Proposed rule issued for ‘VA Anywhere to Anywhere’ telehealth cross-state care

The Department of Veterans Affairs ‘Anywhere to Anywhere’ program, which would enable VA doctors to treat VA patients across state lines via telehealth and telemedicine, yesterday (2 October) published in the Federal Register the required Federal proposed rule. There is a mandated 30-day comment period (to 1 Nov). In the Federal government, these rules move faster than any legislation. From the rule: “VA has developed a telehealth program as a modern, beneficiary- and family-centered health care delivery model that leverages information and telecommunication technologies to connect beneficiaries with health care providers, irrespective of the State or location within a State where the health care provider or the beneficiary is physically located at the time the health care is provided.” PDF of rule.

VA Home Telehealth has both doctor-to-patient telemedicine and vital signs remote monitoring components. While VA is fully able to waive state licensing requirements if both the physician and the patient are in a VA clinic, because of state telemedicine laws they have not been able to provide the same care for veterans at home. VA also has a care distribution problem, with many veterans living in rural areas, at great distances from VA facilities, or with limited mobility. What this will enable is VA hiring in metro areas primary care and specialist doctors to cover veterans in rural or underserved areas and the expansion of mental health care. It also will facilitate the rollout of the VA Video Connect app for smartphones and video-equipped computers now in use by over 300 VA providers [TTA 9 Aug].

The VETS Act (Veterans E-Health and Telemedicine Support Act of 2017, S. 925) would permanently legislate this, but in the US system this type of Federal rule, in this circumstance, moves faster.  Fierce Healthcare, Healthcare Finance, mHealth Intelligence 

Tender Alerts: Staffordshire’s £70m contract, Yorkshire and The Humber test

Susanne Woodman, our Eye on Tenders, alerts us to two tenders, the first which will definitely pique our UK Readers’ attention with its size and duration. The second is for a proposal using TECS and telemedicine as an alternative to emergency services.

  • Staffordshire: This is a huge seven-year contract to create the Support For Independent Living In Staffordshire (SILIS) Service to enable older and disabled adults to age in place in their current homes. “A key aim of the Service is to help Individuals to make changes to their home environment that will prevent the need for more costly interventions, such as admission to hospital or residential care, following life crises.” The Service will improve upon existing services in Assistive Technology (AT) including referral to telecare providers.

There are six borough and district councils involved, with the potential for use by nine more. The contract is valued at £70 million to start April 2018 with renewal points, ending in March 2025. Deadline is Wednesday 1 November at noon. Much more information (you’ll need it) on TED EU-Tenders Electronic Daily

  • NHS Greater Huddersfield & North Kirklees CCG: This tender is for the provision of a technology-assisted, rapid access service offering an alternative to hospital-based A&E services. Market test site is in Kirklees for residents of a care home. Requirements are:
    • A 24/7 clinical teleconsultation service delivered via secure video link into residential/ nursing homes, that is utilized instead of patients having to be taken to the local A&E department.
    • A service that provides clinical consultation not a logarithm based approach like 111.
    • A fully managed technical service utilizing bespoke laptops with HD cameras and with 4G SIM or broadband.

The CCG may also commission an accountable care organization (ACO) for this care in future, to which this contract would transfer. Deadline is 5pm on Friday 20 October to brenda.powell@greaterhuddersfieldccg.nhs.uk. More information on Gov.UK.

Want to know effectiveness of telehealth, interoperability? NQF reports take their measure.

There’s been an increase in doubt about the efficacy of telemedicine (virtual visits) and telehealth (vital signs monitoring) as a result of the publication of two recent long-term studies, one conducted by the University of Wisconsin and the other by CCHSC for Telemonitoring NI [TTA 13 Sep]. These follow studies that were directionally positive, and in a few cases like the VA studies conducted by Adam Darkins, very much so, but mostly flawed or incomplete (low N, short term, differing metrics). What’s missing is a framework for assessing the results of both. In an exceptionally well-timed announcement, the National Quality Forum (NQF) announced their development of a framework for assessing the quality and impact of telehealth services. 

In a wonder of clarity, the NQF defines telehealth’s scope as telemedicine (live patient-provider video), store-and-forward (e.g. radiology), remote patient monitoring (telehealth), and mobile health (smartphone apps). Measurement covers four categories: patients’ access to care, financial impact to patients and their care team, patient and clinician experience, and effectiveness of clinical and operational systems. Within these categories, NQF identified six areas as having the highest priority for measurement: travel, timeliness of care, actionable information, added value of telehealth to provide evidence-based practices, patient empowerment, and care coordination. Finally, the developing committee identified 16 measures that can be used to measure telehealth quality.

The NQF also issued a similar framework for interoperability, a bête noire that has led many a clinician and developer to the consumption of adult beverages. Again there are four categories: the exchange of electronic health information, its usability, its application, and its impact—on patient safety, costs, productivity, care coordination, processes and outcomes, and patients’ and caregivers’ experience and engagement. And it kept the committee very busy indeed with, from the release, “53 ideas for measures that would be useful in the short term (0-3 years), in the mid-term (3-5 years) and in the long-term (5+ years). It also identified 36 existing measures that serve as representative examples of these measure ideas (sic) and how they could be affected by interoperability.”

Both reports were commissioned and funded a year ago by the US Health & Human Services Department (HHS). We will see if these frameworks are extensively used by researchers.

NQF release, Creating a Framework-Telehealth (download link), Creating a Framework-Interoperability (download link), Mobihealthnews 

Equivocal long term telemonitoring studies released by Telemonitoring NI, U. of Wisconsin

The HSC Public Health Agency for Northern Ireland and Queen’s University Belfast have released an evaluation of the six-year (2011 – 2017) Remote Telemonitoring Service for Northern Ireland (RTNI). The Centre for Connected Health and Social Care (CCHSC) launched the Telemonitoring NI project in 2011, which enrolled over 3,900 patients with COPD, diabetes, weight management, stroke, heart failure and kidney problems in both telehealth (vital sign) and telecare (behavioral) monitoring. The study period was through 2015, but the program continues to be implemented by all five NI Health and Social Care (HSC) Trusts across a range of chronic conditions. 

The Northern Ireland findings were at best equivocal. While the qualitative data gathered from patient, carer, and clinician focus groups and interviews were positive in terms of engagement and on reassurance–to be able to carry on with their lives as usual–the quantitative data did not confirm gains in effective care.

Although there were a number of testimonials from the participants in the patient focus groups regarding
reduced hospitalisations and a reduced need to attend outpatient clinics, this did not carry through to
the data obtained in the effectiveness aspect of the current evaluation. In general terms, the number
of hospitalisations, length of hospital stay and outpatient clinic attendance (and therefore overall cost
of healthcare provision) did not differ between the quasi-control ‘never installed’ group and any of the
groups who received some amount of telemonitoring. The results, where they were statistically
significant, were largely driven by an anomalous result for the heart failure ‘never installed’ group. (page 17)

The Executive Summary, Telehealth, and Telecare Reports are available for free download on the HSC R&D Division website. Many thanks to former TTA Ireland Editor Toni Bunting for the information, summary, and researching the previous TTA coverage below.

This is the second discouraging study on the long term effectiveness of patient monitoring released in the past month. A five-year, 140,000 patient/90 provider study conducted by the University of Wisconsin found that giving patients the option of telemedicine, instead of being more convenient for the provider, created new issues. It increased office visits by six percent, added 45 minutes per month of additional visit time to practices, and reduced the number of new patients seen each month by 15 percent. For the patient, the researchers found “no observable improvement in patient health between those utilizing e-visits and those who did not. In fact, the additional office visits appear to crowd out some care to those not using e-visits.” The study suggested that the telemedicine visits could be made more effective by structured questions prior to the visit. (This approach has been taken by telemedicine provider Zipnosis with adaptive online interviews and patient triage.) Mobihealthnews

Previous commentary by TTA’s Editor Emeritus Steve Hards on the procurement of the NI Remote Telemonitoring Service:

http://archive1.telecareaware.com/the-long-and-winding-road-that-leads-to-your-doorin-northern-ireland/
http://archive1.telecareaware.com/african-elephant-ecch/
http://archive1.telecareaware.com/remote-telemonitoring-northern-ireland-service-tender-long-list-mystery/
http://archive1.telecareaware.com/short-listed-companies-rtni-service/
http://archive1.telecareaware.com/northern-ireland-remote-monitoring-servicegoes-to-tf3/

 

Can unused “TV white spaces” close the rural and urban broadband–and telehealth–gap?

click to enlargeThe digital divide comes one step closer to closing. Microsoft’s release of its white paper proposing an alternative to the expensive build-out of the US broadband network deserved more attention than it received in July. The Rural Broadband Strategy combines TV white spaces spectrum (the unused UHV television band spectrum in the 600 MHz frequency range which can penetrate through walls, hilly topography, and other obstacles) with fixed wireless and satellite coverage to economically deliver coverage to un/under-served areas versus fiber cable (80 percent savings) and LTE fixed wireless (50 percent).

34 million Americans lack broadband connection to the internet. Some of these are voluntary opt-outs, but 23.4 million live in rural areas without access, with huge economic consequences estimated in the hundreds of billions. TV white spaces can also expand coverage in small cities and more densely populated areas, including usages such as within buildings. This effort also presses the FCC, which in turn has pressed for broadband for two decades, to ensure that at least three channels below 700 MHz are kept unlicensed in all markets in the US, with more TV white spaces for rural areas.

The first part, the Rural Airband Initiative, builds on Microsoft’s present 20 programs worldwide, and is planned to connect 2 million people in by July 4, 2022, with 12 projects across the US running in the next 12 months. Much of the connectivity is dedicated to nonprofit efforts like 4-H’s digital literacy program and ‘precision agriculture’ in New York State and Washington. Microsoft is also granting royalty-free access to 39 patents and sample source code related to white spaces spectrum use in rural areas.

A positive move for telehealth’s spread. Rural healthcare providers pay up to three times as much for broadband as their urban counterparts. Telemedicine increasingly connects for consults between hospitals in rural areas and city-based health systems for specialty coverage and to provide assistance in specialized medical procedures. Telemedicine and telehealth remote monitoring has difficulty spreading with poor internet coverage; this has already been a barrier to patients in rural ACOs who can be 1-2 hours from the doctor’s office and notably for the VA in providing rural veterans with home telehealth support. Paramedics increasingly rely on internet connections and dropped connections lead ambulances to go to hospitals at a greater distance. If the FCC cooperates and Microsoft’s partners can find a way to profitably execute, broadband can finally achieve that promise about closing the ‘digital divide’ made back in the Clinton Administration. A Rural Broadband Strategy: Connecting Rural America to New Opportunities  The Verge, mHealth Intelligence, Becker’s Hospital Review

Weekend Big Read: will telemedicine do to retail healthcare what Amazon did to retail?

Updated. Our past contributor and TelehealthWorks’ Bruce Judson (ATA 2017 coverage) has penned this weekend’s Big Read in the HuffPost. His hypothesis is that telemedicine specifically will disrupt location-based care, followed by other digitally based care–and that executives at health systems and payers are in denial. More and more states are recognizing both parity of treatment and (usually) payment. Telemedicine also appeals to three major needs: care at home or on the go, with a minimal wait; maldistribution of care, especially specialized care; and follow-up/post-acute care. His main points in the article:

  • Healthcare executives are being taken by surprise because present digital capabilities will not be future capabilities, and the shift to virtual will be a gradual process
  • Telemedicine will address doctor shortages and grow into coordinated care platforms embedding expertise (via connected diagnostics, analytics, machine learning, AI) and care teams
  • Telemedicine will eventually go up-market and directly compete with large providers in urban areas, displacing a significant amount of in-person care with virtual care
  • Telemedicine will start to incorporate continuous feedback loops to further optimize their services and move into virtual health coaching and chronic care management
  • Telemedicine platforms are also sub-specializing into stroke response, pediatrics, and neurology
  • Centers of expertise and expert platforms will become larger and fewer–centralizing into repositories of ‘the best’
  • Platforms will be successful if they are trusted through positive patient experiences. This is a consumer satisfaction model.

Mr. Judson draws an analogy of healthcare with internet services, an area where he has decades of expertise: “A general phenomenon associated with Internet services is that they break activities into their component parts, and then reconnect them in a digital chain.” Healthcare will undergo a similar deconstruction and reconstruction with a “new set of competitive dynamics.”

It’s certainly a provocative POV that at least gives a rationale for the sheer messiness and stop-n-start that this Editor has observed in Big Health since the early 2000s. A caution: the internet, communications, and retail do not endure the sheer volume of regulatory force imposed on healthcare, which tends to make the retail analogy inexact. Governments monitor and regulate health outcomes, not search results or video downloads (except when it comes to net neutrality). It’s hard to find an industry so regulated other than financial/banking and utilities. FierceHealthcare also found the premise intriguing, noting the VA’s ‘Anywhere’ programs [TTA 9 Aug] and citing two studies indicating 96 percent of large employers plan to make telemedicine, also with behavioral health services, available, and that 20 percent of employers are seeing over 8 percent employee utilization. (Under 10 percent utilization gave RAND the vapors earlier this year with both this Editor and Mr. Judson stinging RAND’s findings with separate analyses.)

Analyses of New Jersey’s new telemedicine regulations

click to enlargeWith New Jersey’s telemedicine regulations now signed into law by Governor Christie to be effective 21 July, both providers and payers are adjusting to what the expansion means for those covered by Medicaid, Medicaid managed care, commercial health plans, and NJ state-funded health insurance. Our 27 June article reviews key points, and they are largely positive for expanding telemedicine in the (now official) Garden State. However, the payment parity part was diluted in the final version, with the in-person reimbursement rate set as the maximum ceiling for telemedicine and telehealth reimbursement rates.

Unique parts of the NJ bill require:

  • Telemedicine or telehealth organizations operating in NJ to annually register with the Department of Health
  • Submit annual reports on activity and encounter data, which will include patient race and ethnicity, diagnostic and evaluation management codes, and the source of payment for the consult (final details determined by succeeding legislation)
  • A seven-member New Jersey Telemedicine and Telehealth Review Commission
  • Mental health screeners, screening services, and screening psychiatrists are not required to obtain a separate authorization in order to engage in telemedicine or telehealth for mental health screening purposes

Full reviews of the legislation are available from law firms Foley & Lardner and in the National Law Review by an attorney from NJ firm Giordano, Halleran & Ciesla.

VA unveils several ‘anywhere’ new telehealth services for veterans

The new Veterans Affairs Secretary, David Shulkin, has wasted no time since his appointment in introducing several technology and mobile-based services at the VA, all of which are long overdue in this Editor’s estimation:

  • Anywhere to Anywhere VA Health Care will authorize telehealth consults and cross-state care for veterans no matter their location and regardless of local telehealth restrictions. VA is already the largest provider of telemedicine services (called VA Telehealth) in 50 specialties to 700,000 veterans annually. This new regulation will enable VA to hire primary care and specialist doctors in metro areas to cover veterans in rural or underserved areas. 
  • Rolling out nationally over the next year is the VA Video Connect app where veterans can use their smartphones or home computers with video connections to consult with VA providers. At present 300 VA providers at 67 hospitals are using it.
  • The Veteran Appointment Request (VAR) app will also roll out from its test. It will enable veterans to use their smartphone, tablet or computer to schedule or modify appointments at VA facilities nationwide.

Dr. Shulkin advocated these programs while undersecretary, especially ‘Anywhere to Anywhere’, which required advice from the Justice Department. VA’s technology is also being supported by the American Office of Innovation to improve care transitions between the Defense Department and VA. 

President Trump participated in the announcement with Dr. Shulkin and sat in on between Albert Amescua, a 26-year Coast Guard veteran at a VA clinic in Grants Pass, Ore., and Brook Woods, a VA internist in Cleveland. VA announcement with videos, POLITICO Morning eHealth, HealthcareITNews

Can Google Glass’ enterprise iteration solve the patient documentation crisis?

click to enlarge“Glass is a hands-free device, for hands-on workers.” What a marketing position! Google Glass finally arrives at where it should have started–not a techie toy or a social snooper banned from bars, but a tool for specific work needs that solve specific but important problems. This is not only ‘on trend’, but also the ‘professional case’ is steak on the grill as a powerful way to lend legitimacy to a new product (the classic is Tang ‘orange drink’ going into space in the early ’60s). The recent announcement of Glass Enterprise Edition (EE) marking its emergence from stealth mode was a refreshingly low-key (for Google and parent Alphabet) surprise. Even the revamped look is sturdy and utilitarian in full glass mode (left) or in clip-on (and also serves as eye protection). 

Their on-trend position for healthcare is to reduce the amount of time that doctors spend charting and documenting patients. Augmedix, a Glass partner, built the documentation automation platform for Sutter Health and for Dignity Health that captures the information from the interaction between patient and doctor via a ‘remote scribe’. Jay Kothari, the Glass project lead, quotes data from Dignity that it reduces clinician daily documentation time from 33 percent to less than 10 percent,  The Sutter Health estimate is two hours per day. Out of the gate this is extremely valuable because it improves the clinician-patient face-to-face (and presumably virtual) visit in eye contact, reduces the break in taking notes, and reduces time pressure generated by post-visit review. Netherlands-based swyMed concentrates on facilitating virtual visits, and is testing a home visit pilot with Loyola University Health System practitioners in Maywood, Illinois. Others, like John Nosta, have been continuing to use Glass in business. Our Readers may want to check out these partners as that is how Google is making the Glass available, not directly. SF/Boston-based partner Brain Power wasn’t mentioned in Mr. Kothari’s blog, but their AI/VR applications for brain conditions such as autism and TBI, as well as other uses such as clinical trials and care for older adults. mHealthIntelligence interviewed Augmedix’s CEO Ian Shakil, who notes that Glass still needs improvements in battery life for the hard work of documenting patient visits.

Update: An interesting comment on this via Twitter. The paper is from 2015 but the regulatory and privacy questions around recording patients and information remain. Augmedix does state on its website that it is HIPAA compliant.

 
click to enlarge

Telemedicine, payment parity finally are ‘perfect together’ in New Jersey

The years-long telemedicine battle in the populous state of New Jersey–the ever-contradictory home of history, high taxes, ‘the Boss’, Newark Airport, and some of the world’s finest beaches and resorts–has finally concluded with a strong win. Last Thursday, the NJ Legislature unanimously passed two bills that set telemedicine practice and payment standards. The General Assembly passed A.1464 and then hours later, the State Senate passed its bill (S.291). Governor Chris Christie had already indicated his support and his signature is expected once both bills are formally reconciled. The new regulations will be effective immediately.

The bill defines telemedicine as doctor-patient two-way videoconferencing and store-and-forward technology, omitting audio-only, email, texting, and fax as usual on the consults. Telehealth is defined as communications technologies including remote patient monitoring and telephone to support clinical health care, provider consultations, and health-related education. No pre-qualifying in-person visits are required to establish a “proper provider-patient relationship” except for conditions requiring treatment with Schedule II controlled dangerous substances. Another exception is for unpaid consults in the wake of an emergency or disaster–something that NJ is experienced with, having been hit hard in the past by hurricanes.

Healthcare providers (inclusive of doctors, nurses and other healthcare professionals) must be licensed in the state and telemedicine/telehealth organizations must register with and submit reports to the Department of Health. A seven-member Telemedicine and Telehealth Review Commission will be set up within six months and will review DOH reports that contain de-identified data on usage, diagnostic code, and payment. These public reports could provide valuable insights on the efficacy of telemedicine and telehealth treatment.

The bill includes full parity of telemedicine payment with in-person visits for both public (Medicaid, state benefit plans) and private insurance plans. There is also parity of a different type affecting mental health providers, with mental health screeners, screening services, and screening psychiatrists not being required to obtain a prior authorization or a waiver prior to engaging in telemedicine and telehealth. (more…)

Telemedicine may be appropriate for delivering ‘bad news’: study

A study of a pilot telemedicine program, JeffConnect, administered by Thomas Jefferson University in Philadelphia during 2015 with 32 patients who received free primary care services via doctor-patient video consults (called telehealth here) has some interesting directional findings. The first was high overall satisfaction among the 19 respondents interviewed, including caregivers, with minimal wait times and far more convenience from home or work, aside from some difficulty in connecting. The second, and the most surprising, was this:

Patients had different perspectives on whether they prefer to hear bad news in a video call. Some said they preferred it, thinking that they could get the news earlier and be in a comfortable location with supportive people. One participant explained, “If it was something earth-shattering, you could cry in your own bedroom and not have to worry, I mean driving from downtown and you’re upset or what-not…” Others preferred to receive serious news in person, explaining, “If the doctor were telling me I have a fatal disease or a disease that could be fatal, and I have to go into immediate serious care, probably better in-person.” Several patients stated no clear preference between the 2 options.

This subject warrants more investigation with a larger cohort. Annals of Family Medicine. Also mHealth Intelligence.

GE’s change at the top puts a healthcare head first

This Monday morning’s Big News was the stepping down, after 16 years, of GE‘s CEO Jeff Immelt effective August 1, and the rise of GE Healthcare’s head, John Flannery. The focus of most articles naturally was the fate of GE. Mr. Immelt may have steered the company through a severe recession starting in 2008, but he managed to lose about a third of the company’s value in the process. Expect some changes to be made in Boston. “I’m going to do a fast but deliberate, methodical review of the whole company,” Flannery told Reuters in an interview. “The board has encouraged me to come in and look at it afresh.” In an earlier call with investors, he said the review would have “no constraint.”

Mr. Flannery is a 30-year GE veteran, head of Healthcare since 2014, and previously head of GE India, its equity business in Latin America and GE Capital in Argentina and Chile. According to Fortune, GEHC is 15 percent of GE’s total business and in recent years has been smartly up in revenue. They have partnered recently with UCSF on predictive analytics, Boston Children’s Hospital on a pediatric brain scan database, and Johns Hopkins of a more efficient hospital bed allocation process. Also is an example of telemedicine remote diagnosis using a GE Health portable ECG device connected to the Tricog smartphone app to take a reading in India which was diagnosed in San Diego.

Usually healthcare CEOs become CEOs of other healthcare companies–witness the rise of one of Mr. Flannery’s predecessors, GE veteran Omar Ishrak, as CEO of Medtronic.  Fortune’s healthcare reporter interviewed Mr. Flannery two weeks ago–more of this interview will be published according to the author. (But hasn’t as of June 21!)

76% of health systems to adopt consumer telemedicine by 2018: Teladoc survey

We normally don’t feature corporate or sponsored surveys, but are making an exception here as it demonstrates two trends: that hospital systems can’t fight consumer telehealth** anymore, and that the future mix of usage is starting to change. Teladoc’s/Becker’s Healthcare Hospital & Health Systems 2016 Consumer Telehealth Benchmark Survey projects that by 2018, 76 percent of health systems will adopt consumer telehealth (vs. site-to-site), double from 2016, and that most who have it will be expanding offerings. As a benchmark survey, it tracks services offered or plan to offer, organizational priorities, and goals.

An interesting part is how the mix of services under telehealth is evolving. Presently, the top three among current users are urgent care, primary care, and psychiatry/mental health. For new users, their priorities are ED/urgent care (45 percent), readmission prevention (42 percent), primary care, including internal medicine and pediatrics (42 percent), chronic condition management (41 percent). Nearly one in five (18 percent) plan to include cardiology services.

As implemented by health systems, telehealth has run into problems that were totally predictable and will provoke the ‘Duh?’ response from our Readers. From the report:

  1. They didn’t measure patient or physician satisfaction with their telehealth programs, even though improving patient satisfaction is a leading motivator for offering telehealth services.
  2. Gaining physician buy-in was cited by 78 percent of respondents, and rated as the #1 lesson learned
  3. The second most important? The importance of aligning telehealth initiatives with organizational goals (75 percent). (more…)

Tech that assists those with speech impairments, telemedicine for mapping public health

This year’s trend to develop technologies that solve specific but important problems, such as improving navigation for the visually impaired, [TTA 8 June] continues:

  • Voice-controlled assistance systems are becoming commonplace, from improved interactive voice response (IVR) to Siri, Echo, and Alexa. Their limitation is that their recognition systems understand only standard, not impaired or even heavily accented speech. For those with the latter, a Tel Aviv-based startup called Voiceitt has developed Talkitt, an app that learns an individual’s speech based on basic, everyday spoken (or typed input) phrases and after a training period, converts them into normal audio speech or text messages on a tablet or smartphone. This aids with everyday life as well as devices like Echo and Alexa. Voiceitt is out of the Dreamit Health accelerator and was just seed funded with $2 million. This Editor notes from the TechCrunch article that it’s described as ‘the thin edge of the wedge’ and ‘a market with need’. It will be introduced this year to health systems and schools to assist those with speech impairments due to health conditions. Hat tip to Editor Emeritus Steve Hards
  • Diagnosing degenerative diseases such as diabetic retinopathy, which is preventable but if untreated eventually blinds the patient, is doubly difficult when the patient is in a rural, economically disadvantaged, predominantly minority, and medically underserved area of the US. Ophthalmologist Seema Garg has been on a quest since 2009 to have this recognized as a public health threat. The North Carolina Diabetic Retinopathy Telemedicine Network out of University of North Carolina-Chapel Hill, headed by Dr. Garg, collaborated with five NC clinics to recruit patients with diabetes. Her team then trained primary care staff to take digital retinal photographs transmitted over a secure network to be examined for symptoms. The public health study used Geographic Information Systems (GIS)-mapping for patient accessibility to ophthalmologists, demographics, and risk factors such as higher A1C levels, minority race, older age, kidney disease, and stroke. JAMA Ophthalmology, Futurity  Hat tip to Toni Bunting of TASK Ltd. (and former TTA Ireland editor)

Texas gets its telemedicine on: governor signs off on full direct-to-consumer access

The telemedicine stars at night–and day–are big and bright, deep in the heart of Texas. Over the weekend, Governor Greg Abbott signed into law Senate Bill 1107 which ended the requirement that a physician-patient relationship had to be established offline before a telemedicine visit could take place. MedCityNews  The Texas House earlier this month passed House Bill 2697 permitting direct-to-consumer virtual doctor visits, followed by the concurrent bill SB 1107 in the Senate. JD Supra (Jones Day), Modern Healthcare

The new legislation allows for previously prohibited initial care via telemedicine (versus in person), asynchronous “store-and-forward” typically used for data and images or other such audiovisual technology so long as it complies with rules that ensure safety and quality. The bill’s terms were negotiated between the Texas Medical Association, the Texas eHealth Alliance, and Teladoc. It also effectively ends the long-running, six-year standoff between Teladoc and the Texas State Medical Board, and the shutout of other providers such as American Well.

Both rivals cheered the good news on, which was timed beautifully for Teladoc’s 1st Quarter earnings call on May 9, adding to record-high visits, plus healthy revenue and membership increases. While it has many internationally known medical centers, Texas is a huge state and is notoriously short of primary care physicians, with 71.4 primary care physicians per 100,000 people and 46th among all the states for primary care physicians per capita.

There is one aspect of the bill that ensures further legal challenge, which is the language prohibiting the use of telemedicine to prescribe abortion-inducing medication as it does in 20 other states. Mobihealthnews. Further background in March article

CBO finds as budget neutral telehealth in Senate CHRONIC Care Act

Sneaking under the holiday week wire, when Congress high-tails it for home, the Congressional Budget Office (CBO) reviewed the telemedicine and telehealth provisions in the US Senate’s pending CHRONIC Care Act and found last week that they do not increase or decrease Medicare spending overall. Formally S.870 – Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017–and sponsored by Sen. Orrin Hatch of Utah, this means that this bill developed by the Senate Finance Committee’s bipartisan Chronic Care Working Group has passed a key spending acceptability test, and is another step further towards passage. CHRONIC removes many of the qualifiers that Medicare hedged around telehealth and telemedicine, with most restricting reimbursement to rural areas. There are four areas where the Act removes barriers:

  1. Nationwide coverage for Telestroke
  2. Home remote patient monitoring for Dialysis Therapy
  3. Enhanced telehealth coverage for ACOs–this expands the provisions in the Next Generation ACO program to ACOs participating in the Medicare Shared Savings Program (MSSP) Stages II, III and the few left in Pioneer, so that telehealth will be reimbursed regardless of geographic location and in the home.
  4. Increased flexibility for telehealth coverage under Medicare Advantage plans

There’s a long way to go, but this is an important step forward to an equal playing field for telehealth services. National Law Review’s summary