March 3, 2014
by Ben Guarino
It was nighttime in Berlin, Md., when a patient was admitted to Atlantic General Hospital in early February, with a suspected diagnosis of necrotizing fasciitis. Given the rarity of the flesh-eating bacterial infection, the ICU nurse sought the opinion of a critical care physician to corroborate the diagnosis. One obstacle: No specialist was at hand.
Despite this, the nurse was successful—thanks to telemedicine, a doctor could make a confirmatory diagnosis from more than 100 miles away.
The level of detail afforded by telemedicine is a far cry from grainy black-and-white security camera footage, thanks to advances in video conferencing technology and data streaming capabilities. As the technological barriers fall, telemedicine is poised to become increasingly widespread; however, several hurdles remain, particularly with respect to reimbursement and clinician adoption.
“I think we are at step one of a very, very long race,” said Brendan Carr, MD, assistant professor of emergency medicine at the University of Pennsylvania’s Perelman School of Medicine, in Philadelphia.
Even in these early stages, telemedicine’s lens can capture a wide range of specialties.  At Mercy Hospital in St. Louis, the telemedicine program includes areas of care such as pediatric neurology and endocrinology, as well as pulmonology and dermatology. “We are using telemedicine across the continuum of care, from the inpatient setting to the outpatient clinic setting and then into the home setting,” said Wendy Deibert, RN, BSN, vice president of Mercy Telehealth Services. “You can create all kinds of paths down the telemedicine road.”
Patients seem to be responding positively. “The patients are the easy ones,” Ms. Deibert said. “They love being able to go to their hometown to see a doctor from wherever. They really don’t mind the video perspective.”
Ms. Deibert offered the example of a patient who lived in Arkansas and had a cardiology procedure performed in Missouri; via telemedicine, he was able to have a postoperative visit in his hometown. “When we asked him about it afterward,” Ms. Deibert said, “he was almost in tears, saying: ‘My daughter just got chemotherapy yesterday, and if I would have had to go to St. Louis, I would have been away from her for two to three days.’”
A recent study published in Critical Care Medicine evaluated the quality of care for pediatric patients who visited five rural emergency departments (2013;41:2388-2395). Through a chart review, the investigators found that quality of care was highest for patients who received consultation by telemedicine, intermediate for patients who received consultation by telephone and lowest for patients who did not receive consultation. Likewise, a survey of the patients’ parents revealed that parental satisfaction was highest for the telemedicine consultations.
“In our experience, patients are very satisfied with the consultation [through] telemedicine,” said Madan Dharmar, MBBS, PhD, a pediatric telemedicine specialist at the University of California, Davis Children’s Hospital, and an author of the report in Critical Care Medicine. “Overall, patients seem to receive telemedicine very well.”
Telemedicine, Dr. Dharmar said, “changed how we are able to deliver our medical care” by helping to close the gap “between an underserved population and a medically served population.”
Unique Issues for Clinicians 
In contrast to patients, winning over clinicians may prove to be a more difficult challenge. “Anecdotally, we have had plenty of resistance because [telemedicine] is new and change is hard,” Dr. Carr said.
Clinicians who frequently consult patients using telemedicine may encounter unique licensing and credentialing problems. “We never think about where [patients] are when they’re on the phone,” Dr. Carr said. But with telemedicine, state lines may come sharply into focus.
Mercy Telehealth Services covers five states: Arkansas, Kansas, Missouri, Oklahoma and South Carolina. Some of those states, such as Arkansas, Missouri and South Carolina, have compacts that recognize out-of-state nursing licenses. Still, “you’ve always got to pay attention to the state lines,” Ms. Deibert said. “It takes a lot of work to get a physician licensed in a different state, anywhere from three months to a year,” she said.  Both Ms. Deibert and Dr. Dharmar noted that proponents of telemedicine comprise some of the voices in the call for universal medical licensing.
Telemedicine also raises issues of privacy for the patient and the physician. “We’re pretty far away from figuring out how you make this HIPAA-compliant on both sides,” Dr. Carr said.
Consultation Compensation
Another aspect of physician resistance stems from the uncertainty of compensation for telemedicine calls. On the website of the American Telemedicine Association (ATA), CEO Jonathan Linkous wrote that a question he has been asked most frequently during his 20-year experience is: “How do we get paid for telemedicine?”
Reimbursement for telemedicine consultation, from an insurance perspective, varies from state to state. As of February 2014, 21 states have introduced bills that would mandate provider coverage for telemedicine, according to the ATA, which tracks the state legislature addressing telemedicine reimbursement. Medicaid coverage of telemedicine, which also differs by state, depends upon where the consultation occurs—a health care system on the receiving end of the videoconference must be deemed “rural” to be eligible for coverage.
Better Outcomes
Telemedicine also can save money in other ways, such as decreasing errors or length of stay. Dr. Dharmar and his colleagues evaluated physician-related medication errors by analyzing the charts of 234 pediatric patients. They compared the rates of medication errors based on the type of consultation: phone, telemedicine or no consultation (Pediatrics 2013;132:1090-1097).
Pediatric patients who received telemedicine consultation as part of their care had lower odds of medication errors than patients receiving phone consultation (odds ratio, 0.19; P<0.05) or no consultation (odds ratio, 0.13; P<0.05).
Implementing telemedicine can increase efficient use of resources at health care systems. Preliminary study findings, Dr. Dharmar said, indicate that telemedicine could save tens of thousands of dollars due to more informed transfer decisions. From the perspective of a tertiary care hospital with limited ICU beds, he said, “telemedicine can enable health care systems to prioritize ICU care to those who need the higher level of care, and also help local hospitals in caring for those admitted in their facility.”
A critical component of telemedicine is that the technology enables information to spread from clinician to clinician. It can take up to 17 years for a medical discovery to transition into common practice, Dr. Carr said, referring to a review that assessed the lag time between research and integration (Pediatr Ann 1998;27:581-584).
 “Waiting two decades to get the word out is probably not the goal,” Dr. Carr said. By offering their expertise to other physicians via telemedicine, specialists can help “bend the dissemination and implementation curve.”
Drs. Carr and Dharmar, and Ms. Deibert reported no conflicts of interest. 

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