By Bruce Brod, MD
Note: Guest blogger Bruce Brod, MD, is a Clinical Professor of Dermatology at the University of Pennsylvania and also practices in Lancaster, PA. He is a Pennsylvania Medical Society (PAMED) member and Political Advocacy Chair of the Pennsylvania Academy of Dermatology and Dermatologic Surgery. In addition, he served on PAMED's Telemedicine Task Force that helped write draft legislation.
While telemedicine seems like one solution to the high cost of delivering medical care, it is important to remember that patient safety and quality of care must be the guiding principle behind any use of telemedicine. It is a huge and complex topic and I will limit the discussion to encounters with patients rather than remote patient monitoring or diagnostic laboratory services.
With the availability of web-based telemedicine, the movement to streamline medical licensing across state lines, the inclusion of telemedicine in Alternative Payment Models (APMs), and the inclusion of telemedicine in the Sustainable Growth Rate (SGR) repeal law by way of the Merit Based Incentive Payment System (MIPS), we are poised to see a massive shift in medical practice.
Of historical interest is that the first reference to telemedicine in the medical literature occurred in Pennsylvania.
This involved a transmission of a radiologic image between West Chester and Philadelphia. Since that time, teleradiology has been on the forefront of telemedicine. That being said, I think we can all agree that there is a difference between diagnostic services and direct clinical services when it comes to providing care remotely.
Initially, clinical telemedicine was designed to provide consultative care in remote areas of the world, such as Africa, or for use in the military to provide medical advice near the battlefield.
I am a dermatologist and this is a field which naturally lends itself to teledermatology, but alas there are pitfalls.
I cannot begin to count the number of times a patient has come in to the office to show me a large but benign skin lesion, and when I peer around the corner to their back I pick up signs of a skin cancer such as melanoma. This ability is limited with teledermatology, but how helpful would it be to follow up with an elderly psoriasis patient who lives 90 miles from the office and has limited transportation or ability to drive to assess their response to treatment after an initial office visit, especially when you can access his or her entire medical records remotely from your office?
Before committing yourself to teledermatology, I might suggest working with your local hospital or large medical group or community health clinic to develop a pilot program pertinent to your specialty. I know of several areas in the country where dermatologists are using telemedicine to help ED physicians and remote health clinics diagnose and triage certain skin problems in patients.
The questions you need to ask yourself: What is your definition of appropriate telemedicine that will maintain high quality patient care? Is it a telephone conversation with a new patient you never met before, a digital image with detailed patient information, or a live videoconferencing session? Is filling out an online questionnaire and sending a digital photo of the affected body part in a low acuity problem to the remote physician who has never encountered the patient an appropriate way to receive a prescription for a $45 fee?
The Federation of State Medical Boards (FSMB) defines telemedicine as the practice of medicine using electronic communications, information technology or other means between a licensee in one location, and a patient in another location with or without an intervening health care provider.
I encourage you to review the FSMB policy on telemedicine as well as any policies that have been established by your specialty society for appropriate use of telemedicine in your specialty. Here is a link to the FSMB policy on telemedicine.
PAMED has taken the lead to develop standards as well as payment parity for telemedicine.
Currently there is very limited ability for payment mandated into law, including Medicare and Medicaid. Payment is currently limited to rural areas in the Medicare arena. New codes are being developed by specialties in conjunction with AMA RUC committees to insure fair payment.
The federal government is working on legislation to expand payment for telehealth services.
Despite the seismic shift in the way medicine is being delivered there are still a lot of unknowns, including the effect of telemedicine on patient outcomes. Studies are under way but this will take some time. After all, this should be our No. 1 priority.
Lastly, it is important for patients to maintain the ability to choose their physician in a remote type patient visit, especially in the direct-to-patient model in a clinical encounter. I will leave it up to the reader to decide whether you think patients will choose the remote physician they never met or their trusted group in their own backyard when it comes to telemedicine.