T
o James Luecke, MD, and Thomas J. Kim, MD, pictures are worth more than a thou- sand words. They are worth their patients’ very lives.
In the middle of a delivery, Dr. Luecke suspected the baby was in respiratory dis- tress but did not have access to a neonatolo- gist at Big Bend Regional Medical Center in remote Alpine, Texas. So the family phy- sician went down the hall to connect to a subspecialist in Lubbock through Texas Tech University Health Sciences Center’s (TTUH- SC’s) telemedicine program. The neonatolo- gist saw through the video and from x-rays that the baby was in trouble and helped Dr.
Luecke stabilize her in time for transfer. Those pictures not only opened the door to a subspecialist, but they also “saved the baby’s life,” Dr. Luecke said. “You don’t know it’s a rash until you know it’s a rash. You don’t know it’s a fracture until you know it’s a fracture. In situations where you need help, and you need a visual for somebody who does it every day, that’s where telemedicine works perfectly and where it saves lives.” When Dr. Kim was out of town at a conference, the Austin internist and psychiatrist got a phone call from his care team reporting suicidal tendencies in one of his juvenile detention center patients. Dr. Kim quickly determined the youth was up- set about a recent court decision. The boy’s family was there to testify, and Dr. Kim knew they had a rocky relationship. He told the boy to “pull it together” and he would see him via videoconference the next day.
Because the two had developed a therapeutic relationship via telehealth, Dr. Kim could “leverage his [patient’s] trust to engage him at a critical moment and use telehealth to offer a timely response that avoided a costly emergency room visit and an unnecessary potential hospitalization.” That’s the thrust of a new Federation of State Medical
Boards (FSMB) model policy that aims to create a roadmap for the safe and appropriate practice of telemedicine amid grow- ing interest in the technology. The guidelines — which parallel long-standing Texas Medical Association policy and reinforce existing Texas Medical Board (TMB) rules — say that whether physicians and patients meet virtually or in person, the stan- dard of care remains the same. That means taking appropriate steps to establish the physician-patient relationship for proper evaluation and treatment and following established principles for other key areas of medical practice, FSMB says. The policy is available online at
www.fsmb.org/pdf/FSMB_Telemedicine_ Policy.pdf.
The advisory document for state medical boards says physi-
cians can safely practice telemedicine using a wide range of electronic technologies that include videoconferencing, phone, text, and email interactions. But a provision that has sparked debate goes on to say a telephone call or online visit by itself won’t suffice for newly established patient relationships. Proponents say the growing national attention validates
20 TEXAS MEDICINE July 2014
telemedicine’s place in today’s health care system. Dr. Kim, who prefers the broader term “telehealth,” (see “Glossary,” op- posite page) describes the model as simply another environ- ment — like clinics or emergency departments — in which physicians treat patients. But different care environments do not mean different care standards. “We have the opportunity to create all sorts of innovative en- gagements with patients on the remote end for the betterment of their care, to take care of at-risk populations who aren’t cared for at all or so minimally that it costs everyone,” said Dr. Kim, who has testified on telemedicine on behalf of TMA be- fore the Texas Legislature. But the first step, he says, “is to es- tablish a therapeutic relationship. To do that, I need a picture, and I need sound. Without both, I do not know how I would be able to render an assessment, opinion, or recommendation, including and especially the prescribing of medications. In my opinion, this is the minimum bar for telehealth care.” But the FSMB policy has sparked criticism from some cor- ners that the restrictions could hinder telemedicine and the thousands of patients it now reaches. American Telemedicine Association (ATA) Chief Executive Officer Jonathan D. Linkous says the group agrees with “90 percent” of FSMB’s guidelines, and most of the group’s diverse membership — which includes academic medical centers, as well as hospitals, clinicians, government agencies, vendors, and companies — offers a combination of video and audio services.
But if telemedicine is going to be held to the same standard
of care, “treat it the same,” he said. Several hundred thou- sand patients access care using just the phone, and excluding it
“would cut down on patient access and what doctors do every day. If you ask consumers if they want to be able to email or talk to their doctor when they have a question, you know what the answer is. This is what they want. Telemedicine is a tool, and we don’t think you should have an arbitrary guideline to say you can only do certain things with this tool. We are all concerned about patient safety. But telemedicine is the future, and we hope state boards don’t put a cap on that innovation.”
Telemedicine gains momentum
As telemedicine gains momentum, so does policy interest at the state and federal levels. Physicians, patients, and policymakers agree the technol- ogy can help spur health reform, ease care shortages, and cut down on high health care costs. At the same time, patient, em- ployer, and insurer demands for affordable, convenient access to care have attracted a flood of companies promising to bring medicine directly to the patient via a phone call or virtual on- line visit. TMA has tracked several new companies expanding their business into Texas. At the national level, Congress is considering the Telehealth Modernization Act and the Telehealth Enhancement Act, among other bills aiming to define the services and broaden Medicare payment policies, for instance. In February, a group of former Senate leaders created the Alliance for Connected Care to promote policy reform around telehealth, which in-
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