For decades, telemedicine has long been associated with patients who are far, far away: Native Americans in Alaska, workers on oil rigs, scientists in Antarctica or astronauts in space. Numerous roadblocks—chief among them reimbursement, physician licensure, clinical workflows, infrastructure costs and unclear value propositions—have, for the most part, hindered telemedicine's advance into regular care delivery.
However, 2013 may be the year that the healthcare industry begins to move from isolated pilot programs to more widespread use of telemedicine.
It's not just that the technology is cheaper and easier to use, either. Washington, D.C. is taking notice. The Obama administration's healthcare reform law emphasizes coordinated, accountable care—in which telemedicine can play an important part—while proposed legislation from U.S. Rep. Michael Thompson (D-Calif.) would remove many of the bureaucratic barriers that hinder telemedicine's spread.
The American Telemedicine Association was formed in 1993, so CEO Jonathan Linkous isn't exaggerating when he says he's been waiting 20 years for this. "Healthcare is a late adopter," he says, "and it doesn't do anything without plodding, moving ahead and thinking about it."
Now is the time, he says, because the healthcare industry in the United States is undergoing "transformation." Healthcare reform, the needs of baby boomers, the growing challenge in treating chronic conditions and the sheer number of uninsured Americans leaves the industry at an inflection point, and telemedicine can accelerate this transformation. "It's not the answer, but the tool:hellip;to solving a lot of healthcare's problems."
Telemedicine Adoption Slow; Healthcare Cost Increases Fast
Those problems are well-documented. In 2012, the United States spent 18 percent of its GDP on healthcare, compared to less than 5 percent in 1950, and that's projected to rise to 30 percent by 2050. Meanwhile, roughly one-third of the $2.5 trillion spent in 2012 was wasted, thanks to a combination of fraud, red tape and duplicate tests.
Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology who spoke at the recent MIT Future of Health and Wellness Conference, says American healthcare is broken because the status quo works well for 75 percent of Americans—largely the healthy ones covered by corporate insurance plans—but is "substantially broken" for everyone else. The Affordable Care Act—which Gruber helped draft, along with the Massachusetts healthcare reform law of 2006—makes numerous strides to change this, with initiatives such as the accountable care organization and the health insurance exchange, but it's a process that requires humility and patience, he notes. (Few in Washington possess either characteristic, Gruber adds.)
For the most part, adoption of telemedicine has proceeded similarly. Case studies such as the Veterans Heath Administration, which uses telecommunications and home health monitoring technology to keep tabs on more than 50,000 patients and reports patient satisfaction levels of 85 percent, are the exception rather than the rule. The majority of telemedicine implementations, research firm Gartner notes in its Hype Cycle for Telemedicine, are pilot projects, and few have made it to a "self-sustaining state where costs are offset by reimbursements and the clinical value obtained."
"Reimbursements" is the operative word. Of the 22 telemedicine technologies Gartner identified, lack of reimbursement is an adoption hurdle for at least seven—including some, such as home health monitoring and remote video consultations, which have a "high" benefit for healthcare organizations. (Without reimbursements, physician will just stick to office visits, for which they are reimbursed.) Licensing is another issue, as many physicians are licensed to practice in states that won't let them practice telemedicine across state lines.
Legislation Aims to Remove Telemedicine's Bureaucratic Barriers
That's where Rep. Thompson's bill, the Telehealth Promotion Act of 2012, comes into play. (The bill was introduced in the waning days of the 112th Congress, which ended January 3, 2013, and must therefore be reintroduced this year. It also refers to telehealth, an umbrella term that encompasses telemedicine, the use of technology in the practice of medicine, as well as more academic and research-oriented uses of technology in healthcare.) Linkous says the bill is attracting the support of both political parties—and, judging from what he heard at the Consumer Electronics Show, technology executives as well.
Among other proposals, the bill would no longer exclude from federal reimbursement medical services "furnished via a telecommunications system." In addition, physicians licensed in one state could treat patients anywhere in the nation, and accountable care organizations would be exempt from telemedicine fee-for-service restrictions.
Finally, hospitals would receive incentives to use telemedicine technology to lower readmissions. This is in line with healthcare reform, which is penalizing hospitals if too many patients are readmitted within 30 days. Hospitals that miss the mark could lose up to 1 percent of their annual Medicare reimbursement.
David Lindeman, director of the Center for Technology and Aging and co-director of the Center for Innovation and Technology in Public Health, both within the Public Health Institute, says that provision of healthcare reform is driving organizations to determine how they can ramp up their telemedicine efforts beyond the pilot stage and start to incorporate them into care management strategies. With that, says fellow CITPH co-director Andrew Broderick, comes cost savings as well as a more productive and more efficient clinical staff.
The PHI recently examined three case studies in telemedicine adoption. In all three cases, Broderick says, the pilot projects succeeded because leadership saw the value of expanding the use of technology to accomplish a larger strategic initiative, whether it's reduced readmissions, better patient engagement or improved long-term care for those with chronic conditions.
United Kingdom Also Experiencing Telemedicine Growing Pains
Strong leadership also drives telemedicine adoption in the United Kingdom. There, as in the United States, most pilots have been initiated at a local rather than national level, says Tola Sargeant, director of analyst firm TechMarketView. That said, those programs thrive when there's a close relationship between national and local health authorities, she adds. This is important; in Britain's healthcare system, telemedicine benefits National Health Service hospitals (which lower their costs as admission rates go down) at the expense of local social care providers (which take on the responsibility for home care).
One way the United Kingdom is advancing telemedicine is through private sector partnerships, which Sargeant describes as "telehealth as a service." Many NHS hospitals already outsource human resources and IT operations, so outsourcing telemedicine management for medical device installation or even triage services makes sense for some institutions.
Use of telemedicine technology is even more nascent in the United Kingdom than in the United States, and it's largely been incumbent vendors participating in early U.K. pilot projects, but Sargeant sees the market progressing with the spread of broadband, smartphones, tablet PCs, mobile applications and smart TV.
"We do see telehealth as something that becomes mainstream in the not too distant future, though more slowly than the government would like," Sargeant says. (Britain's 3millionlives campaign aims to attract three million long-term care patients to telemedicine technology by 2017, but it's an unfunded mandate and questions about how to deliver services have been left to local authorities.) "It's been talked about for a long time, but I think we're finally at a tipping point."
To Realize Savings, Bring Telemedicine to the Masses
Few deny the role that telemedicine can play in improving healthcare. It's spreading, too. Even now, with reimbursement and licensing questions still unanswered by federal legislation, 10 million Americans benefit from telemedicine, Linkous says. Many, for example, may not realize that one in 10 intensive care unit beds is monitored by an offsite teleICU.
Growth will continue. According to research firm InMedica, worldwide use of wireless remote monitoring devices is expected to increase six-fold by 2017, with the majority of users being monitored for chronic conditions such as diabetes, heart disease or mental illness following a hospitalization.
Meanwhile, researchers at Indiana University have found that artificial intelligence improves patient outcomes by simulating treatment paths and making adjustments as additional information becomes available. This type of mathematical modeling made it possible to identify more possible outcomes than a doctor could, researchers found.
However, the key to successfully using telemedicine isn't in the latest technology, or even in expanded broadband Internet connections, which the Federal Communications Commission continues to make a priority and which Sargeant says is important to the United Kingdom as well. As Linkous puts it, you may be using a fancy digital stethoscope, but "it's still a heart with basic, fundamental issues that you need to recognize and treat."
When telemedicine adoption hurdles pop up, Broderick suggests, they are 10 percent technology issues and 90 percent human or organizational factors. These include patient engagement, physician engagement, clinical workflows, business processes, return on investment and an overall difficulty in tracking and demonstrating both clinical and financial outcomes. (To that end, the Center for Technology and Aging has assembled an ADOOT Toolkit that outlines these challenges for providers looking to implement telemedicine.)
Ultimately, Linkous says, telemedicine will succeed when it transcends simply using technology to transforming care delivery in a meaningful way. Put another way, as InMedica notes, it's about encouraging patients—and their physicians—to use technology such as home health monitoring before they end up in the hospital in the first place. Only then can the healthcare industry begin to realize the value, financial and clinical, that telemedicine promises.