As the world changes, our regulations and laws often scramble to keep up.

Whether it’s Uber being challenged in individual cities or schools struggling to adapt to children owning cellphones, the legal side of life often lags behind our technology, our culture, and our needs.

So it shouldn’t be surprising that telehealth regulations face similar challenges across states — but the consequences are indeed challenging for those who do direct-to-patient telehealth.

A recent article in Fierce Healthcare looked at a few examples of recent telehealth challenges arising from state-to-state regulatory differences.

As they report, “Whether a medical professional can treat someone via telehealth—and if so, how—varies widely by jurisdiction, since medical practice is regulated at the state level.”

For instance, court cases involving doctors seeing patients via telehealth touched on:

• The administration of medical abortions
• Prescription of controlled substances
• Etc.

Further, doctors and patients often run into challenges when the intended telehealth patient didn’t have access to the Broadband internet needed to access an electronic visit with a doctor (thus limiting care in the very places that telemedicine could be most useful.)

These challenges are real, and important to explore. That said, it's not necessarily the case that the challenges are inherent in using telemedicine across state borders.

The regulatory issues presented in the Fierce Healthcare article all boil down to the challenges inherent in a doctor seeing a patient electronically.  But “telehealth” is NOT synonymous with doctor-to-patient online visits. As we’ve written about extensively, the umbrella term "telehealth" includes the use of many different kinds of technology to care for patients. A doctor seeing a patient via an online platform is only one version of that.

In fact, the challenges of videoconferencing or electronic visits are the very reasons that we created iClickCare to revolve around medical collaboration among healthcare providers, NOT between a single medical provider and a patient. There are many reasons that a short, technology-supported visit between a healthcare provider and a patient via videoconferencing may not be adequate to provide strong, holistic care of that patient. There isn't a useful archive of the visit; other members of the care team can't be involved; there is often little longitudinal knowledge of the patient; and care is infrequently holistic. The regulatory issues inherent in a “visit” like that are only one aspect of the shortcomings involved.

As an alternative, telemedicine-based medical collaboration allows providers — regardless of location — to collaborate on a case. It also means that if a provider in California is consulting with a provider in New York about a patient in California, the provider in California remains responsible for that patient. And that is “responsible” in all senses, legally and otherwise. Telemedicine-supported medical collaboration allows the flexibility and location independence that telehealth promises. But it doesn’t put the sole responsibility for a patient in the hands of a provider who is 300 miles away and has interacted with them, once, on Skype.

As we step forward into this new age of telehealth, telemedicine, and technology, it's important that we don't simply replace our old system (one-on-one doctors' visits, for instance) with a technological version of that old system. Our patients deserve more imagination than that. And we deserve the ease that can come from a tool that really works to help us deliver great care. 

A new article in the New England Journal of Medicine takes a controversial stance on the topic of whether an in-person doctor's visit is always "Plan A."

Perhaps, the author argues, we are moving towards a time when patients will be better served by a model in which in-person visits are actually the "last resort" of care. 

Our take? Yes and no. Read on...

In "In-Person Health Care as Option B", Sean Duffy and Dr. Thomas H. Lee advocate for a new framework for healthcare visits. Rather than seeing telehealth visits or other virtual options as "in the meantime" approaches or ways to cut costs, they argue that perhaps patients can be cared for better when in-person visits become much rarer, only used when absolutely necessary.   

They describe the analogy of a tech support ticketing system, as might be used at your favorite software company. Perhaps a patient would submit a "ticket" with their concern or medical issue... it would be handled first via telehealth means (even automated or low level support at first)... only being "escalated" to an in-person visit if absolutely necessary. And the ticket wouldn't be closed out until or unless the initial complaint was resolved.

The technology is there, the authors contend. “Smartphone penetration of the mobile-phone market increased from 17% to 81% between 2009 and 2016.” And the reality is that in many ways, our medical system is already moving in this direction: "At Kaiser Permanente, for example, 52% of the more than 100 million patient encounters each year are now “virtual visits.”

One important point that the authors make is that doctors are often approaching care this way currently -- but with improvised methods that aren't really meeting the provider's or the patient's needs. True enough: “Virtual visits are more convenient, but there’s a difference between recreating an in-person approach with digital tools and designing the safest and most efficient way to achieve an optimal outcome." Further, if doctors are simply using text messaging, email, or informal photos to replace a visit, that's not a safe or sustainable way to replace the richness and HIPAA-compliance of a real visit. Also, improvised approaches tend to be lesser replacements for in-person care, rather than innovative ways to save money AND get a better result.

Although we agree that there is a lot of potential to rethink how we approach clinical visits in healthcare, we also worry that the authors' approach isn't appreciating some of what can be lost if telehealth approaches aren't designed thoughtfully.

For instance, the example of the tech support "ticketing" analogy would fall severely short of our goals for any medical visit. Sure, the patient's complaint needs to be addressed. But medicine is more complex than software.

So any approach to increasing the use of telehealth solutions also must:

• Support medical education.
  This means that simple videoconferencing or "e-visits" likely aren't sufficient, as they don't create an archivable, searchable, teachable record of the encounter.
  
  
• Provide holistic care to the patient. 
  Support not just solving the immediate problem, but truly caring for the patient -- which doesn’t always just mean solving only the problem the patient presents with.
  
  
• Enable providers to collaborate effectively.
  It would be a tragedy if telehealth caused a further silo-ing of providers across specialities and across the continuum of care.

Healthcare needs innovation, certainly. And technology will be a crucial part of any solution that stands a chance of survival moving forward. But we advocate for approaches that truly support access, education, and collaboration -- not just completing a ticket and checking off a box for a patient.

To learn more about alternative technologies for telehealth, download our Quick Guide to Hybrid Store and Forward Telemedicine®: 

Sometimes it is said that one needs to "slow down in order to speed up" -- meaning that the things that take time now can often save us time later. 

UnitedHealthcare's HouseCalls program, which recently surpassed 5 million visits, seems like just that kind of "slow down to speed up" situation. You wouldn't think that the program -- which brings healthcare to people's homes with house calls -- would be any kind of revenue generator or money saving initiative. But the results have been surprising.The program brings healthcare providers into peoples' homes, primarily for checkups and preventative care. For Paul Engwall, the visit by Hesper Nowatzki, a nurse practitioner, was life-saving. A simple urine dipstick done during Nowatzki's home visit, revealed kidney disease, which has since been treated. 

As Fierce Healthcare reports, "The program was solidified six years ago with the purchase of XLHealth, a Medicare Advantage plan that focused on beneficiaries with chronic conditions that were also eligible for Medicaid. At the time, UnitedHealth predicted it would add about $2 billion in revenues." 

The program tends to cut hospitalizations and high-cost admissions. "Practitioners typically spend 45 to 60 minutes with each member, often addressing issues that a primary care physician can’t, such as access to food and transportation that may be inhibiting access to care." 

This program may not win any awards for most cutting-edge technology, but the care and savings are exemplary. To us, it's a great example of a simple program that questions what we think are the most cost-effective ways to provide care, in order to prioritize care that is truly helpful for our patients.

Of course, we happen to think the program would be even more powerful if nurse practitioners like Hesper Nowatzki had the capability of collaborating with other providers (like specialists). How much better if any little "red flag" didn't mean the patient immediately needing to jump in the car, but could rather be additionally helped by a remote team. But for now, programs like these are certainly steps forward -- they question the things that we think will save money and prioritize the things that will really improve care.

Hear stories of how telemedicine programs are cutting costs and improving care: 

We often think of fields like engineering as being quite collaborative.

We know that no one professional has all of the knowledge to build a car, so many people need to offer their expertise when, say, a Ford is built.

But the creation of the new 787 Airliner from Boeing demonstrates going far beyond what we even thought was possible when it comes to collaboration — inspiring me for what may be possible in healthcare collaboration.

In building the new 787 Dreamliner, Boeing is using 3 suppliers and 40 global partners to build the airplane, “sharing the risk and the design burden.”  It's a feat of global coordination and collaboration — and certainly seems to demonstrate that more is possible than we often think when it comes to collaborating on a complex project. 

So we pulled out the most surprising — and helpful — aspects of the project and looked at what the Boeing project has to teach us in the medical field about healthcare collaboration. 

3 Surprising Insights from the Boeing Collaborative Design Project:

1. Even in a collaborative environment, it's still important to have someone who is responsible. 
This was not a completely equal collaboration in which 40 partners participated. Ultimately, Boeing was the owner and guide of the project. Similarly, with any iClickCare consult, there is always a "requesting provider" who remains the responsible owner and guide of the collaborative effort. This clarity helps, especially when collaboration is happening across geographies or in quite complex conditions.

2. Good collaboration is good business (and good medicine).
Some people think of collaboration as positive, but time-consuming, inefficient, and costly. Boeing’s example shows that this complex collaboration was actually the most efficient of all the possible alternatives. The 787 project has costs that are about 20% lower than they would have been and shaved a year off their production schedule. That said, it did involve some behavior change, on the part of the collaborators, and new ways of doing things.

3. To do collaboration effectively, you need a tool to help you. 
In Boeing’s case, they describe the lynchpin of the project as having a common “development environment” (a proprietary software) and set of design processes. This allowed the partners to have a single place to share and store information as well as a single system for moving through the design process. That’s one key challenge with telemedicine solutions that are based entirely on texting or videoconferencing — it does not create a single place or single system where all of the collaboration can happen. And this central location can be key to supporting collaborative efforts becoming effective.

It's certainly courageous to not just effect "business as usual" in building yet another airplane. And Boeing's example is an inspiring way to highlight the truth that healthcare collaboration does involve change, but it leads to better outcomes and lower costs. Even in a very big, or very complicated, project.

Last week Elon Musk announced a new plan for getting people to Mars — and a clearer idea of how SpaceX would make money at it.

As the New York Times reports, “The key is a new rocket — smaller than the one he described at a conference in Mexico last year but still bigger than anything ever launched — and a new spaceship.”

But it was a specific aspect of his vision that reminded me of the potential, promise, and reality of telehealth…

Mr. Musk’s Mars vision is interesting and almost unbelievable. (And, indeed, may not be practical, but time will tell.) “For Mars colonists, the rocket would lift a spaceship with 40 cabins, and with two to three people per cabin, it would carry about 100 people per flight. After launching, the B.F.R. booster would return to the launching pad; the spaceship would continue to orbit, where it would refill its tanks of methane and oxygen propellant before embarking on the monthslong journey to Mars.”

What is even more fascinating to me, however, is Mr. Musk’s vision for using the reusable rocket here on earth.

Because the rockets are reusable and because they travel up to 18,000 miles per hour, the rockets could take off to the atmosphere, and then come down in, say, Shanghai. Any two points on earth would be less than an hour apart. And, in fact, he says that the cost of a ticket would be cheaper than an economy ticket on a plane today. (He didn’t mention the leg room, but I’ll assume it’s better!)

When you watch the BFR “Earth to Earth” video, imagining the idea that you could get to Shanghai in 39 minutes, or from New York to Paris in 30, you start to wonder how our world would change if we could connect to each other so easily, so quickly. You think about how our understanding and empathy of other cultures might grow. You think about how new ways of practicing business, medicine, and art might emerge. How we might work and live differently, better. And you wonder -- if I could go to any country in the world before lunchtime, what would I do with that ability to connect? If I had the power to connect across the world, how would I use it?

The truth, of course, is that you have that power now.

Mr. Musk’s vision is big, and it’s encouraging to know that entrepreneurs with big visions are working towards new futures. But the truth is that in the palm of our hands, we have tiny computers that let us collaborate with medical colleagues in any corner of the world, even in a HIPAA-safe way, for a cost that is tiny. The reality is that telehealth now allows us to connect with patients and people across the spectrum of care in ways we couldn’t, even 20 years ago.

What will you do with that power?

Photo by NASA on Unsplash

We have all seen the movie scene:  

It is dark. The opposition is all around us; no one knows precisely where, how many, or how powerful. You are hunkered down.

It is silent. And then, a crack echoes out in the dark as one of your teammates steps on a branch.  Lights go on, flares fill the sky. We've unwittingly caused an attack.

Similarly, your data is encrypted. Your EHR requires two factor authentication. Your team is trying its best to get the work done. And then, crack! A well meaning provider sends a photo of a patient via text.

We're all too aware of what can happen when HIPAA is violated by something as simple as a doctor texting a picture of a patient. Fines for a single HIPAA violation have reached $5 million dollars. The Joint Commission completely rejects texting, even secure texting as safe for data. And the risks for individual providers as well as organizations are sky-high.

But our colleagues continue to text and email patient data and patient photos -- as if the rules (or the consequences) don't apply to them. Hospital administrators are taking dramatic and well-organized precautions against HIPAA breaches. But providers, many times, don't seem cognizant of the costs of their actions. 

So I was really appreciative of a well-researched study that came out recently, by the Ponemon Institute LLC, via their research sponsored by IBM Security. Their study looked at 419 companies in 13 country samples and measured the costs of data breaches. As the authors say, “We define a compromised record as one that identifies the natural person whose information has been lost or stolen in a data breach.” Their findings emphasize just how devastating a breach (including the kind caused by a doctor sending an "innocent" text about a patient) can be for an organization.

Their findings: the average cost of a data breach is $3.62 million. The US is, by far, the most expensive place to have a data breach. The costs are absolutely huge — almost twice the global average.

Further, the cost of a data breach in the Health sector is dramatically higher than it is (almost twice) in any other sector:

Of special interest to me is that the study used the data to predict the likelihood that an organization will have a data breach in the next 24 months. Based on the data set and the number of breaches that have occurred, the researchers find that organizations have a 27.7% chance of having a data breach in the next 24 months.

To me, that means that it's not a question of whether your organization will have a data breach -- but when it will have a data breach. And it's not a question of whether your texting of patient data can have a consequence, but simply when you will experience that consequence.

In fact, hackers and malicious attacks get a lot of press, but 28% of breaches are caused by human error.

We certainly understand that the day-to-day of medical practice can be overwhelming enough, without having to worry about patient data. But the evidence that this problem is urgent and (in large part) in our hands is too weighty to ignore. 

There is technology that will let you share patient information and patient photos in a secure, HIPAA compliant way. iClickCare is a simple tool to let you do that, using your own smartphone. It's affordable, and it's fast -- and the consequences of doing anything else are simply too large.

If you're concerned about HIPAA data breaches in your organization, get the information to keep you safe. Download a free HIPAA checklist and toolkit here:

Top photo by Mareks Steins on Unsplash. Graph photos used courtesy of the Ponemon Institute LLC, via their research sponsored by IBM Security.