Telemedicine is not a new technology.

In fact, we’ve been doing telemedicine for almost 20 years at ClickCare. As you may know, we started by pioneering in a School-Based Health program at local underserved elementary schools. That program used newer technology — including some digital cameras — but really, the success of it was related to the approach and openness of the providers, patients, and families involved.

Because the school nurses and the pediatricians were so oriented towards caring for their young patients as well and as holistically as possible, they were open to trying new approaches. As participants saw the success of the program, it became broader and more organizationally supported. And honestly, at no point was there any conversation around reimbursement or policy — it was just one more way they cared for their patients.

All of the providers that use iClickCare today approach it similarly. While telemedicine is increasingly common, it’s certainly not the default. And so providers or hospitals that incorporate the tool do so as a conscious choice. Reimbursement improves; political and organizational support expands; but through it all, providers carry on with the tools and approaches they think will help their patients the most.

I was interested to read a report in JAMA, however, and extended in Fierce Healthcare, looking at how telemedicine use is expanding (or, in some cases, not), and how reimbursement laws relate to these adoption phenomena. Parity laws demand that insurer reimbursement be the same for telemedicine-based care as for in-person care. These laws have been adopted in 64% of US states. In confluence with this, there was a significant uptick in telemedicine usage among primary care physicians between 2015 and 2017. For more rural areas, mental health services seemed to be higher usage than other specialities. While in urban areas, primary care telehealth was more common.

This is all in line with the expansion of both telemedicine and reimbursement that we’ve seen. Parity laws demand that insurer reimbursement be the same for telemedicine-based care as for in-person care. That said, one interesting fact stood out: “the data showed a negative association with states that enacted comprehensive parity laws mandating reimbursement for the services.”  Perhaps that is because those states struggled the most with adoption in the first place — but either way, it’s clear that adoption “from the grassroots” may be more effective than approaches that aim to implement telemedicine starting at the policy level.

With any shift in practice, there is always a combination of technological, personal, psychological, and societal factors that need to come together for the technology to be incorporated into use.

For instance, simply inventing the telephone doesn’t create a culture that calls your friends. A combination of phone lines, social change, and early adopters combine with the new invention to lead to a society that talks on the phone.

On the one hand, telemedicine is becoming increasingly widespread, generally. There is increasing consensus that telemedicine can contain costs, increase access, and cut healthcare provider burnout. It’s not surprising that so many providers, patients, and payers are incorporating the technology into how they “do medicine.”  On the other hand, telemedicine implementation isn’t a matter of policy or a “snap of the fingers.”

Ultimately, telemedicine adoption must come from providers and patients. There is no way to legislate or demand creative ways of caring for our patients.

Learn more about how to implement telemedicine in your organization, economically and quickly, with our Quick Guide to Hybrid Store-and-Forward Telemedicine: 

In a fee-for-performance world, we are all under huge amounts of pressure to improve our metrics. 

We are expected to cut costs, drop readmissions, decrease length of stay, and even improve healthcare provider burnout.

As you probably know, we believe that telemedicine-based healthcare collaboration can dramatically improve almost every one of these metrics. But a recent study had us asking -- is there a down side?

A recent JAMA study looked at 115,245 fee-for-service Medicare beneficiaries hospitalized with heart failure at 416 sites across the United States. Then, they looked into the consequences of a Hospital Readmissions Reduction program implemented at the sites. 

Happily, and as expected, implementation of the Hospital Readmissions Reduction Program was associated with a subsequent decrease in 30-day and 1-year risk-adjusted readmissions. The shocking part, however, is that implementation of the program was also associated with an increase in 30-day and 1-year risk-adjusted mortality.

In other words, people were coming back to the hospital less, but they were dying more. 

This type of story -- in which we see unexpected consequences of well-guided programs in healthcare -- comes up frequently. And it's easy to adopt a kind of nihilism in the face of a study like this: nothing will actually improve the situation so why bother. 

But we believe that that is the wrong conclusion. Rather, it's crucial to pioneer new initiatives to both improve care and improve our performance against metrics. But initiatives must be holistic. It's not enough to create a program that aims to improve readmissions but worsens care overall. That's why we are such advocates for telemedicine and healthcare collaboration. Initiatives like these are holistic enough that results across multiple dimensions of care are improved. On the flip side, it means that the "sell" to hospitals that have to improve in one dimension in 6 months is more difficult.

But ultimately, the only sustainable improvements are those that take care, metrics, and the whole picture into account. 

If you're ready to try iClickCare, you can download it for free here: 

Last week, Fierce Healthcare reported that the Joint Commission has decided to table the Telehealth standards that, in May, they had originally announced were in the works.

The primary focus of the standards was the portion of telehealth where care is provided direct from, and to, the patient. As The Center for Telehealth and e-Health Law reports, attorney Nathaniel Lacktman of Foley & Lardner said the standards would have "forced Joint Commission-accredited hospitals to obtain informed consent from patients prior to delivering care via telehealth. In addition, providers would have had to discuss with patients the 'type of modality that will be used' before providing care."As readers of this blog well know, iClickCare is all about using technology to help providers collaborate. This collaboration results in the best care for the patient, and the patient can be invited to join when desired and necessary. See our answer from our FAQs “Can I include my patient of family members in iClickCare?"

We're largely appreciative of the Joint Commission's dropping the standards. It's not that telehealth standards of any kind are out of the question. But the Joint Commission's proposed standards were troublesome because they were simultaneously narrow and too restrictive.

We believe that the portion of telehealth that is direct-to-patient is over emphasized in the telemedicine landscape. It's a tool with specific applications and potential because it doesn't allow a team of thoughtful providers to partner with a patient in asking the right questions about their own care. Instead, a "fix" is sought, and via technology, seemingly obtained.

As an architect friend of ours said recently, “Sometimes we come to a conclusion before we have defined the problem”.  We all know that the patients who often get the worst care are physicians and nurses.  Why?  Because they make the diagnosis, and seek the treatment from an ultra-specialist, before the big picture is analyzed. They seek the tree and miss the forest. Similarly, direct-to-patient telehealth can risk the same challenges. 

None of this has been addressed fully. Narrow standards applied to a isolated topic will do little to advance a broader view of technology and health and worse, stifle innovation and adoption.

 

 

Healthcare providers tend to feel like they're being pulled in five directions at once.

We're supposed to improve patient satisfaction, use the new EMR/EHR more meaningfully (read: spend more time on the computer), connect deeply with each patient, and increase productivity.

No wonder most of us are burnt out.

Similarly, there are two dramatic trends that are pulling in opposite directions for healthcare -- and unless they use tools to reconcile them, providers are the ones who will feel, even more, torn apart.

I came across an article recently -- published by the consulting megalith McKinsey -- looking at how industries are beginning to change shape. The future, the article argues, will be made up of industries without borders, in which sectors and company lines become more fluid, and the organizations that collaborate best, win. 

I don't naturally apply learning from the business world directly to medicine because I believe medicine is unique. It's not an "industry" in the real sense of the word. It's an art, a calling, a science. 

But the business world is often the first to identify trends, as their profit motive drives them to identify changes before they are blindsided by them. And the changes predicted in the McKinsey piece seem to herald changes that are very much afoot in medicine as well. 

The general idea is that moving forward, organizations will need to collaborate more with each other, share data, and rethink how they draw the lines around what they do.

Current examples of this happening are like Amazon (sells consumer goods, providers digital content, and does logistics -- all in one company) or Apple. McKinsey argues that these blurry lines are just the beginning of what's to come. These shifts are in the works for a few reasons:

• Technology makes it easier for communication to happen.
• Customer (or patient) expectations have shifted. In the past, it was acceptable to tell a patient that you had no way to see their chart from another provider. In the future, this will become untenable.
• Regulatory shifts demand it. In medicine, shifts away from fee-for-service models mean that we can no longer just provide our narrow service and expect to survive. We're expected to manage costs, readmissions, length of stay, and ultimate outcomes from the work we do.

McKinsey says, "As the approaching contest plays out, we believe an increasing number of industries will converge under newer, broader, and more dynamic alignments: digital ecosystems... This new environment will play out by new rules, require different capabilities, and rely to an extraordinary extent upon data."

I believe that we will see a similar dynamic in medicine moving forward. The lines among functions, sectors, and hospital systems are blurring. That's why we see this demand for coordination. We're no longer in a fee-for-service world. Instead, care coordination is explicitly our job, we're held responsible for outcomes and results, and the teams we work on are becoming broader and more complex.

But hospital systems and healthcare providers are not equipped to handle these dynamics. In fact, healthcare has spent the last 20 years moving in the exact opposite direction. We've seen huge consolidation, in which insurance companies become more powerful, hospital systems grow larger, and the siloes we work in become evermore separate. We're asked to become piecework laborers, keeping our head down and performing the task for which we are specialized.

It is more necessary than ever to collaborate and coordinate care but it is also harder than ever because we are separated in the work that we do. That's why healthcare providers feel so torn and overworked; they are being tugged by both of these forces simultaneously. 

We believe that the only resolution of this dynamic is to use tools, like iClickCare to collaborate and communicate within the current medical structure. The demands on you to do healthcare collaboration (HIPAA securely of course) are only going to increase as the lines, among organizations and sectors within medicine, blur. But you won't necessarily be given the tools to do those things. That's why iClickCare is available at the enterprise level or at the individual level -- we believe that in any given organization, it may be the administration or it may be the individual providers that truly chart the course forward amidst these competing demands. 

As Bill Gates is quoted as saying, "I’m a great believer that any tool that enhances communication has profound effects in terms of how people can learn from each other, and how they can achieve the kind of freedoms that they’re interested in.”

It's an exciting time, for sure -- but only if we're equipped with the proper tools. 

 

On Friday, President Trump signed a bill reauthorizing the Food and Drug Administration’s user fee agreements for drugs and devices. 

The bill authorizes user fee agreements before they were set to expire in October. Interestingly, the bill also establishes several new approaches to the regulation of digital health and creates a digital health unit within the FDA’s Center for Devices and Radiological Health (CDRH).

Advocates of digital health, telehealth, and telemedicine might worry about whether this change is positive or negative for medicine and for progress in digital health. Here’s our take…

The Food and Drug Administration was created to regulate, make safe, and (perhaps), facilitate the development of food and drug products in the United States.

Of course, in 2017, digital technology is every bit as important as biochemistry in contributing to our health and wellness. So the Food and Drug Administration is working to keep up with the new forms that “food and drugs” take — and how data and technology can contribute to or potentially endanger the nation’s health.

As digital science becomes increasingly important, it will need to be regulated. But, at this point “watchful waiting” is more important than regulation to allow the development of creative technologies. These changes probably mean little to you using iClickCare but we wanted to keep you abreast of the changing regulations in the field.  On the other hand, here will more control of the hardware and medical device side of telemedicine.

ClickCare is proud to be a leader during an exciting and innovative time. And ultimately, we are advocates for technology that is safe because it is in service to providers caring for their patients — like telemedicine for medical collaboration — not a circumvention of the way providers care for patients.

Tools, technology, and drugs are only as safe as the professionals using them. So we see our job as simple: use technology but get out of the way so that you and your colleagues can care for your patients.

Learn more about the most innovative form of medical collaboration (that is also the simplest) here:

 

 

 

 

 

 

Photo by Glen Alejandro on Unsplash

In the last week, 18 states signed on to a common licensure process, allowing physicians to apply for expedited licensure in all or some of the participating 18 states.

This has long been a goal of telemedicine and telehealth advocates. The lack of a common license has made it difficult to provide care from one state when the patient was in another. If a doctor had wanted to practice in all 18 states and filled out applications for each sequentially, it could have taken four to eight years, tens of thousands of dollars, and hundreds of hours of form filing and document gathering.Licensure certainly brings standardization and review of qualifications to protect the public. It prevents bad doctors from moving to be just a step ahead of the posse as they flee from misadventure. It also acts as an income source for states (via fees) and protection from competition for doctors already in the state.

A licensure compact is regarded as a great step forward for the patient. Access to care can be instantaneous and at a distance. It also solves the problem of mal-distribution of doctors. In theory, over populated cities could share their providers with sparsely served rural areas. This of course, assumes that already too-busy doctors want to work harder to care for strangers far away. Time will tell if this is valid or a mere shibboleth that sounds true but really is not.

We have other concerns, however. We know that three problems continue to grow and increasingly affect patient care safety and satisfaction:

1. Silos are becoming predominant
2. There is too much knowledge for any single person to absorb (never mind, master.)
3. No provider has enough time to struggle with telephone tag and HIPAA

Together these issues, combined with introverted personalities, result in a failure to collaborate. This failure results in outcomes that we have described before: lower quality, higher errors, and provider burnout.

Of course, licensure across state lines makes all of this worse. Teams cannot be built without trust and communication. When the caregiver is more important than the prescriber, an unknown, unproven and unrelated prescription can only be made on technical terms alone and not in concert with those who know the patient best.

However, what we advocate for -- true coordination of care and true medical collaboration -- doesn't necessitate licensure across state lines. The consulting physician who is geographically close to the patient remains responsible for the care, even as they collaborate with physicians from across the US or even internationally.

If a sore throat becomes a strep septicemia, when abdominal pain becomes an ectopic pregnancy -- then the patient needs to have a collaborating team somewhere that understands each other, trusts each other and is aware of the attitudes -- as well as ability -- of each member. Teams can always cross state lines, even when licenses can't. 

 

Use iClickCare to collaborate with your medical team, for free:

 

iClickCare has strong information security baked in, but what about the rest of your life? How are you handling your own desktop and mobile device?
The complex becomes simplified by the Federal Trade Commission in a recent Consumer Information post. We will summarize it here, but it is worth a look. First, the most feared situation is covered: how to recover if your email is hacked. Second, the FTC goes over three areas of personal online security with their extensive resources:

• Online Security
• Tips for Educators and Parents
• Videos and Games

The FTC's recommendations for online security are especially interestng for healthcare providers, as our personal and professional realms can sometimes mix in ways that we don't anticipate. The FTC suggests that you:

• Use security software that updates automatically.
• Remember that Personal information is more valuable than cash.
• Ignore phone calls that scare you by saying you have a virus or need technical repair.
• Make sure that a website is secure before you transmit any financial information. Look at the “S”; for example with iClickCare the address looks like this - https://iclickcare.com/ … Do you see the “S” at the end of “http” and before the “:” ?
• If you have a question about a company, then search for the company name and follow that with one of these words such as “review”, “complaint”, “scam”. Then look for contact information that seems credible and assess the risk.

And of course, always be backing up your files.

One important last note: let’s talk about your camera or smart phone. Back up those as well, but also realize that you may have information there that you may wish not to share. A hacker, kids' pictures, and kidnappers seem like bad elements in a disastrous recipe. Address books and notes are also sources of valuable information which could be abused.

What about clinical pictures? iClickCare separates them from your regular camera roll and they are protected inside the app. Beware that downloading patients photos to your desktop is also a HIPAA compliance risk unless you meet the extensive physical guidelines in the law such as a locked room, entry logs, separate servers, encrypted databases and the like.

But as we often say - take care of yourself. At first, the idea of personal IT security seems too hard. But some of these simple rules make it seem manageable enough to actually do.

If you're interested in taking secure photos in your medical practice, we put together a guide here:

“The Americans have need of the telephone, but we do not. We have plenty of messenger boys.” – Sir William Preece, Chief Engineer, British Post Office, 1878

“This telephone has too many shortcomings to be considered as a means of communication. The device is of inherently no value to us.” – Western Union internal memo, 1876

A recent article called The State of Teleheath, written by respected colleagues in the New England Journal of Medicine, looks at the challenges telemedicine and telehealth face as technology. 

They list three trends in medicine, and describe them as linked:

1. A shift in focus from increasing access to healthcare to a focus on convenience and cost.
2. A change from caring for acute conditions to caring for episodic and chronic conditions.
3. Migration from hospitals and satellite clinics to home and mobile devices.

They also identify four potential barriers to telemedicine and telehealth, and provide legitimate solutions:

• Reimbursement: limited coverage, fear of abuse or overuse.
• Clinical concerns: lower quality patient-physician relationships, physical examination vs in person visits.
• Fragmentation of care: potential for narcotic prescribing abuse, legal issues.
• Credentialing: licensure, and social / geographic limitations which limit access.

The review is well written and comprehensive, by established and respected authors and leaders in the field. And we also share their concern about many of the challenges that telemedicine faces.

But when we step back and consider all of the indicators that telemedicine is actually gaining huge momentum and overcoming many of the barriers that used to exist, we tend to come to a different conclusion about the "state of telehealth." We step back and look at how technologies become tools, particularly three examples that healthcare providers use every day:

• The telephone
• The fax
• The stethoscope.

Telephones, of course, are now so common that we don't think of them as technology -- we think of them as a tool, or just a daily part of our lives. The fax took 50 years to be adopted and (although it can easily replaced by Hybrid Store-and-Forward Telemedicine®), it persists to this day. The stethoscope was invented by Laënnec in 1816 but did not reach its non digital state of the art until after 1956.

Telemedicine and telehealth are still thought of, by mainstream medicine, as technology. The opportunity is to move on to incorporating “telemedicine” not as something different, but as just part of the fabric of seamless care. This will be done by simply changing our mindset. Just as we have done with the telephone, fax, and stethoscope. Each of these is just an everyday tool, and two -- the stethoscope and the telephone -- are symbols of medicine. Imagine the image of a doctor with a stethoscope around the neck and a telephone against the ear. You probably see a worried look on that doctor's face, but undoubtedly you are not seeing a technology barrier.

Our conclusion? The state of telehealth is strong -- not as a technology, but on its way to becoming just another tool, that is woven into our daily lives.

Our mantra from the very beginning over 20 years ago is Access, Collaboration and Education. Drs. Dorsey and Topol have done a good job of discussing access. And we want to champion a broader view -- one that also includes collaboration and education.

Current attitudes about telemedicine and telehealth are problematic. The prevailing view is that data is all, singularly, important. We encourage you to think beyond this. We encourage you to expand your thoughts beyond the excellent review of Drs. Dorsey and Topol. View data as valuable to the patient only when it is personalized for that patient. Use data as a language, but use the language to communicate and collaborate.

We are committed to going farther. We are committed to using human insight, compassion and judgment to master data and create solutions. It is time to do in health care that which we do in life -- use the technology that is available to improve the lives of our patients and ourselves. 

An interesting twist in what goes around, comes around.

Jason Helgerson, the Director of New York State Medicaid, wrote recently to offer encouragement and advice to Great Britain’s National Health System. Despite many of its laudable accomplishments, it turns out that the NHS is strapped for funds. We applaud Helgerson's attitude around creativity, innovation, and the merits of a positive attitude. We also hope to assist his New York State efforts by providing our iClickCare care coordination and telehealth system.

We have often argued for change over control. Contrast change which Helgerson suggests with that of the subtle rationing approach, which of course prioritizes control.

On the other hand, too much creativity can be problematic. When should profit be prioritized for good?

ClickCare is not a pharmaceutical company and respects that big pharma is providing value. The product iClickCare is a new technology with plenty of development and testing. Now all we have to do is to have innovative people step forward and do something different -- collaborate.

 

To learn more about how telemedicine can play a role in your organization, download our quick guide:

You have been there. You look for a better way to collaborate with photos, videos, medical records and conversation. You decide the price is right. You look forward to making things more efficient and better. You will be glad to decrease readmissions and trips from Long Term Care Home and Skilled Nursing Facility and back again. You are eager to start.

Inurement: a word whispered in the back of your mind. You check with legal. The response: don’t help the patient, don’t help the institution, don’t help the provider. Better to look the other way while HIPAA laws are broken left and right.

An unintended consequence of legislation usually called the Stark Law, authored by Rep. Stark of California was to make sure that compensation could not be hidden and that competition was fare. The common case was low rent in exchange for exclusive admissions.

It is increasingly well documented, and increasingly being made obvious by various government entities, that value based healthcare requires sharing of revenue and risk. If a hospital or a physician buys iClickCare for its great advantage and gives it to non salaried by loyal referral sources -- suddenly these legal issues make that look like a "kickback."

Both the US Senate and the American Hospital Association see this interpretation as a big problem and have written about the need for improvement. We thank FierceHealthcare for bringing these recent statements to our attention. We are often frustrated by this as we work to empower providers to take care of patients.

Should you wait? We advise providers not to, because the costs related to poor care coordination and HIPAA compliance issues are just too high to not take action. As for Stark, we can support you in creating different arrangements to keep you legal from Stark and HIPAA -- at the same time.