

• Health is one aspect of humanness.
• Medicine is but one aspect of health.
• Telemedicine solutions are one aspect of medicine.
• Medical collaboration is one aspect of telemedicine.  

Telemedicine solutions benefit the patient because the patient gets the right care at the right time in the right way. Medical collaboration makes sure that conflicting approaches are harmonized by adding the right minds to the mix.

Healthcare debate has assumed a fading role in the USA election process. The much anticipated US Supreme Court decision, in the end, came to a discussion about money — healthcare defined as a tax.

Nearly every US citizen has access to some sort of communication technology. Around the world, common citizens have gained freedom by using technology that has become stronger than bombs and thugs.

It is time for each of us, to do the same for our health care.  

iClickCare is a tool which allows those who care for patients to collaborate on behalf of their patients for the good of their patients. In return, the providers get immense satisfaction and amelioration of fear. And as they age, they will have educated others to care for them as well. As doctors and nurses become cannon fodder in a war of healthcare, maybe we can keep them happy enough to take care of all of us.

So, my suggestion is, that while debate continues with only 3 months to the election, each of us must push ahead to use technology to empower ourselves. 

We watch the Olympics in real time, we micro-blog news as it is happening, we use calculators in place of fingers, we listen to music from around the world, and we set timers on coffee pots and washing machines. We even use the telephone.

We, each of us, cannot just give up and watch as an election take place. We can make change now, and need to do so.  Each of us makes all of us one.

Collaborate today…

Accountable Care is a payment and delivery model that relates quality and cost. It is conceptually very similar to the HMO models of the 1970s. Interestingly, the same players have rejoined the game.

Tallies are made on three items:

• Appropriateness
• Efficiency
• Quality

At first reading, these are undeniable truths, but further thought brings untenable falsehoods.

They are significant, and both the process and the products arehighly questionable. 

• Where are the Carl Bernstein’s, Jacob Riis’s, and Robin Cook’s of the world? Why does the Affordable Care Act (Obamacare) feel as complicated as the disease of the system itself?
• Why have thousands of lobbyists participated in a process that leaves the individual citizen/patient overwhelmed and under-informed.
• Why must discussion be brought down to sound bites?

Instead of sound bites, let’s focus the fundamentals of health care. Let’s focus on patients and those who care for them. When it comes to paying and payors, it all becomes too impersonal, too murky, and frankly, too suspicious. Maybe the healthcare system has become so complex, and so inter-twinned, and so self-interested, than no one Bernstein, Riis or Cook can take on the investigation that is needed. Still, fortunately, questions are being raised.

All of that said, and all of that needed, we each can do our part. Our warning is about quality. Not quality itself, but about defining quality. Our concern is that to measure quality one needs numbers. To get numbers one needs definitions. To get definitions on needs language. To get language one needs ideas. And that is where the problem lies. Ideas can be new or old; accepted or controversial; hackneyed or original; common or cultural. 

It is naive to think that judging data will “incentivize” quality. What is measured, indeed, is what is changed, but when an institution (government or corporate) measures things, its citizens and employees fill out whatever form is offered to get the reward, and most often do not accept the penalty to reach a higher good. Can complete, comprehensive empathetic care be measured by ICD-9 or ICD-10?

For instance, is "incentivize hospitals, physicians, post-acute care facilities, and other providers involved to form linkages and facilitate coordination of care delivery" really collaboration? Who benefits? Is the patient or the ACO at risk? Is doing nothing good or bad? Does compromise of treatment, because of a compromised patient, acceptable.

This is not a new debate. Thus the reminder is that the patient must be the final beneficiary of quality improvement. It is the patient who sits before you, places trust in you, and ultimately lives or dies because of you. True quality is getting the best data available (yes even from an EMR/EHR) and then doing your very best, as an individual with an individual to get he best answer. This requires true medical collaboration on behalf of the patient. Collaboration requires exchanging data, experience and judgment. It is an extra effort. It takes work—in the past telephone tag, long and inaccurate descriptions, and long meaningless “reports and consults” from  “incentivized” consultants were bad enough. Not to be out done, primary care providers now send a 12 page EMR referral with every single checkbox filled in. Nobody thinks, they just generate data, devoid of interpretation, and without understanding.

Now, iClickCare makes it much better and easier. We must not jump over the bar that is given to us, but instead consider what is needed for the patient in front of us, and raise the bar for ourselves. iClickCare empowers the part of ACOs that matter for the patient -- patient centered collaboration.

References:  

(1) McClellan, Mark, et al. A National Strategy to put Accountable Care into Practice. Health Affairs. 29(5). 2010. 982-990.

(2) http://capsules.kaiserhealthnews.org/index.php/2011/10/nixons-hmos-hold-lessons-for-obamas-acos/

We are awed, inspired, and appreciative of the contribution Steve Wozniak has made. As a pediatrician, I also know that stability, success and optimism must necessarily come from within, but need to be modeled by someone else.

At the American Telemedicine Annual Meeting 2012 keynote, Steve was asked about his family.  He mentioned some things about his father which may have made Steve, Steve. Listen to these few seconds of tape, captured, of course, with an iPhone, as he speaks of his childhood development and of his Dad.

Why are these comments included in this blog?  It's because we wish all Fathers the very best everyday, but especially on Father's Day, June 17th, 2012. And it is particularly impressive that in addition to everything else Dads do, like Steve's Dad, many also:

1. Are patient teachers

2. Bring out the best in their children, for a lifetime, and

2. Inspire laughter, which is very good medicine, along with medical collaboration and accountable care.

Steve Wozniak is also a published author with the release of his autobiography, iWoz: From Computer Geek to Cult Icon, available (as is our book iPhone Medical Photography) at these retailers:

Apple ITunes Store:

Amazon:

Barnes and Noble:

Google:

It all starts the beginning.  Share Caring for Baby.

Care coordination and telemedicine are coming to the fore.  The last two weeks have made 5 P's worth discussing.

• Publicity
• Pinterest
• Pigeon Holes 
• Principles
• Patients

Briefly, Publicity and Pinterest have introduced many new people to ClickCare. This is exciting and we will talk about both first. Secondly, with the introduction of something new, the natural inclination is to try to fit the new into something old -- in other words a Pigeon Hole. Since  innovation and disruption cannot be pigeon-holed, we look to the Principles, based on classic oaths, to codify good Patient care.

 

Publicity.   The New York Times article by Eilene Zimmerman created a lot of conversation. Clear and concise, it was described by a respected colleague who lives in the independent country of Georgia as "informative, analytical and useful." This article also lead to a lot of conversation and interpretation of just what ClickCare is, and what iClickCare can do, and for whom.

Pinterest.   Next, ClickCare now has beautiful and informative boards on Pinterest. Curated by Carol Robbins, a respected photographer and designer, the boards offer a variety of broader, richer and lighter resources for all who take care of patients. The boards also bring more questions about what, how and for whom.

Pigeon Holes.   We ask: “Why just one?” Part of being on the cusp of change is enjoying the challenge of communicating a message. We know where we are and we know when we are going. One of these challenges is that the critical concepts of medical collaboration, coordination of care, care management, accountable care seemed to have been lost to history in just a few short years.

As accountable care expands, and ACO becomes as familiar an acronym as HMO, the delivery of care will change.

In a way, it seems as if this mega-industry reflects the same stresses as the disintegration of the nucleur family: two jobs, job sharing, a parent on the day shift, and one on the night shift, soccer, music lessons, friends. No wonder the calendar on the refrigerator door is so important.

A shortage of providers will be met by, as CMS describes it, by expanding the workforce. This brings up an interesting discussion of collaborative care and telemedicine.

Donald W. Fisher, Ph.D., CAE, is AMGA president and chief executive officer. AMGA is the American Medical Group Association. His organization reports a study about manpower needs on March 12, 2012.

"Collaboration and teamwork are significantly more important to medical groups and health systems because care models and performance measures require it. The ability to work effectively as a member of an accountable care team becomes a valued skill for physicians and advanced practitioners who increasingly will partner with colleagues in primary care, hospital medicine, a wide range of specialties and subspecialties and allied health."

Accountable Care Organizations (ACOs) and the medical home model are growing concepts in modern health care delivery. This survey by the American Medical Group Association (AMGA) and Cejka Search 2011 Physician Retention Survey is most interesting as it describes physician, nurse practitioner, and physician assistant staffing needs and turnover. Many shocking facts are brought to light. These facts add up to a roiling environment of instablility. Medicine, now consolidated as a "medical industry," if nothing else, was once considered stable. Now the core -- providers -- shows itself to be unstable and changing.

Thus, there are shocking facts:

• 67% of respondants reported "somewhat or significantly" increased involvement of advanced practitioners (non-physicians) in the past 5 years.
• Turnover rate of nurse practitioners and physicians' assistants is 12.6%.
• Three fourths will hire more in the next 12 months than the previous 12 months.
• Turnover can cost as much as $1 million per physician in recruitment, startup costs and lost revenue

Four more interesting facts from the survey:

• There is increased turnover. Turnover is nearly 6% in 2011.
• There is more part-time work. 22% of male physicians and 44% of female physicians as compared to 7% and 29% in 2005.
• More work is is being done by advanced (mid-level) practitioners.
• There is a huge shortage of providers developing.                                                                                 

Incentives to address these issues have been:

• Reduce hours
• Flexible scheduling
• Performance incentives.

There is a strong motivation to develop teams since they are the core of accountable care and of the medical home. With incentives, efficiency becomes important. 

Our interpretation of this data is both more specific and more broad: that there is a strong need to provide a way to build teams. These teams cannot just be items on a work schedule, but strongly need to have communicating, sharing, handing off, following up and educating -- people.

Moreover, the concept of centralization is no longer necessary, advantageous, or even possible. Just as the internet has decentralized commerce, the same forces will decentralize health care.

Our passion is to support and connect each individual to all the others in the team. We want to ensure that the patient does not continue to fall through the cracks, as a "disconnect" from care delivered from silos. We need to enable sign-outs, on- and off-call, continuity and creativity. With turnover, more education, and more collaboratoin is paramount.

Sources:

American Group Medical Association

Fierce Practice Management 

Cejka Search 

Calendar: www.bmscentral.com 

 Pearson Scott Foresman

Well, not really. You can get paid...

Are you on salary? Are you working under fee for service? Are you primary care?  

As a primary care provider, by collaborating you are working at a higher level of care and can bill accordingly. Reimbursement for telemedicine and telehealth is rapidly changing. More and more states (see California’s Telehealth 2011 Law) are paying for more and more forms of telemedicine. They see that there is real value in collaboration. Until every payor, everywhere catches up, you can use these codes.

For the requesting provider:

• Bill using appropriate E&M codes 99122-99215, as well as the time spent in telemedicine medical collaboration.
• Charge a remote facility fee Q3014.

Check and see if the patient’s insurance company needs a prior authorization.

Note pre-authorization information along with the patients insurance plan and an ID number in your collaboration request on iClickCare as a courtesy to your consultant.

Now that we have talked about actual payments. What about your time?  How many HOURS a week to you spend playing telephone tag? How many weeks does one call take to complete? Do you ever have any questions after receiving a referral letter? What if you disagree and want to discuss alternatives? Then what? Send the patient out on his hopeless mission again? Call the consultant and start the telephone tag game again? How long does it take you to get the letter in the first place? Could you get through the reimbursement generated chaff for the answer. 

You have an EMR or EHR? So you need to initialize the letter, get it scanned, and then search for it among the immunizations, broken arms, visit for anxiety, viral syndrome and rash. Only electronic?  Same drill, you just never marked it with a pen first. Store and Forward technology makes this all so much easier.

iClickCare has a reimbursement page that you may wish to review. It shows the previous version of the software. The new iClickCare, reviewed nicely here, makes all this even easier.

Did we mention the patient?

• Improve your skills.
• Be sure you have time off.
• Consider Accountable Care.