Telehealth Potential Remains, Trapped by Regulations and Licensure Barriers

Dr. Alan Lee's Perspective article in the December 2011 Physical Therapy journal offers hope tempered with a dose of pragmatic reality - much work still needs to be done if telemedicine techniques can be brought to bear for the benefit of physical therapists' patients.

Some of the barriers on the provider side identified by Dr. Lee include:

• licensing and credentialing - Alaska and Washington state are the only two states to include telemedicine language in their practice acts. New legislation promoting "license portability" is being prepared for the Congress in 2012.

  “Telemedicine is medicine, just practiced virtually”,

  ...said the office of the bill's sponsor, Senator Tom Udall of Utah. 

On the policymakers' side the barriers include:

• billing and reimbursement - payment for physical therapy services is currently dictated by the setting or delivery method, ie: home health, outpatient, hospital, etc,

Telemedicine's biggest benefit is probably its costs savings to both the provider and the patient.

But, new evidence that telemedicine can impact relevant patient outcomes that are "hot topics" among payers and policymakers is increasing.

Geisinger Health Plan, using telemonitoring technology, has demonstrated a 44% reduction in 30-day readmissions compared to a control group.

How Can Outpatient Physical Therapists Use TeleMedicine?

I imagine a scenario similar to the Geisinger program where patients are followed after discharge to monitor their status and identify risk factors before symptoms occurs, or before an adverse event happens.

Can you imagine Skype connection (available for free on newer laptop computers) with your geriatric patients?

What if you could measure the 10-foot Gait Velocity over Skype and predict the need for Skilled Intervention based on slowing gait speed?

What if Medicare would pay - based on this one measure alone?

Overheard at the American Telemedicine Association Meeting...

Tampa Convention Center: May 1, 2011 - Morning Session. Some snippets of conversation I overheard at ATA 2011...

Telerehabilitation or Telemedicine?

• No professional associations 50 years ago
• Power-based relationships – students, clients, consumers
• Asynchronous vs. synchronous? Store-and-forward (dermatology and radiology) use one way communications to help diagnose patients. Interactive video is synchronous because it happens in real time.
• “Follow the money”
• Who had the most control in 2011? Payers, consumers, providers?
• Ossifying technologies? Eg: BLACKBOARD in academia

“Store-and-Forward” Technologies in Telerehabilitation

• Asynchronous sharing for home exercises and physical therapy prevention of falls. Content server contains files, videos such as a home exercise library.
• Poor broadband connection in Australia?

Is your Telerehabilitation Practice HIPAA Compliant?

• Is Voice Over Internet Protocol (VoIP) HIPAA compliant? Is VoIP a Business Associate (BA) under HIPAA?
• If VoIP is a BA then they must meet the HIPAA Privacy Rule requirements. If VoIP (eg: Skype) works for a covered entity then they are a BA.
• Top 10 Risk Assessment: 58 question checklist (is the checklist validated and published?)
• Non-recorded data falls under the Privacy Rule but not the Security Rule. If data is not in electronic format at the time of transmission (eg: a fax piece of paper or a real –time synchronous video chat) the data does not fall under the Security Rule.
• Hackers are ALWAYS thinking about how to gain access to PHI but are hospital administrators ALWAYS thinking about how to protect their data?

Licensure and Reimbursement for TeleRehabilitation

• SLP doesn’t have “practice acts” but have “licensure laws”.
• SLP Assistants not recognized by Medicare.
• Texas has prescriptive (3 pages) in practice act. Some experts state that “…Texas is a leader...” in telerehabilitation
• APTA Definitions and Guidelines recommend a PT be licensed in the state in which they practice telemedicine.
• Some experts surprised that this definition was not provided by the Federation of State Boards of Physical Therapy (FSBPT)

Model Telerehabilitation Program for Rural Areas

• Kentucky pilot telerehabilitation in rural areas
• Community based rate $89/ 1-hr. session
• Telehealth rate $63/ 1-hr. session

Model Telerehabilitation Program for Occupational Therapy

• 30 sessions on telehealth at AOTA 2011.
• Works in the home. Training spouse/family members. Cash-based OT practice in West LA. Lots of DSL and 4G networks.
• Life coaching for cancer survivors – 12 week program.
• Work in industry using video conferencing to assess work stations and make recommendations for adaptive equipment.
• Does not see an issue with offering “wellness” services for Medicare patients and is able to avoid the “opt out” issue for physical therapists in private practice.
• Using mobile and video devices to connect with patient in a direct access model with “store-and-forward” technology that enables therapists and patients to interact asynchronously (at different times).

You may get the impression from this blogpost that telerehabilitation is a bulleted list of techniques and technologies rather than an integrated body of knowledge, practices and standards...

Your assessment would not be incorrect...

Can anyone help me define and refine this field for physical therapists?

American Telemedicine Association Advocates for Physical Therapists

The American Telemedicine Association (ATA) is advocating for physical therapists to deliver telerehabilitation services and receive Medicare reimbursement in order to succeed under Medicare Accountable Care Organizations (ACO):

"Medicare law bars some providers from delivering telehealth services - even as they are otherwise permitted under Medicare.
Notably, physical therapists, occupational therapists and speech-language pathologists, are barred from delivering telehealth services."

The ATA sent Medicare administrator Dr. Donald Berwick a letter on April 25th asking for five regulatory waivers, including the restriction on physical therapists performing telerehabilitation services.

The ATA request reads:

"ATA strongly urges the Secretary to waive this restriction. Otherwise, the ACOs will fail to fulfill Congressional and Agency intent...

...section 1834(m)(4)(E) needs to be waived... to permit any beneficiary to get the otherwise covered Medicare services of physical therapy, occupational therapy and speech-language pathology and audiology..."

The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies.

ATA and its diverse membership, works to fully integrate telemedicine into transformed healthcare systems to improve quality, equity and affordability of healthcare throughout the world.

The ATA 2011 annual meeting started today, Saturday April 30th in Tampa, Florida and runs through Tuesday, May 3rd.

I'll be attending the pre-course meetings, presentations and trade shows and posting the technology and innovations I find to this blog.

Tell me what you'd like to know about the emerging telemedicine industry.

How do you think physical therapists should fit into this new paradigm?

A Physical Therapist at the American Telemedicine Association's Annual conference

The American Telemedicine Association (ATA) is coming to the Tampa Convention Center here in Florida on May 1st to 3rd, 2011.

The ATA 16th Annual International Meeting and Exposition is the world's largest focusing exclusively on telemedicine and health.

I will attend the meeting representing PhysicalTherapyDiagnosis.com and I will interview several important people in the telemedicine industry. Among the luminaries I've already scheduled:

• Jean Bisio, President of Humana Cares, will present Emerging Markets in Federal Telehealth from 4:15 - 5:15 p.m. on Tuesday, May 3rd and I plan to attend this event - booth #1117.
  
  
• Jay Culver will demonstrate the Total Exam Camera by GlobalMedia - booth #717.
  
  
• IDEAL LIFE, the industry leader in remote health management solutions - booth # 1617.
  
  
• MD2GO, Sony's remote HD IP camera system, is designed to enable HD Video communication between a healthcare professional and a patient - booth #416
  
  
• Louis Burns, CEO of Care Innovations, is participating in the Emerging Markets for Remote Monitoring Applications roundtable on Monday, May 2, from 1-2pm in the Plenary Ballroom C.
  
  
• Alice Borrelli, Director of Global Health and Workforce Policy for Intel, is participating in the Transitioning Successful Pilot Studies into Mainstream Applications roundtable on Monday, May 2, from 3-4pm in the Plenary Ballroom C.
  
  
• Intel-GE Care Innovations™ has its blog set up so you can see some of the innovative, new telemedicine devices available this year.

I encourage physical therapists, especially private practice therapists and those in a position to lead their healthcare organizations, to learn about and perhaps embrace these technological changes - not for the sake of either change or for technology - but because of the promise that they bring to make better our patients lives.

Florida Representatives have Concerns about Telemedicine Bill

A new bill covering telemedicine services (HB 505/SB 1882) was read on the full Florida House of Representatives floor on Tuesday March 8th, 2011.

The bill requires health insurers, corporations, and health maintenance organizations issuing certain health policies to provide coverage for telemedicine services.

The new bill prohibits the exclusion of telemedicine cost coverage solely because the services were not provided face to face.

The bill provides coverage under the state plan without a condition that telemedicine services are restricted to health care providers licensed by the Florida Deptartment of Health.

If the telemedicine bill is passed in its present form it would require the insurer to reimburse for services provided by a health care provider not licensed within Florida

This would render the regulation of health care professionals by the respective professional boards, where telemedicine is concerned, moot with regard to out of state practitioners.

Similar telemedicine legislation is being debated in California, Oregon and Washington state right now.

Nurses have created "Nursing Compacts" with government grants that are, in effect, seperate licenses allowing them to practice across state lines.

Physicians have a "special license" that allows them to practice medicine across state lines and still retain the supervision of their state licensing boards.

Why should Physical Therapists be left out of the party?

A recent randomized, controlled trial in the Journal of Bone and Joint Surgery showed that telerehabilitation, in one setting, can produce superior outcomes than conventional Physical Therapy for Total Knee Replacement.

What do the readers of PhysicalTherapyDiagnosis.com think about telerehabilitation services, such as remote video monitoring?