Do the risks still far outweigh the benefits?
THE HEALTHCARE LANDSCAPE has changed radically in recent years. Implementation of the Affordable Care Act, expanding roles for nurse practitioners and physician assistants, meaningful use, and ICD-10 preparation are just the highlights. But one change that often gets overlooked is the rapid expansion of telemedicine.
Forty years ago, hospitals used a form of telemedicine to reach patients in remote areas. Triaging a patient over the phone is, after all, just another form of telemedicine. Modern technology has opened up many new avenues for patients and physicians to communicate. Today, telemedicine encompasses a vast array of services offered by virtually all medical specialties. Telemedicine is defined as “the ability to provide interactive healthcare utilizing modern technology and telecommunications.” It includes interactive video, home monitoring devices, scanning and emailing photos, and a myriad of other ways physicians and patients can communicate without a face-to-face interaction.
Telemedicine is expanding not only by volume, but also by services offered. In 2013, a consulting firm estimated worldwide telemedicine use would grow by 18.5 percent per year through 2018. Another source opines that the United States telemedicine market “will grow from $240 million in revenue in 2013 to $1.9 billion in 2018” — an annual growth rate of more than 50 percent.
Telemedicine not only could increase revenue, but also decrease spending. One study revealed a health insurer saved approximately $10 million over six years using telemedicine. The study followed 3,000 congestive heart failure patients receiving in-home monitoring of weight, blood pressure, heart rate, and pulse oximetry. Readmissions dropped by 44 percent for these patients, boosting savings. Although this study represented a small sample size, the savings realized were significant — just using common telemedicine tools. As telemedicine expands and services become more accessible, cost savings presumably will grow.
DRIVERS
Several factors are driving the increased use of telemedicine, and convenience may be the biggest. A patient can sit in their living room and consult with a dermatologist who can view the problem area. A cardiologist can review monitor readings from their office while the patient is at home. Diabetics can check blood sugar levels and upload the results for their physicians to monitor.
Cost effectiveness makes telemedicine an attractive alternative to traditional healthcare models. Telemedicine allows physicians to consult with more patients within a smaller timeframe. This increases revenue for the physician, saves patients money on travel expenses, and decreases patients’ time away from work and family.
Consultations also can be more efficient for all parties involved. Rather than sending x-rays or medical records to another provider through the mail, images and documents can be sent electronically. The consulting physician can conduct an electronic visit with the patient. This convenience decreases the potential for noncompliant patients (especially with regard to specialist follow-ups), saves time, and increases physician-to-physician collaboration.
Rural communities with limited means to access healthcare still benefit from telemedicine. Someone living 200 miles from the nearest urban area needs to see a dermatologist, but does not have the means to travel the requisite distance. Telemedicine offers that individual an opportunity to speak with a specialist through a computer screen. These patients may end up being treated for something within a couple of days — even hours— for an ailment that, 20 years ago, may have gone undiagnosed for several years.
DRAWBACKS
While technological advances have helped drive telemedicine, technological failures can be one of its biggest drawbacks. Networks are subject to interruptions, delays, system overloads, or other technical difficulties. Because telemedicine is wholly dependent on working technology, its effectiveness is severely hampered when technology fails.
Privacy, security, and confidentiality are other potential serious problems. Even when healthcare providers take necessary security precautions, hackers may still access electronic communications — and HIPAA extends to the patient’s living room. It’s essential to take necessary precautions to ensure telecommunications (and any form of electronic communication) are as protected as possible. Use encrypted emails; consult with cyber-security experts when setting up your telemedicine practice, and develop a well-written consent form that addresses the risk factors of telemedicine.
It also is important not to overlook physical interactions between physicians and patients. Sometimes patients need a physical exam for an effective diagnosis (e.g. broken bones). Seeing patients in person helps establish a trusting, cooperative relationship that may be challenging to build electronically. Both parties may be more engaged if conversations are conducted in-person. This may be less of an issue if you only use telemedicine for established patients. It is still a good idea to suggest an annual in-office examination.
MOBILE APPS
Mobile app use is booming. According to one estimate, mobile app revenue will reach $13 billion in 2015, with a compounded annual growth rate of 40 percent over the next six years. The implications are equally enormous.
In January, the FDA approved an app for glucose monitoring via a mobile device. This app allows healthcare providers to track patient glucose levels via a smartphone or tablet.
Mobile apps can be used for anything from monitoring patients remotely to facilitating physician/patient communication. A brief review of cardiology related mobile apps revealed several that allow physicians to demonstrate, illustrate, or show videos to patients to help explain certain conditions. Mobile apps also can provide decision support for physicians or help with diagnoses.
Dermatology apps can help patients track moles and other skin lesions to document changes. One app, developed by University of Michigan physicians, includes a skin cancer risk calculator. Another dermatology app claims to be 70 percent accurate in predicting the severity of a mole; dermatologists are about 85 percent accurate according to the same article.
RISK MANAGEMENT CONSIDERATIONS
Increased availability and real-time data are key telemedicine benefits. But while these two factors seem to foster patient/physician communication and nurture that relationship, they also may increase your risk exposure.
If you offer electronic availability to your patients, consider how it could negatively impact you when something doesn’t go as planned for a patient. A plaintiff’s attorney could present to a jury your claim to be available, and then state the patient didn’t receive the type of response promised. The attorney could assert your failure to be immediately available directly led to the patient’s negative outcome.
Real-time data also can present challenges. On one hand, it may increase your effectiveness as a healthcare provider. However, it also can create professional liabilities, particularly in the event of a claim. Consider: If you receive real-time blood sugar results from a patient and fail to notice a large spike or depression, could you be held liable for a negative outcome? A juror might look at this information and ask, “Why didn’t the doctor notice this sooner?”
These examples highlight the importance of full disclosure and informed consent when it comes to telemedicine. It is important patients and healthcare providers are aware of both the advantages and limitations telemedicine presents.
Services providing online consultations to the general public, like “HealthTap,” “InteractiveMD,” or “MYidealDOCTOR,” are another area of liability concern. While these sites are great for patients and provide immediate access, physicians need to consider certain risks before participating:
• Are you licensed to provide medical care in the state the patient is contacting you from?
• Are you required to be licensed in the state the patient is contacting you from?
• How can you track and follow up with patients if necessary?
• How will calls be documented?
• If a liability claim arises, in which state will you have to defend yourself?
• How can you verify treatment recommendations?
• Will your service provider be involved in any way if you have a claim filed against you? (Review your contract with your provider.)
• Does your state’s medical board prohibit this practice across state lines?
• Does the patient’s state prohibit this practice?
• Are you allowed to prescribe any medications?
• Is the service HIPAA compliant?
Before entering into any agreement, be sure to thoroughly research and consider all of the pros and cons. You also may wish to consult with your insurance agent to determine if your current policy covers Internet-based services.
CREDIT
article by JEREMY A. WALE, JD
ProAssurance Risk Resource Advisor
REFERENCES
1. What is telemedicine? American Telemedicine Association website. Accessed April 15, 2015.
2. What is telemedicine? Telemedicine.com, Inc. website. Accessed April 16, 2015.
3. Thomas K. Year in review: 2014 was the year of explosive growth for telehealth. Advanced Telehealth Solutions website. December 18, 2014. Accessed April 20, 2015.
4. Shaping your telehealth strategy: Leveraging telehealth technologies to lower costs, improve quality outcomes and enhance the patient experience. Ernst & Young website. Accessed April 20, 2015.
5. Ridin R, Auerbach D, Zaydman M, & Mehrotra A. Paying for Telemedicine. AJMC website. December 12, 2014. Accessed April 30, 2015.
6. Chief Editor. 10 major pros and cons of telemedicine. NLCATP website. January 26, 2015. Accessed April 22, 2015.
7. Chief Editor. 10 major pros and cons of telemedicine. NLCATP website. January 26, 2015. Accessed April 22, 2015.
8. Mcaskill R. Mobile healthcare market expected to reach $13B in 2015. mHealth Intelligence website. March 26, 2015. Accessed April 27, 2015.
9. FDA news release. FDA permits marketing of first system of mobile medical apps for continuous glucose monitoring. FDA website. January 23, 2015. Accessed April 27, 2015.
10. Misra S. Top 10 medical apps for cardiology. iMedicalApps website. October 23, 2014. Accessed April 28, 2015.
11. Dolan B. University of Michigan Health System offers skin cancer app. Mobihealthnews website. July 12, 2012. Accessed April 28, 2015.
12. Dolan B. University of Michigan Health System offers skin cancer app. Mobihealthnews website. July 12, 2012. Accessed April 28, 2015.