This post was originally published on July 24th. Since this piece of our website was not working for all viewers, we're republishing some selected posts this week. 

As big fans of TED Radio Hour, and even bigger fans of medical collaboration, we loved the recent Radio Hour episode about the "chaos and power of collaboration."

The piece weaves together perspectives from diverse folks (everyone from Wikipedia's Jimmy Wales to the guy that invented CAPTCHAs.) And interestingly, the diversity of viewpoints actually highlights the common threads. Here are the points that struck us as being applicable to medical collaboration, and resonate with what we observe in our ClickCare users:

1) Collaboration isn't motivated by money.

We get so used to the idea that people are interested in saving time and earning money. But the existence of a massive collaborative effort like Wikipedia proves that people's motivations to collaborate go beyond just making a dollar. 

• Interviewer: "Human motivation is driven by incentive, usually financial, and your model upends that principle." 
• Jimmy Wales (of Wikipedia): "Well I don't think so. And that's what's interesting, is that, yes, if somebody has a view that human beings are only motivated by money then they're going to have a pretty blinkered view of how humans behave -- and also a fairly sad life."

Later in the episode, Clay Shirky lists the intangible rewards that people get for collaboration: autonomy, competence, belonging, and generosity. He also says that "cultures get what they celebrate." Which means that we can facilitate collaboration in whatever group we're a part of. Not by plying folks with financial rewards, but by celebrating generous, creative, collaboration.

2) Collaboration can happen 10 seconds.

Early in the episode, Luis von Ahn explores whether there is a way to use just 10 seconds of effort to do something great for humanity.

Later, Clay Shirky confirms that most people have a surplus of time and talents… but it might be found in little bits throughout the day. In fact, he says that world has over 1 trillion hours/year in "cognitive surplus." For many people, huge amounts of that free time are spent watching TV. For the rest of us, it's likely that our free time comes in such small bits -- 5 minutes here, 10 minutes there -- that we don't recongize its value. But both in Luis von Ahn's massive translating effort and in ClickCare's medical context, even seconds of collaborative effort can have world-changing consequences.

3) Collaboration shouldn't interrupt you.

The practice of medicine has become frantic and interrupted. No healthcare provider has as much uninterrupted time with patients, other providers, or herself as she needs. If it's not a page interrupting us, it's paperwork. And when it comes to collaborating with other providers, it starts to seem like one long game of telephone tag. 

ClickCare's store-and-forward technology (read: you respond when you have time and don't have to hunt colleagues down for consults) was designed to solve exactly this problem. Because as 37 Signals's Jason Fried says, "If people don't have time to think -- and thinking time has to be your own time -- then they have a really hard time producing great work."

Fried couldn't be a bigger proponent of collaboration. But as he says emphatically (and we agree): "Collaboration is good, but we shouldn't mistake it for interruption."

Want to experience iClickCare Hybrid Store-and-Forward for yourself? Try iClickCare for the iPad and let us know how it made a difference for you.

Could this be the next telemedicine new thing? This review by Walt Mossberg describes an exciting device that let’s your HD TV become a whole room conferencing center.

It is manufactured by a company called Tely Labs. It costs $250 and links through Skype. We are enthusiastic about such new developments, but we also remember that our 16 years of experience has shown us three things to think about:

• Is what we are viewing easy to use, solid and usable on demand with the patient in front of you?
• Is it secure?
• Does it make a medical record for later teaching and documentation?
• Does it allow a shift in time as well as place? In other words, do the requestor, the consultant, AND the patient all have to be present at the same time?

We also, in the past, have gone through the drill of purchasing a considerable amount of expensive equipment. Based on those purchases and experiences, we found that access to care is easier when scheduling is easier. Collaboration is best performed at a relaxed time for each provider individually, and that by having a database of each consultation, not only lawyers are served, but more importantly all those we educate -- the new hire, the graduate nurse, the medical student, the resident, or the nurse in training --  are served even better.

While we are very aware that Store and Forward technology provides all of these advantages, it is still not universally reimbursed. This is rapidly changing as noted in our previous post. In the mean time, creative products like this should be considered.

Please contact us if you would like to discuss further nuances of these types of decisions.

 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?

It’s been six weeks since California passed Bill AB 415. The new law, California Telehealth Advancement Act of 2011 gives providers in California more choice in how to best collaborate on behalf of their patients.

This blog posting will highlight points about the California law and telemedicine:

• The vision of the legislation and how it will make patient care better.
• The limited interpretation of the true potential of the law by many commentators.
• How the inclusion of store and forward technology in the law is important.

The Center of Connected Health Policy offers a focused review of what the law does and does not do.  This single page is remarkable for its clarity and brevity.

Obvious, but rarely stated, are three paragraphs expressing a strong vision about telemedicine and telehealth directly quoted from Section 2:

(e) Telehealth is a mode of delivering health care services and public health utilizing information and communication technologies to enable the diagnosis, consultation, treatment, education, care management, and self-management of patients at a distance from health care providers.

(i) Consumers of health care will benefit from telehealth in many ways, including expanded access to providers, faster and more convenient treatment, better continuity of care, reduction of lost work time and travel costs, and the ability to remain with support networks.

(k) Without the assurance of payment and the resolution of legal and policy barriers, the full potential of telehealth will not be realized

Just as a toddler learns basic behaviors such as please and thank you, these three (of ten paragraphs) define the value (and that value will be manifest by ROI) that any health care provider, agency or institution should learn. It is a vision of better access, collaboration and education.

Portions of the law, and many of the commentators view the purpose of telemedicine as providing for the underserved and the rural.

(g) The use of information and telecommunication technologies to deliver health services has the potential to reduce costs, improve quality, change the conditions of practice, and improve access to health care, particularly in rural and other medically underserved areas.

But, a deeper, wider and more comprehensive vision must be developed. 

Why? It is never good to be sick. It is never convenient to be sick. It is even more inconvenient to maintain health. Everyone regardless of richness or poorness, high or low IQ, rural or urban deserves coordinated, collaborative care. Care management is equally the right of the CEO as the homeless child. The inner city tenant suffers the same as the rural migrant. The too busy entrepreneur faces the same constraints of place and time as the uninsured food service worker. Unfortunately, each faces the same challenge in receiving the right care, at the right time, from the right (and conferring) care giver. Each of us, all of us, should expect good care and encourage the use of telehealth and telemedicine to get it. When we have it, we have safe, efficient, cost effective and holistic care. That is what we used to have, it is what we need now, and with such good legislation, what we can expect in the future.

There are a lot of lessons in this law.  Next we look forward to discussing the immense value of Store and Forward technology.  iClickCare is a leading example of this.

A focused review and set of references are here.  They are both a starting place and a quick review.

• Note of an erudite presentation facilitated by telemedicine
• How access and collaboration lead to education at the highest level

Jagmohan S. Sidhu, MD is presenting a fascinating case of Cutaneous B cell lymphoma and has included Dr. Ronald Harris, oncologist, and ClickCare founder Dr. Lawrence Kerr as co-authors. The intricacies of the disease and management are likely beyond the interest of our readers, but the implicataions of the process are very interesting.

This presentation is on Friday, October 28, 2011 at the Society of Hematopathology and European Association of Haematopathology combined meeting in Los Angeles California.  FinalProgram 

The patient is elderly. Access to specialized is needed. Care coordination is important. The patient needs to be seen but not sent all around. So, three or four years ago, telemedicine collaboration allowed better diagnosis and to be followed by coordinated management. Moreover, because a store and forward technology was used, the case (no individual is no longer a patient, fortunately) is available for sharing again, this time with scientists who give a week of their time, meet and share in order to education themselves and improve care for all of us.

Special people who care for patients with store and forward telemedicine make a better future for all of us.

This is a great story about care coordination. It is about
collaboration between two caring providers and should be lauded. Breast cancer, and really, any illness is very traumatic. Read how two responsible physicians worked together to help their patient.

This is stimulating, but brings up 3 concerns.

1. What if there are greater distances involved?
2. What if emergencies or schedules preclude a meeting?
3. What if a third, fourth, or fifth provider need to participate?

Technology can help the patient receive the specialized care she needs. It can help to make sure that each member of the team who cares for her is "in the right place, at the right time."

We have all heard of telemedicine. While we have heard the term, we think of it as futuristic and impossibly difficult. It has been difficult and it has been highly dependent on expensive complex equipment.
Because of the internet, bolstered by modern computing, things can be different: 

1. Distance is less of a problem because an iPhone alone or a common desk or laptop is needed.
2. Scheduling is eliminated because, as any reader of this blog is familiar with...emails, chats, and notifications are at the convenience of the user.
3. Not only one physician, but any caregiver, can participate – doctor, nurse, therapist, nutritionist, etc. and, yes, even the patient.

Doctor, nurse, therapist, nutritionist, etc. and the patient. This means there is real continuity of care. There can be better hand-offs, conflicting medication and treatment resolution, faster response to change, and enabled focus on the patient.

Let's not forget the providers either. Wouldn't it be nice to obliterate telephone tag and realize the satisfaction of really being involved and sharing something special in the future?