Announcements

The Next Frontier of Telemedicine: Quantum HoloMedicine

Dr. Fernando De LaPeña Llaca, President and CEO, Aexa Aerospace, Houston, Texas, USA

As we set our sights on becoming an interplanetary species, with Mars as a potential first stop, we are faced with a multitude of challenges. Not only must we overcome the physical barriers of space travel, but we also need to grapple with the complex task of maintaining constant communication.

The distance between Earth and Mars is, on average, 140 miles (225 km) from Earth, creating a delay in communications of up to 20 minutes for one-way communications and 40 minutes for two-way communications.¹ If one of the astronauts has an emergency and calls Houston, it may take 20 minutes to receive the initial conversation and about 40 minutes to complete an audio greeting.

However, there is a promising solution on the horizon for real-time three-dimensional communication: quantum holographic communications. This innovative approach will consist of two main components:

Quantum Communications

Quantum communicationsare a revolutionary approach that harnesses the power of quantum physics rather than traditional physics. It relies on two unique properties: quantum entanglement and superposition.

Quantum entanglement is a phenomenon where two or more particles become linked and instantaneously affect each other, regardless of the distance separating them.²In other words, from Earth to Mars or anywhere in the universe.

Quantum superposition allows particles to exist simultaneously in multiple states.³We use this approach to use qubits or quantum bits instead of traditional binary computer bits. A qubit can represent 0 and 1 simultaneously, allowing exponential states concurrentlyrather than traditional computing, where there is only one state at a time.

HolographicTeleportation in Space

Holographic teleportation is a type of capture that allows high-quality 3D models of people to be reconstructed, compressed, and transmitted live anywhere in realtime.⁴In October 2021, NASA flight surgeon Dr. Josef Schmid, industry partner Aexa Aerospace CEO Dr. Fernando De La Peña Llaca, and their teams were the first humans holographically teleported from Earth into space.  Dr. Schmid performed the first holographic medical evaluation to one of the astronauts, which was holographically teleported to the International Space Station. Since October 2021, NASA has used one-way and two-way holographic teleportation for medical evaluations in space.

Quantum Network

To establish this quantum network, the particles must be entangled. Entangling two particles in different planes involves creating a quantum state where the properties of one particle are correlated with the properties of the other, regardless of the spatial separation or orientation.⁵ The process begins when two particles interact so that their quantum states become linked by either collision or energy exchange. After the interaction, the particles enter a state of superposition, where they exist simultaneously in multiple states.

This interaction ensures that certain physical quantities, like angular momentum, are conserved using conservation laws. In other words, if one particle is measured to have a certain property, such as spin up (a traditional 1 in bits), the other particle will have a corresponding property, spin down (a traditional 0 in bits), to maintain the conservation law.⁶The interesting property of quantum mechanics is that with superposition, the particle exists simultaneously in multiple states. Still, when a measurement is made on one particle, its quantum state collapses to a definite value. Because the particles are entangled, the other particle’s state also collapses instantaneously to a corresponding value, no matter how far apart they are (e.g., Earth to Mars or beyond). The best part, in my opinion, is that the entanglement particles remain correlated in their properties even when separated by large distances or different planes. This happens not because of a physical connection but because of quantum mechanics.

The signal travels instantaneously between entangled particles because of a phenomenon known as quantum non-locality, which allows the signal to travel faster than the speed of light.⁷

Some physicists suggest that entangled particles are connected through a quantum field that permeates space-time.⁸ To make this happen, a teleportation process allows us to entangle particles from different locations. The process starts with a pair of entangled particles, so when the scientist interacts with the first particle (A) with another quantum particle, they arrange this interaction with the second entangled particle,culminating in the same state as particle (A). When this happens, particle (X) has been teleported. By the time this editorial was written, scientists had been able to manipulate particles by varying magnetic fields; they used the magnetic field in one region of space to continuously control the state of a particle elsewhere, achieving quantum remote control.

Quantum Holographic Teleportation

By using quantum communications at a basic level, we can transmit at least instantaneous information, zeroes, and ones, which is the basic structure of our holographic communications. For example, suppose an astronaut on Mars wants to communicate with Earth. In that case, the crew members can place their holographic representation on Earth in realtime. They will also receive holographic representations of NASA surgeons, subject matter experts, or family members and interact instantaneously. In addition,they can feel the other person by using haptics (i.e., conveying information to the user/operator through their sense of touch. The person will not be there, but their essence will be. Furthermore, there are other aspects in terms of exploration; the scientists or the public, in general, will be able to walk with the astronauts, feel the environment, and touch rocks, among many other aspects. In addition, it will be a good way to reduce the effects of long-term isolation in space by allowing the crew members to holographically teleport to a baseball game with their children or have dinner together.

In terms of medical advances, this is a game changer, as physicians will be able to interact with patients on another planet, in this case, Earth to Mars, instantaneously. The physician will be able to feel the patient, and the patient will be able to interact with the physician by using six axes of freedom—the number of axes that an object can freely move within a three-dimensional space.

Another aspect is the recreation of holographic recordings by capturing a training session or exploring “the Red Planet” by using this technology. Holographic teleportation is device agnostic, meaning that astronauts can capture the holograms with a good variety of devices that range from LIDAR (light detection and ranging) cameras to smartphones or tablets, and people on Earth will be able to reproduce it by using mixed reality, augmented reality, virtual reality, smartphones, or tablets.

Conclusion

The distance between Earth and Mars is a limitation to our current communications and limits our ability to become an interplanetary species; however, quantum holographic telecommunications can be a cosmic bridge connecting worlds in real-time. Humans will encode our communications not in binary but in entangled particles across space. Our future Martian pioneers will be entangled with Earth-bound counterparts, working together, assisting each other, and sharing with their families and the public the mysteries of the universe in a novel way. Scientists, engineers, and anyone can materialize on the red sands of Mars.

There are two aspects of telemedicine, or holomedicine, that will be revolutionary. The first one is the idea of performing medical evaluations in real-time and the capability of the doctor on Earth to potentially feel the lymph nodes of the patient on Mars as if they are physically present, which will allow future people on Mars to receive the best medical attention from Earth.

The second aspect is the isolation aspect; long-term isolation in space can reduce the performance of the astronauts. Holographic teleportation in space can reduce the sideeffects of this isolation and help improve the performance of the astronauts.

This quantum holomedicine will be key to the success of missions to Mars. The human body will change immediately in multiple ways as gravity is different, the atmosphere is different, and radiation, among many conditions. An established colony will have humanoids, different from humans as we know them today, and medicine will need to play an active role in keeping our explorers healthy; meanwhile, physicians and researchers will write new books on human anatomy on other planets.

In addition, from the psychological aspect, missions to Mars may take years or be one-way only; however, with this technology, the astronauts can holographically teleport to Earth instantaneously to enjoy sports, spend time with their families, and rest in a paradisaic place, among many other activities. Meanwhile, space tourists can enjoy holographic vacations in real time on Mars.

The future is now!

Resource Holographic Journal Video: https://www.youtube.com/watch?v=6G8CulO9i9c

References

1. Hazard: Distance from Earth. Telemedicine: Quantum HoloMedicine. NASA. 2024.Available from: https://www.nasa.gov/hrp/hazard-distance-from-earth/
2. Hidki A, Pen JX, Singh, SK, et al. Entanglement and quantum coherence of two YIG spheres in a hybrid Laguerre–Gaussian cavity optomechanics. Sci Rep. 2024; 14(1), 1–13. Available from: https://doi.org/10.1038/s41598-024-61670-7
3. Ruan S, Yuan R, Guan Q, et al. VENUS: A Geometrical Representation for Quantum State Visualization. Computer Graphics Forum, 2023; 42(3), 247–58. Available fromhttps://doi.org/10.1111/cgf.14827
4. Innovative 3D Telemedicine to Help Keep Astronauts Healthy. NASA Humans in Space. 2022. Available fromhttps://www.nasa.gov/humans-in-space/innovative-3d-telemedicine-to-help-keep-astronauts-healthy/
5. V, A. (2024, June 15). How do particles become entangled? Physics Stack Exchange. Retrieved June 26, 2024, Available fromhttps://physics.stackexchange.com/q/119429
6. Brook, M. How quantum entanglement really works and why we accept its weirdness, New Scientist. 2024. Available from https://www.newscientist.com/article/mg26234921-800-how-quantum-entanglement-really-works-and-why-we-accept-its-weirdness/ (Accessed: 26 June 2024).
7. Aghababaei S, Moradpour H. Generalized uncertainty principle and quantum non-locality. Quantum Information Processing, 2023; 22(4), 1–12. Available fromhttps://doi.org/10.1007/s11128-023-03920-7.
8. Romatschke P. (2024). Quantum Field Theory in Large-N Wonderland: Three Lectures. Acta Physica Polonica B. 2024; 5(4), 4–A2.1–4–A2.55. Available fromhttps://doi.org/10.5506/APhysPolB.55.4-A2
9. .Holographic teleportation in space and astronauts’ stress: A Delphi study/ SX De La Peña Llaca F Phillip L. Davidson PLcience Talks. 2023. Available from:https://doi.org/10.1016/j.sctalk.2023.100228

Published 8.16.24

Enhancing Hospital Resilience for Future Pandemics: A Focus on FEMA Public Assistance

Divya Sharma, Wellesley Cove Group
Angelica Lovquist, Wellesley Cove Group
Jennifer Reichart, Wellesley Cove Group

Hospitals have long been primed to address emergencies, maintaining dedicated departments solely for this purpose. Nevertheless, the advent of the COVID-19 pandemic, which prompted a federal emergency declaration from January 20, 2020 through May 11, 2023, ushered in unparalleled circumstances, challenging hospitals and the entire nation to adapt swiftly. This transformative and costly experience underscored an array of invaluable lessons.  One such lesson is that hospitals were, in many ways, not prepared to navigate the intricate applicationprocess of the FEMA Public Assistance (PA) program. While data indicates that by August 2023, FEMA has disbursed more than $3.8 billion in public assistance to hospitals nationwide[1], this sum does not fully alleviate the financial strain that hospitals endured while addressing the pandemic. This paper serves as a guide, identifying strategic pathways that hospitals can embrace to elevate their disasterpreparedness and better position themselves to apply for federal funding, including FEMA Public Assistance.

Understanding FEMA Reimbursement Policies

Seeking reimbursement from FEMA entails hospitals delving into the agency's intricate reimbursement policies and guidelines, a task made more complex by the fact that these policies are not inherently tailored to the healthcare landscape. FEMA's guidelines, often formulated with broader emergency contexts in mind, necessitate substantial effort to align seamlessly with the intricate workings of hospitals. The foundational framework for this endeavor rests on adherence to the Stafford Act, a cornerstone that delineates the spectrum of eligible expenses and the exacting documentation prerequisites essential for reimbursement. To meet this challenge, hospitals are advised to institute dedicated internal teams vested in consistently reviewing FEMA's evolving guidelines, including the Public Assistance Program and Policy Guide (PAPPG). This meticulous review process serves a dual purpose: enhancing comprehension of FEMA's specific requirements while also establishing robust mechanisms to ensure ongoing compliance within the dynamic hospital environment.

Learning from Eligibility Determinations

In the wake of the COVID-19 pandemic, hospitals were confronted with the challenge of distinguishing between eligible and ineligible expenses for FEMA reimbursement. For instance, labor expenses from hospitals’ own force account labor staff were often deemed ineligible, whereas incremental expenses from temporary contracted labor were allowed.  An understanding of FEMA’s framework for eligible vs. ineligible is crucial for maximizing financial recovery while complying with FEMA's policy requirements. As hospitals prepare for future pandemics, it is paramount to scrutinize the expenses that were deemed ineligible during the COVID-19 response. By conducting a comprehensive analysis of these disallowed expenses, hospitals can proactively identify steps to streamline potential future application processes. This introspective process equips hospitals with the insights needed to recalibrate their financial strategies, ensuring that future expense documentation aligns more closely with FEMA's reimbursement criteria. Furthermore, a proactive approach to addressing previously ineligible expenses enhances hospitals' ability to manage their resources judiciously while fostering a more streamlined reimbursement process in future emergencies.

Another category of disputed expenses pertains to bulk purchases of supplies and equipment made by hospitals at the pandemic's outset, following CDC or other guidance, which subsequently proved ineffective, resulting in unused stock. Hospitals are urged to maintain detailed records of purchase rationales for potential future expense justification. Enhancing documentation can bolster expense submissions.

Coordinating Insurance Reimbursements with Incurred Costs

In the realm of pandemic response, the intricate interplay between insurance reimbursements and FEMA's financial assistance presents a unique challenge. FEMA enforces strict requirements that there is no duplication of benefits between FEMA Public Assistance and other sources of funding. Hospitals must therefore establish a robust process to align these two streams of reimbursement effectively. This entails meticulous documentation of expenses, including clear delineation between costs covered by insurance and those eligible for FEMA reimbursement. By cultivating a systematic approach that avoids duplication of benefits, hospitals can not only enhance their financial recovery but also uphold transparency and accountability. This process also necessitates collaboration between hospital finance departments, legal counsel, and risk management teams to ensure that each avenue of reimbursement is optimized without creating redundancies. As hospitals refine their strategies for future pandemics, this harmonious approach to reimbursement will be pivotal in maintaining fiscal resilience while navigating the complexities of multiple reimbursement sources.

Comprehensive Pandemic Preparedness

A robust pandemic preparedness plan forms the foundation for effective response and FEMA reimbursement. Hospitals should create comprehensive emergency preparedness policies and plans that cover medical surge capacity, staffing, communication strategies, and supply chain management, including clauses in procurement policies to address emergency and non-competitive procurement.FEMA guidelines have specific requirements around procurement and contracting that hospitals should research to ensure alignment. Additionally, accurate documentation of all pandemic-related expenses is essential for successful reimbursement. Hospitals should maintain meticulous records of expenses, including costs related to personnel, supplies, equipment, facility modifications, and additional services. Leveraging technology can significantly streamline documentation and communication processes. Hospitals should adopt electronic record-keeping systems that facilitate expense tracking and reporting and may wish to set up dedicated cost centers and codes to accurately classify emergency-related expenses.

Forging Collaborative Partnerships with State Recipients

In the realm of applying for FEMA reimbursement, hospitals are encouraged to cultivate a deeper and symbiotic relationship with the state recipients of FEMA funds, typically the state's emergency management agency. This collaborative approach lays the groundwork for alignment of policies, procedures, and documentation practices. Establishing open channels of communication with these agencies allows hospitals to gain insights into the nuances of state-level expectations, which often play a crucial role in facilitating a smooth reimbursement process. By coalescing efforts and sharing insights, hospitals can proactively work with state entities to refine their pandemic response plans in ways that seamlessly align with FEMA's reimbursement criteria. This collaborative partnership not only streamlines the reimbursement process but also fosters an environment of mutual understanding and support, enabling hospitals to efficiently navigate the complex landscape of pandemic response and financial recovery.

Conclusion

Hospitals play a crucial role in emergency response, and their preparedness efforts directly impact their ability to provide quality care while minimizing financial strain. By aligning their practices with FEMA policies, hospitals can enhance their preparedness, streamline reimbursement processes, and ultimately contribute to a more resilient healthcare system that is better equipped to manage future pandemics and other emergencies that require increased hospital resources. When hospitals successfully maintain financial resilience, they are better positioned to continue growing and expanding their services, including innovative offerings such as digital health and remote patient care. The ability to invest in cutting-edge technologies and remote care solutions not only bolsters a hospital's capacity to respond to future crises but also caters to evolving patient needs and expectations. This expansion into digital health and remote patient care can help hospitals diversify their revenue streams, reduce the strain on physical resources, and increase access to medical services for a wider population.

References

     1. Data obtained from the Public Assistance Funded Projects Details Open Data Set available on             FEMA.gov

Published: 12.8.2023

Improving Women's Health Through Telehealth: A Summary of Expert Insights

Matt Sakumoto, Professor, USCF​
Bronwyn Harris, CEO, Carbon Health
Andrea Ippolito, CEO, and Founder SimpliFed
Aditi Joshi, Founder, Nagamed Digital Consulting

Telehealth has emerged as an important tool for improving access to and quality of healthcare, especially for women. A recent panel of experts explored how telehealth can enhance women's health services in a hybrid care model. Key discussion topics included using telehealth to increase access to care, providing personalized and holistic care, and supporting new mothers.

The panelists included Dr Aditi Joshi, an emergency medicine physician with experience at startups and academic medical centers and author of a telehealth success book (https://www.amazon.com/Telehealth-Success-Thrive-Remote-Care/dp/B0CBM31HGQ), Dr Bronwyn Harris, a pediatric cardiologist and clinical product manager with experience at her own startup, Apple, Carbon Heath and Care Evolution (https://careevolution.com/), and Andrea Ippolito, the founder and CEO of SimpliFed (https://www.simplifed.com/), a virtual breastfeeding and baby feeding support company and former biomedical engineer.

Increasing Access to Care

A major benefit of telehealth is increasing access to care for populations that face barriers to in-person care. The panelists emphasized how telehealth improves access for women, who often prioritize family members' health over their own. Pre-pandemic studies found women citing convenience as a reason for not seeking care; telehealth removes obstacles like childcare, transportation, and taking time off work. Dr. Joshi stated, "Telehealth has bridged that gap in women receiving care and treating conditions like mental health issues, which women have historically neglected."

Since the pandemic, women comprise the majority of telehealth users from ages 25-64. Women frequently use telehealth for behavioral health and chronic disease management. By removing logistical barriers, telehealth bridges gaps in women receiving care and in treating conditions like mental health issues, which women have historically neglected.

However, realizing telehealth's full potential requires optimizing insurance coverage and reimbursement. Speakers urged healthcare organizations to proactively understand federal and state policies around telehealth billing and coverage of women's services. This ensures vulnerable populations aren't inadvertently excluded due to confusion over what services are covered. Ms. Ippolito said, "When there is no policy or when there's ambiguity with the policy, people defer to the most conservative interpretation of a policy because folks are afraid of overstepping."

Panelists also highlighted the need for innovative reimbursement models to incentivize comprehensive virtual care. Current fee-for-service models reward in-person visits over virtual care coordination. Value-based models could better support telehealth's role in improving outcomes and reducing costs.

Personalized, Holistic Care

The panelists emphasized telehealth’s capacity to facilitate personalized, holistic care for women. Remote monitoring and patient engagement tools enable more continuous care between visits. This gives physicians more comprehensive data for treating the whole patient instead of isolated symptoms. Dr. Joshi stated, "I actually think the tech tools that we have are not going to change [fragmented care] but we can use them to create this comprehensive picture for ourselves and to share it with our physicians and clinicians."

Dr. Harris stated, "In my mind, it's not a replacement, but when done well, can really help augment all of the time that providers spend and get them the resources that they need."

Speakers noted that while technology can augment care, artificial intelligence (AI) won't replace clinicians' critical thinking and relationship-building skills. But thoughtfully designed tools can reduce busywork, surface insights from data, and enhance patient-provider interactions. This human-AI collaboration is key for holistic care.

Supporting New Mothers

The panel highlighted breastfeeding and postpartum support as areas where telehealth demonstrates particular value. The federally mandated Women's Preventive Services Initiative (https://www.womenspreventivehealth.org/) requires health plans to cover lactation support without cost-sharing. However, confusion persists around how to bill for these services delivered via telehealth. The panelists encouraged education for providers on coding and documentation to ensure new mothers receive virtually-enabled support.

For breastfeeding mothers, telehealth provides convenient access to lactation consultants without needing childcare or transportation. The panelists shared examples of how virtual lactation support helped identify and resolve breastfeeding challenges that otherwise may have required in-person or emergency care.

Comprehensive postpartum care is also crucial yet often lacking, especially after families leave the hospital. The speakers emphasized the need for ongoing holistic care addressing both physical and mental health. Remote monitoring and telehealth visits make this model more feasible and scalable.

Looking Ahead

While gaps and challenges remain, the panelists were optimistic about telehealth's future role in enhancing women's healthcare. They envisioned innovations like expanded remote monitoring, deeper electronic health record (EHR) integration, and new reimbursement models tailored to telehealth's benefits. But ultimately telehealth is just one component of quality care. The speakers emphasized that maximizing health equity for women requires comprehensive policy and payment reform, not just technological solutions.

These telehealth experts provided valuable insights into leveraging virtual care to improve women's health. By increasing access to services, enabling holistic and continuous care, and better supporting new mothers, thoughtfully implemented telehealth can help meet women's previously unmet healthcare needs. But realizing telehealth's full potential requires optimizing policy, payment models and technological capabilities in tandem. Continued research and education will further equip healthcare stakeholders to enhance women's wellbeing through telehealth capabilities.

Acknowledgements & Disclosures:This summary was based on a virtual panel for the Converge to Accelerate 2023 (#ConV2X23) Symposium.

Published: 11.3.2023

State of Nursing June 2023

Kelly Ayala, DNP, BSN, Founding Nurse Practitioner, Pair Team

Rebecca Love, Chief Clinical Officer, Intelycare and President-Emeritus of SONSIEL

Between the two of us, we have nearly 40 years of nursing experience. We have worked in various areas including medical-surgical, critical care, charge nurse roles, teaching roles: Advanced Life Support and CPR classes as well as in a local community college. Our expertise extends to writing academic papers, working in ambulatory specialty care, academic medicine, community medicine, long term care staffing and primary care. 

Throughout our careers, we have encountered a wide range of experiences, from successfully coding patients to witnessing the heart-wrenching moments when CPR and medical technology fell short. We sat in quiet solidarity with grieving mothers who lost their babies during childbirth. In one memorable instance, we even assisted in delivering a baby in the ICU for a mother on life support. We have consistently advocated for families to have choices and have engaged with ethics committees to address complex moral dilemmas. We have held the hands of patients in clinics as we delivered difficult news, promising to stay by their side. 

During the COVID-19 pandemic, one of us took dictation from a mother and read her heartfelt letter to her critically ill child through the glass doors of the ICU, hoping to convey a message of love from afar. Our advocacy extends to marginalized individuals in society, including the unhoused, those with bed bugs, individuals transitioning from prison or jail, the inebriated, non-native English speakers, as well as those who are paralyzed and unable to speak.

Throughout our careers, we have provided a significant portion of this care as part of our responsibilities while working in hospitals or running clinics. Unfortunately, the terms thrown around by administrators in these settings, such as "room rate" and "non-billable work," do not adequately capture the depth and breadth of the care we provide, causing systems and hospitals to devalue nurses’ care and de-incentivize spending to improve nurses' work. In our country, most insurers do not reimburse for the examples we have provided, except when we were practicing as Nurse Practitioners. Unlike other healthcare providers, Registered Nurses do not possess a national number or identifier to bill for the services they provide.

When one of us transitioned away from bedside nursing, we took with us 13 years of valuable skills in complex care, critical thinking, teaching, and advocacy. These skills are portable and often intangible, and the hospital we left no longer had access to the knowledge, compassion, and expertise we had accumulated. To the casual observer, this may raise the question, "Who cares? Can't the system or hospital just hire another nurse?" The answer today is: maybe, maybe not.

This brings us to the current state of nursing, where we find ourselves in what is referred to as a Liminal Space. A liminal space is characterized as a transitional or intermediate state or place. Nurses today are leaving the profession, departing healthcare systems, retiring, or redirecting their skills elsewhere. The work of nurses is not fully comprehended by outsiders, is inadequately defined by financial leaders in healthcare, and is not adequately reimbursed by insurers, resulting in a sense of invisibility within healthcare systems. Moreover, this invisibility leads to a misunderstanding and devaluing of the work that nurses perform. 

As we look back from this Liminal Space in 2023, we can trace the historical path of nursing work (often associated with the work of women), from being paid in cash for services rendered, to being bundled into hospital room rates in the 1920s to the advent of HMOs, PPOs, and insurance, and near constant staffing crises to the recent COVID-19 pandemic. Nurses also have a history of political advocacy, fighting for change, rights and protections for patients, themselves and society-at-large.

It is crucial to address the nursing workforce gap and payment model to redesign the nursing workload to ensure the sustainability and effectiveness of healthcare delivery. Nursing turnover continues to be a substantial challenge for healthcare organizations, as evidenced by recent data. According to a survey conducted by McKinsey this year, the number of Nurses with the intent to leave their nursing jobs remains high. In their most recent nursing survey, 31 percent of respondents indicated they were likely to leave their current role in direct patient care, and these numbers are higher than the 22 percent rate observed in the first survey conducted in February 2021 at the end of the worst of the Covid Pandemic.  The “intent to leave” is highest in inpatient Registered Nurses (RNs) i.e. bedside nurses out of all other demographics of RNs.  In a pulse survey specifically focusing on inpatient RNs, the intent to leave rose from 35 percent in fall 2022 to over 40 percent in March 2023. (McKinsey 2023 Nursing Insights)

These findings highlight the urgent need to address the challenges faced by nurses and take steps to improve their working conditions and job satisfaction. The nursing workforce is the foundation of healthcare, and the high turnover rates are indicative of systemic issues that must be addressed at a federal level–individual nurses, even unionized nurses taking collective action won’t fix it. Without nurses, there is no healthcare. The current power dynamics in healthcare prioritize profits and salaries of administrators over the Nurses and other clinicians providing patient care.

We are taking this opportunity to shape the future direction of the profession and with it, save healthcare. Nurses across the country are connecting as innovators, small business owners, and co-founders of startups, often cutting back on inpatient bedside hours and eventually leaving the bedside altogether. Their licensure combined with their skillset of extreme ownership, problem-solving in high-risk situations, and willingness to challenge the status quo position them as ideal candidates to build new companies, frameworks of care, and advocate for change in institutional and systemic practices. As patients ourselves, we recognize the critical role that nurses play in our healthcare journeys.

However, if we do not address the nursing workforce gap and the challenges faced by Nurses, the profession risks stagnation or even regression. In medicine, the concept of Therapeutic Inertia is frequently observed, referring to a lack of urgency or movement in treatment when clinical goals are not being met. Historically, nurses have lacked power and access to power structures, which limits their ability to challenge and change large systems, in other words, the therapeutic inertia is significant for nurses currently at the bedside to find ways to improve their own daily work and collectively demonstrate their value in dollars both saved and earned. It is essential to shift the power dynamic in healthcare, placing greater emphasis on the value of nursing care and prioritizing the needs of both patients and nurses.

Although we do not speak for all Nurses, we imagine that Nurses would like society at large to become as uncomfortable as we are when we work short-staffed and patients miss out on the necessary care they deserve. Help us cross the Liminal Space into a positive new direction. We call upon the reader to join us in advocating for change, recognizing the invaluable contributions of nurses by allowing nurses to bill for their care, and supporting initiatives that prioritize the well-being of both patients and the nursing workforce. 

Join us: https://commissionforNursereimbursement.com/

posted June 10, 2023

Remote Patient Monitoring in Chronic Care Management: A Practitioner’s Experience using RPM to Increase Patient Adherence and Improve Patient Outcomes

Andrew Mills, BBA¹; Brad Guest, MBA, JD²

¹Chief Executive Officer, CareTrack, Inc., Carrollton, Georgia, USA; ²Managing Member, Caliber Healthcare LLC, Bishop, Georgia.

Contact: bradguest@gmail.com

Remote patient monitoring (RPM) has come a long way. Most people think of it as a relatively new development. In fact, RPM has been in use in the United States for over fifty years. Its first use was a collaboration between NASA and Kaiser Permanente. In the 1970s, they developed and implemented an RPM pilot serving the Tohono O’odham Indian Nation in southwest Arizona. NASA was interested in RPM’s potential for post-Apollo, long-duration manned space flight. Kaiser on the other hand was interested in its use in what we would now call population health. As you might guess, the program had many glitches and technological hurdles, but it ultimately worked. Kaiser physicians monitored basic vital signs and interacted with tribal members through television signals.

Since then, RPM has continued to advance and now plays a key role in primary care and virtually all sub-specialties. Here we discuss another important application that is showing great promise: chronic care management (CCM). We are seeing tangible proof of its ability to impact the Triple Aim of improving quality for the patient, reducing cost, and making populations healthier. We  find that two trends are driving increased adoption of RPM: COVID and the resulting increase in out-of-office care¹ and the continuing embrace of value-based care by providers, private payers, and governments.²

Current Landscape

COVID-19 jolted the steady but moderate growth rate that the industry posted over the prior decade. Faced with new and unexpected challenges, consumer adoption increased dramatically in response to COVID. Prior to the epidemic, roughly 11% of U.S. consumers used telehealth. Now 45% to 50% of consumers have done so in order to replace cancelled, in-person appointments.¹ Visit numbers bear this out. During the first quarter of 2020, the number of telehealth visits increased 50%, compared with the same period in 2019. There was also a 154% increase in visits noted in early 2020, compared with the same period in 2019.

Conversely, during the same time periods, emergency department visits decreased substantially.² As infections abated, telehealth visits declined slightly. Yet, they are still far above pre-COVID levels. This suggests the reality of a long-term and durable change in attitudes of patients, providers, and payers.³

Value-Based Care

“At its heart, value-based care is premised on a belief that our health care system can be significantly improved by transforming care to lower prices and improve outcomes.”⁴ As evidence of its spread, there are now approximately 36.3 million people covered under Accountable Care Organizations (ACOs).⁴ This number has been relatively steady since 2018, after growing rapidly beginning around 2012. However, in the last 12 to 18 months, a small number of organizations exited the market.⁴ Health systems spent significant time and financial resources building programs around their owned or affiliated ACOs. In 2020, approximately 40% of healthcare provider revenues were earned through alternative payment models.⁵

Our clients are responding to the challenge of value-based care, transforming what they do and finding ways to improve outcomes. For them this means being closer to their patients and more intimately involved in their care, over time. The focus is on improving patient adherence. Patient adherence means helping patients closely follow all aspects of their care plans between office visits. It also means collecting and analyzing clinical data so physicians can adjust care plans in an efficient and timely manner. That’s where RPM comes in, presents challenges and opportunities working with older patients.

RPM in Chronic Care Management

Remote patient monitoring refers to the technology and processes necessary to monitor health on an ongoing basis. Remote patient monitoring technology may include physiological monitoring (e.g., blood pressure, glucose, weight, and temperature), medication administration reminders or monitoring, diet and exercise tracking, falls monitoring, and tools to help patients cope with anxiety or depression. The process involves four distinct but interconnected layers:

1. Patient layer
2. Cloud layer (transmission and storage of data)
3. Management/monitoring layer
4. Physician/provider layer

In an effective chronic care RPM program, the management and monitoring layer acts as the central nervous system. It receives, organizes, and interprets clinical data and assembles it into actionable information for physicians and others in the patient’s care team. Real-time, actionable information is what makes RPM so effective. It allows physicians to adjust care plans and change visit intervals based on the most recent and relevant clinical data.

Remote Monitoring for Older Patients

Older patients present unique challenges. It is critical that older patients understand the role of the monitoring equipment and not be intimidated by it. The number of Americans ages 65 and older will more than double over the next 40 years, reaching 80 million in 2040. Additionally, the number of adults ages 85 and older will nearly quadruple between 2000 and 2040.⁶ The chronic disease challenge faced by this population will require an expanding set of resources to both monitor health conditions and use the data to improve adherence to treatment plans. To meet this challenge, we expect remote patient monitoring to become increasingly important.

Digital health literacy is one of the biggest barriers to patient engagement for senior populations. We found several things to be important in assessing and addressing digital literacy:

• For each patient, there should be an assessment of their appropriateness for RPM, including physical and cognitive capabilities.
• Ask are there any language, cultural or literacy barriers that would impede success?
• Are there physical limitations that bear on the patient’s ability to use the device and/or interact with the care team? In recent years, device technology has improved substantially, and we found that the vast majority of older patients are good candidates for RPM monitoring.
• Configure RPM packages so that they require minimal set up and configuration requirements.

We learned the most important reason patients agree to enter RPM monitoring and (just as importantly) remain in the program. The key is if the patient understands the connection between the monitoring and their ultimate health. Patients who want their physicians to be up to date on their health tend to remain in the program and are attentive to the data they receive, as well. We found that this is particularly true for hypertension, where blood pressure readings are easy to understand and respond closely to changes in diet and exercise. In some cases, patients decline or drop-out programs due to co-pay/financial issues. Managed care plans vary in their terms for RPM, with some imposing no out-of-pocket cost. For Medicare beneficiaries, patients are subject to a 20% beneficiary copay, which is not waivable, but may be covered if a patient has supplemental coverage or Medicaid.

Reimbursement

Within Medicare, RPM services can be billed in addition to CCM. This means that providers can bill both RPM CPT code 99457 and CCM CPT code 99490. CMS recognizes that the time and work analysis involved in furnishing RPM services complements CCM and other care management services. There is a 40-minute minimum monthly time requirement for billing these codes together, comprised of 20 minutes of RPM and 20 minutes of CCM.

Applicable Regulations

• Allowed for patients with both chronic and acute conditions
• Must be for an established patient. This is defined as a patient with whom the physician has had a prior new patient E/M service. This E/M service is allowed to have occurred using telehealth.
• Monitoring must occur over at least 16 days of a 30-day period for CPT codes 99453 and 99454 to be billed.
• Even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed only once per patient per 30-day period and only when at least 16 days of data have been collected. CMS has indicated that CPT 99453 can be billed only once per episode of care where an episode of care is defined as “beginning when the remote physiologic monitoring service is initiated and ends with attainment of targeted treatment goals.”

Conclusions

Remote patient monitoring is playing an increasingly important role in CCM. Physicians and health systems are finding that their ability to manage population health depends on the extent and availability of up-to-date patient data. Given recent advancements in technology and cultural acceptance of digital devices, patients are now able and willing to adopt a broad array of monitoring technology. This presents a juncture point from past practice where RPM was often focused on isolated populations and used for shorter duration. Older populations deserve special consideration. They are often those who can benefit the most, yet they present special challenges. We found that these challenges can be overcome by using pre-arranged kits of easy-to-use devices followed by a well-executed education and communication plan. Providers and others in the field of CCM and population health should carefully consider how this technology can improve the quality and effectiveness of their care management programs.

References

1. Bestsennyy O, Gilbert G, Harris A, Rost J, Telehealth: A quarter-trillion-dollar post-Covid-19 reality?, Internet. McKinsey & Co. Healthcare Systems and Services, July 9, 2021. Available from: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality
2. Koonin LM, Hoots B, Tsang CA, et al. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1595–9. DOI: http://dx.doi.org/10.15585/mmwr.mm6943a3external icon
3. Lo J, Rae M, Amin K, Cox C, Outpatient telehealth use soared early in the COVID-19 pandemic but has since receded, Internet. Peterson-KFF Health System Tracker, February 10, 2022. Available from: https://www.healthsystemtracker.org/brief/outpatient-telehealth-use-soared-early-in-the-covid-19-pandemic-but-has-since-receded/
4. Muhlestein D, Bleser W, Saunders R, McClellan M, All-Payer Spread of ACOs and Value-Based Payment Models In 2021: The Crossroads And Future Of Value-Based Care, Health Affairs, June 17, 2021, DOI: 10.1377/hblog20210609.824799
5. Health Care Payment Learning & Action Network, APM Measurement, Progress of Alternative Payment Models, 2021, Available from: https://hcp-lan.org/apm-framework/
6. The Urban Institute, Program on Retirement Policy: The US Population is Aging, available from: https://www.urban.org/policy-centers/cross-center-initiatives/program-retirement-policys

Published 5.17.2022

Digital Health Equity in Nigeria

Idris Umarfarouq, PharmD;¹ Bryan T. Arkwright, MHA²

Affilations: ¹Cromford Health ²Chief Research Officer, Cromford Health, ³Adjunct Faculty, Wake Forest University School of Law ORCID ID: 0000-0001-5500-0700

Contact: mailto:arkwrightbt@gmail.com

Digital health plays a fundamental role in the growth or development of healthcare systems. However, there is a major dearth and gap of knowledge on the basics of digital health equity as a framework to help in the fair share of health and wellbeing for everyone in Nigeria. Here we present a basic overview of digital health equity. More particularly, we suggest increased partnerships with telecommunication companies utilizing digital health equity frameworks (DHEF) and encourage public and private organizations to fund investigation and research to propel digital health equity.

Health equity allows all to have access to the best healthcare amenities and expertise. With the advent of Covid in the past year, the WHO Africa Region member countries have implemented innovative and vast means to promote better health outcomes. Application of information and communication technology (ICT), audio enabled, and televideo enabled interactions are among the innovations implemented by the different WHO member countries to improve their health outcomes. The implementation of different technologies in the development of the healthcare system in Nigeria has contributed to the realization and actualization of the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC) as well as other African countries. There has been a lack of attention to health equity in developing digital health solutions in Nigeria and other African countries, which contributes to the lack of growth in the healthcare system. There are different factors that limit health equity, and they include,

• Poverty
• Underfunding of health systems
• Illiteracy
• Lack of proper infrastructure
• Lack of awareness on the visibility and advantages of digital health
• Inadequate healthcare workers training and competence in digital health equity
• Lack of cultural humility by healthcare providers to understand how their immediate community interacts with technology

Determinants of health which include social, cultural, and economic determinants, contribute to the fair share of health amenities and expertise.

According to a survey by WHO on eHealth, funding for digital health for countries in Africa varies, with an estimated 72% of the funding provided by external donors. Memorandum of Understanding (MOU’s) helps provide opportunities for Nigerian governmental systems to jointly negotiate digital health prices through national economic experts, thereby increasing their bargaining power while lowering the cost of digital health in Nigeria.

The donor alignment principle was launched at the world health summit in Berlin on 16th October 2018. Digital Investment Principle is an essential framework that helps investors align their investments to country digital health strategies.

Top Global Digital Health Investors are:

• Global Health Impact Fund
• AAF Management Ltd
• Advisor Fund LLC
• Structure Capital

The digital equity framework was created to consider health equity factors in the delivery of digital health services, and it encompasses the digital health determinants. Digital health determinants impact a patients’ chances of receiving a quality of care that is person-centered, safe, timely, effective, and efficient.

 The framework includes:

• Social Stratification: this includes the hierarchical allocation, unequal distribution of power and resources. Social stratification allocates individuals to a particular social location.

• Digital Determinants of Health: digital determinants of health interact with other health factors, including psychosocial stressors, pre-existing health conditions, health-related beliefs, and the person's current health state and needs.

• Social Determinants of Health: these are the non-medical factors that influence health outcomes. They include where the individual is born, grow, work, live and age. The social determinants of health also include governmental policies, development agendas, economic policies, etc.

There is an increase in life expectancy, but unequally, also there is a wide gap between the people with best and the worst wellbeing. These gaps are unjust and avoidable. Digital health equity can be achieved by the absence of unfair and avoidable differences in health among population groups defined socially, economically, demographically, or geographically.            

Published: 1.7.2022

Future Implications of Telehealth in the Post-COVID World

Sujatha Alla¹, Vijay Kumar Chattu^2*

Affiliations: ¹Engineering Management and Systems Engineering, Old Dominion University, Norfolk, VA, USA. ORCID ID: 0000-0003-2824-4528; ^2*Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada. ORCID ID: 0000-0001-9840-8335

*Contact: mailto:vijay.chattu@mail.utoronto.ca

The recent global pandemic forced telehealth to play a greater role in global healthcare delivery due to limited healthcare accessibility. The advent of innovative communication technologies has made it easier for patients to get services like health assessment, diagnosis, interventions, supervision, and information remotely. Digital imaging, decision support software, virtual reality, machine learning for error reduction, Internet of Things (IoT) such as wearable sensors, assistive robots, advances in data management (tracking, transmission, and storage), real-time analytics or store-and-forward, are some of the dynamic technologies that provide strong evidence-based support to scalable and sustainable telehealth programs.

Telehealth has become increasingly relevant as global healthcare needs have become overwhelmed by significant increases in the global level of chronic diseases [1] and the insufficient number of healthcare professionals and medical facilities, especially with an increase in aging people. Some studies that compared telehealth to traditional outpatient care recorded savings estimates ranging from 17% to 75%.  In a study on 17,025 US Veterans, the use of telehealth services resulted in a 25% reduction in hospital length of stay, a 19% reduction in hospital admissions, and a mean satisfaction score rating of 86%, all at the cost of US $1600 per patient per annum [1]. In the European Union, it is estimated that chronic illness is a factor in 87% of all deaths [1]. The literature also reported the benefits of Remote Patient Monitoring (RPM) with decreased hospitalizations, improved patient compliance with treatment plans, improved patient satisfaction with health services, and improved quality of life [1].

In 2011, World Health Organization (WHO) launched a policy called “Health 2020” to achieve the highest level of health among European countries [3]. Based on this, Denmark designed a national strategy for digitalization of the Danish public sector by 2020, focusing on implementing telehealth at scale, improving personalized telehealth, and quality of life for patients and citizens within the healthcare and social sectors. However, patients’ acceptance is not sufficient for integrating telehealth, and it still continues to be the fall-back option to the traditional healthcare services.

A three-round study conducted by the CDC on telemedicine access and use during July 2020, Aug 2020, and May 2021, revealed that telehealth services used were highest during the first two rounds, but the trend significantly decreased by May 2021 as many countries managed to get vaccines and control COVID by that time [4]. Some organizational reasons are patient privacy regulations (HIPAA rules), payment parities, billing problems, and medical license jurisdictions, There ar also problems with real-time access to patient data, and unstructured change management policies.

To integrate telehealth into general healthcare, aspects such as human-technology interaction, social factors, strategy development, needs assessment, readiness assessment, business case/plan development, change management, constant evaluation is needed [5]. For example, in the United States, the Medicare plan does not recognize a patient’s home as a reimbursable originating site of care [1]. Hence integration may require challenging adjustment by following systems engineering approaches to healthcare organizational design such as technical and human requirements, adjusting work processes, and streamlining various departments.

Given the need for telehealth, it is increasingly important to develop a strong evidence base of successful and innovative telehealth solutions by developing a robust framework for rigorous evaluation of the implication of emerging telehealth technologies and rapidly adapting best practices through global collaboration.

References:

1. Dinesen, B., Nonnecke, B., Lindeman, D., Toft, E., Kidholm, K., Jethwani, K., ... & Nesbitt, T. (2016). Personalized telehealth in the future: a global research agenda. Journal of medical Internet research, 18(3), e5257.
2. Bartolini E, McNeill N. The Network for Excellence in Health Innovation. 2012 Jun 13. Getting to value: eleven chronic disease technologies to watch   URL: http:/​/www.​nehi.net/​publications/​30-getting-to-value-eleven-chronic-disease-technologies-to-watch/​view [accessed 2021-11-12]
3. World Health Organization Regional Office for Europe. 2014 Jul 01. About health 2020   URL: http:/​/www.​euro.who.int/​en/​health-topics/​health-policy/​health-2020-the-european-policy-for-health-and-well-being/​about-health-2020 [accessed 2021-11-12]
4. Center for Disease Control and Prevention, Telemedicine Access and Use. 2021 Aug 6. National Center for Health Statistics. URL: https://www.cdc.gov/nchs/covid19/rands/telemedicine.htm [accessed 2021-11-12]
5. Mars, M., & Scott, R. E. (2017). Being spontaneous: The future of telehealth implementation? Telemedicine and e-Health, 23(9), 766-772.

Published: 11.21.2021

Measuring the Early Impact Of COVID-19 for Future Market and Policy Corrections in the United States

 Tory Cenaj, Publisher, TMT

The landmark COVID-19 Telehealth Impact Study published in TMT provides a view into the explosive implementation and scaled use of telehealth services during the first year (2020) of the COVID-19 pandemic. Now that most households in the United States are familiar with the term, the way patients chose to interface with health providers has marked a future forward change.

The ‘COVID-19 Telehealth Impact Study’, conducted by the COVID-19 Healthcare Coalition (1), is based on 2 billion US healthcare claims records (provided by Change Healthcare), as well as on surveys from physicians and patients on the current state of virtual care, along with recommendations for right sizing the cost of care. It is a first step in developing a sustainable and fair market plan, in which telehealth can flourish as the US health system evolves.

Topline results moving telehealth squarely into the 21st century for quality care delivery are given below:

• 75% of providers indicated that telehealth services enabled them to deliver quality care, and this rose to 90% when focused on chronic condition management;
• 84% of patients agreed that quality of their telehealth visit was good;
• 12 million telehealth claims in April 2020, accounting for 49.4% of total healthcare claims;
• The highest rated diagnostic classification claims volume were for behavioral health;
• The most frequent modalities were videoenabled (e.g. Zoom) and audio-only (telephone);
• 74% of patients indicated that they will use telehealth services in the future.

To place telehealth’s recent trajectory in full view, the study revealed:

• From January 2019 through January 2020, telehealth claims grew by approximately 44,000 per month. At that rate, it would have taken over 13 years to get to the 7 million monthly claims reported in Q4 2020!
• It would have taken more than 22 years to attain the 12 million claims reported in April 2020 alone - 1 month after declaring the public health emergency!

The challenges we still face in creating a fair, equitable, accessible, robust, and resilient market to leverage discovery, technology, entrepreneurism, and investment appropriately in the United States include credentialing, reimbursement, interoperability, and parity.

Regulators must clear these hurdles for efficient, trustworthy, safe, and effective market growth for multidisciplinary stakeholders and users. Roll backs that stifled progress in the past are resurfacing for pre-pandemic state licensing restrictions for telehealth. If it made practical sense during the height of the pandemic to increase patient access to care, why doesn't it make sense now?

If survey providers indicated uncertainty about reimbursement and if new risks of liability are barriers to continued use of telehealth services, why aren’t we permanently lifting barriers?

And what about cost?

Although there were several study limitations, such as outcomes data, querying patients who were (mostly) white females receiving telehealth services, and not including Medicare and Medicaid indemnity claims, the authors suggest research gaps, including studies for the financial impact of telehealth, be conducted by other organizations. Clearly, the recent adoption of telehealth speaks to its value when regulatory obstacles are cleared and all states operate in unison.

While the authors were delicate in presenting factual study results and recommendations throughout, the overall study provides a most perfect backdrop for the five ‘must haves’ posed for telehealth to be integrated into US healthcare system. They are as follows:

1. Develop a flexible payment system that supports telehealth services for phone (audio only) and video visits;
2. Ensure patient access to telehealth through better broadband access, distribution of technology, and insurance benefits allowing telehealth access regardless of geography (urban, suburban, and rural);
3. Determine what support and education are needed to drive digital literacy of patients and providers to maximize value from telehealth and other digital technologies;
4. Facilitate a regulatory and professional licensure environment that enables qualified healthcare professionals to deliver care across expanded geographies to serve the needs of patients;
5. Expand research studies focused on the optimal use of telehealth and asynchronous modalities (e.g. remote patient monitoring) to produce measurable, clinical, financial, and patient experience outcomes.

To read the research article in its entirety in Telehealth and Medicine Today, open access journal, click here.

Study authors are affiliated with the following organizations: MITRE Corporation, Mayo Clinic, Atrius Health, Massachusetts Health Quality Partners, Always Health Partners, Digital Medical Society, Change Healthcare, and Harvard Medical School. The COVID-19 Healthcare Coalition is a private sector-led response that brings together healthcare organizations, technology firms, nonprofits, academia, and startups to preserve the healthcare delivery system and help protect the US populations. To learn more, go to https://c19hcc.org

Reference

1. Halamka J, Schnitzer J. Together we can. COVID-19 healthcare coalition. The MITRE Corporation; 2021. Available from: https://c19hcc.org [cited 15 July 2021].

Published: 8.2.2021

Telehealth Strategic Imperatives for Meeting Lifelong Consumer Trust and Care

 Tory Cenaj, Publisher, TMT

The pandemic has exponentially accelerated the adoption of virtual care and heightened consumer expectation leading health systems to reimagine their role in the sector. Adopting virtual care has empowered health systems to move beyond siloed applications to a more comprehensive, whole-person approach that consumers need across their healthcare journey. 

This opens new strategic opportunities in the virtual care market for innovators, digital health stakeholders and health systems to play an integral role in the “consumer circle of trust”. Many consumers now expect a digital option where expectations have changed forever. To build a better healthcare system, consumer expectations for healthcare must be met where quality care can be delivered virtually too!

The market will be able to accommodate better care for the consumer at a better price point ensuring a better experience with appropriate regulation. As a result, health systems can take on risk and create new value systems. Teladoc, for example, has a vision beyond large payers and employers and includes hospitals and health systems, but how does ROI factor into the equation for urgent care, chronic care, and preventive care in value-based care?  

The opportunity that virtual care presents is the future of consumerism in healthcare includes big tech companies, retailers, health plans, and NewCos disintermediating care delivery. There is tremendous opportunity for a health system to maximize the trust they have earned and established locally in the community, especially if investing in virtual care – and it pays for itself.  Many health systems start with their own employees.  ROI has been reported as high as three times the investment in the first year of launching virtual programs for chronic condition management alone.

In a fee for value world, opportunities shift to obtaining data to understand where and how to fill gaps and affect behavior change. Risk is rewarded with data insights and the ability to affect behavior change to enable healthy habits, lifestyles and enjoyment of a healthier life overall. The prototype for success is to make adjustments through predictive analytics, in real time, to meet consumers where they are.

If there are not enough primary care doctors for in-person visits and the concept of whole person care appears to resonate with many, this can be the way more virtual engagement benefits both consumer and health systems. The challenge is transitioning from fragmented products to an integrated platform where simple personalized data driven experiences are realized. Health systems are integrating whole person and virtual care with physical care across the health continuum.

Although most data should be contained in an EMR, much occurs outside the EMR. The EMR is an important foundational component, but that could limit the consumer experience. We should look beyond the EMR to capture “whole person” data.

In addition, how do we find physicians – the right physicians for the right care? Can we eliminate traditional geographic boundaries that have restricted access to a specialist into an opportunity to accelerate access to care and improve quality with newly created “Clinical Centers of Excellence” and consults on cases in rural communities?

From a technology and staff perspective, if we expect 20% of care will be conducted online hereon, what are the strategic priorities and imperatives for business?  How will value based care arrangements focus on consumerism and growth strategies? How do you expand into other markets and do so without a brick and mortar footprint? It's time to reimagine how to address those priorities including profitability at government rates. How do you deliver care and democratize access to care underserved populations? What is the purpose built platform for interoperability, scalability and clinical workflows to enable a personalized consumer experience across the entire continuum of care? Opportunities have never been greater for providers and organizations to reinvent themselves because of what's possible with virtual models of care.

To glean more and listen to the new TMT “Unscripted” Podcast Series on “The Path Forward for Whole-Person Virtual Care,” featuring Bruce Brandes, Senior Vice President of Consumer Centered Virtual Care, Teladoc Health and Dr. Lyle Berkowitz, CEO of Back9 Healthcare Consulting and Editor-in-Chief of Telehealth and Medicine Today please visit https://telehealthandmedicinetoday.com/index.php/journal

Listen to Joe DeVivo, President, Hospital and Health Systems, Teladoc Health, ConV2X 2020 Keynote address entitles “Democratizing Healthcare: Accelerating Virtual Care Adoption to Transform Care Delivery,” at https://conv2xsymposium.com

Published: 4.26.2021

Next Steps for Chronic Illness Care After the Taskforce on Telehealth Policy (TTP) Report

Trisha Kaundinya, BS, MD/MPH candidate;¹ Rishi Agrawal, MD, MPH²      

Affiliations: ¹Northwestern Feinberg School of Medicine; ²Associate Professor of Pediatrics (Hospital-based Medicine), Northwestern Feinberg School of Medicine

Telehealth experienced rapid adoption during the Covid-19 pandemic. Hence, the National Committee for Quality Assurance (NCQA), the Alliance for Connected Care, and the American Telemedicine Association (ATA) created a task force on telehealth policy (TTP) to elucidate its role post-pandemic.  TTP identified no care overutilization and fewer no-shows to appointments in analyzing preliminary pandemic data, which were primary concerns regarding telehealth. Cost-related problems also caused resistance towards a telehealth transition, but TTP identified promising cost reduction mechanisms in telehealth through more transitional care management and lowered skilled nursing transfers.¹  These findings are encouraging, but to leverage them in our health system, we must address telehealth specifically in the chronic illness population.

The TTP report already addresses patients with chronic illnesses in some ways. For example, concerning data flow, TTP championed remote patient monitoring to improve patient autonomy and reduce strain on caregivers. They proposed a pilot virtual medical home and Fast Healthcare Interoperability Resource (FHIR) shared care plan, which benefits those with routine and regular follow-up requirements.

TTP also advocated to remove originating site requirements, permit audio-only telehealth when it has proven to be useful, and consider technological access as a barrier to telehealth use—challenges which are all pronounced in the chronic illness population.²

Investment in Chronic Illnesses

Many existing initiatives for telehealth administration and reimbursement support episodic care that accountable care organizations (ACOs) manage, but those with chronic illnesses are perhaps best positioned to benefit from all that a telehealth transition can offer. Currently, almost one-half of the population has at least one chronic illness, and nearly 60% of all emergency department (ED) visits are for people with at least one chronic condition.³ There is currently an apparent mismatch between the CDC’s budget for chronic illness prevention, around $4 per person per year, and our spending on those with one or more chronic illnesses, which is about $8,000 per person per year.⁴

This mismatch coupled with an increased incidence of chronic illnesses means more preventable deaths and increased disability-adjusted life years (DALYs). It also means high costs when care for chronic illnesses is improper: A study found that fragmented care for chronic illnesses increased average care management costs by almost $5,000 over three years.⁵ Racial, geographic, and socioeconomic disparities in access to care and care outcomes are also most pronounced in the chronic illness population. From all of these perspectives, telehealth has the potential to revolutionize chronic illness care.

Instead of acute episodes that mandate brief in-person evaluation, effective chronic illness management requires a longitudinally connected care team. Telehealth in the form of RPM has shown to be useful. RPM is associated with reduced hospital admissions, nursing home admissions, ED visits, and improved preventative care use.⁶  The epicenter of chronic illness is moving away from the clinic and into the home, so the intersection of telehealth and home health care is a keystone to successful adaptation. Home health is also associated with reduced patient mortality and hospitalizations.⁷ The care continuity sought after in health systems managing patients with chronic illness depends on continued prescription access and thus discussion of how this changes in a virtual setting are also warranted.⁸

Given the great potential of telehealth to affect chronic illness management, we have articulated some of our telehealth policy and administration recommendations that follow TTP in this patient group.

Recommendations

Remote Patient Monitoring

Remote patient monitoring (RPM) is one of the most critical telehealth modalities for patients with chronic illnesses, especially as they get older. Many prefer to maintain their independence without requiring caregivers in facilities.

Onboarding:

Earlier in the pandemic, an emergency rule expanded RPM use to new and established patients. This policy does not apply after the public health emergency ends according to the 2021 Physician Fee Schedule released by CMS. The rule needs to extend permanently post-pandemic.

Longitudinal care is one of the most significant challenges for patients with chronic illnesses, especially in rural areas with higher clinician turnover rates and lower numbers of providers. These patients would not be able to engage in telehealth and RPM in their onboarding to new providers without an in-person history and physical. The upfront convenience benefit of telehealth is lost when patients have to travel far and wait for care, and thus these patients are less likely to attend to their chronic illnesses. Patients with more complex chronic illnesses often cannot travel to establish a point of care with physicians in person and thus lose care connectivity from earlier clinicians.

Device Limitations:

The 2021 Fee Schedule mandates that in a 30-day time frame, providers can only bill once under CPT codes 99453 and 99454 for RPM independent of the number of devices patients use. Minimizing overuse of billing may be a driving incentive for this policy, but it disproportionately affects patients with multiple chronic illnesses who require many devices for their RPM. Even for patients with only one chronic illness, providers may need data from the patient’s pressure cuff, pulse oximeter, and glucose monitor, among other devices. Patients cannot be effectively managed by providers if only billed for RPM once a month. Inappropriate management of patients with multiple chronic illnesses has dire outcome and cost implications, so this requirement needs a revision that accounts for complex technology needs.⁹

Home Healthcare

The convenience afforded by telehealth goes hand-in-hand with the setting of home healthcare, which allows patients to sustain functionality and control over their activities of daily living. Home health has been associated with improved outcomes for patients with chronic illnesses long-term.⁷

CMS Reimbursement:

Throughout the Covid-19 pandemic, CMS has generated several telehealth coverage waivers for providers, but reimbursement for home health continues to trail behind. Home health aides (HHA) can legally provide telehealth services. However, these visits cannot replace in-person visits (they do not count towards the low-utilization payment adjustment (LUPA) threshold) and do not receive reimbursement as a virtual visit. HHA providers could engage in multiple mediums of telehealth to meet patient care needs, but they would still need to meet the patient in-person to bill codes covered by Medicare and meet CMS mandates. The incentive for providers to continue to provide telehealth would decrease if it is not covered. They would also be increasing Covid-19 transmission risk to an often immunocompromised population while meeting in-person expectations.

Improving coverage of telehealth for HHA has important uptake implications. One population whose engagement in telehealth long-term is limited is senior citizens, who comprise most patients for HHA. The current payment scheme disincentivizes telehealth use by HHA, when they could facilitate onboarding in a sizeable chronic illness population. Some states are relaxing rules around Medicaid coverage for HHA provision of telehealth. Thus a nationwide coverage expansion should be available for all states to opt into permanently post-pandemic.

Virtual Prescriptions

Medication adherence is a challenge for patients with chronic illnesses, especially patients with several chronic illnesses and complex care regimens. Increased adherence in this population is associated with decreased hospitalizations and ER utilization. Telehealth has a critical role in this relationship, as it can lower the additional burden of long travel and waiting times included in adherence regimens.

Opioid Use Disorders(OUD):

The 2021 Physician Fee Schedule states that through Section 3 of the SUPORT Act, effective January 1^st of 2021, prescription of Schedule II-V controlled substances under Medicare Part D can be done electronically. Still, they are soliciting commentary regarding any exceptions. Recent studies have reported that Medications for Addiction Treatment (MAT) programs for those with OUD which involved telehealth had better outcomes than their in-person counterparts and that telehealth was a primary reason that patients stayed on MAT.¹⁰

When it is clear that telehealth utilization in counseling as well as the e-prescribing process improves outcomes for those with OUD, there should be permanent lifts on controlled substance prescribing restrictions. The variability in states’ decisions to modify controlled substance prescribing laws that mandate in-person office evaluation should also be mitigated by CMS to federally and permanently enable telehealth in e-prescribing MAT even after the pandemic.

The only major exception should be to physicians who work in emergent settings, which would delay or decrease the chance of the patient’s prescription filling. Emergencies for patients with OUD are often outside of typical pharmacy hours, so e-prescriptions are not successful and require the patient to return and a new prescriber would have to engage in care. The existing prescript would have to be canceled as well. Patients with opioid use disorders on MAT are at high risk of relapses when there are delays in their access to medications. In acute emergency settings, they must acquire their medication in a timely fashion and thus in-person issuing of prescriptions could be more efficient.¹¹

Conclusion

Overall, the TTP emphasizes integration instead of devising a new telehealth infrastructure in many of their recommendations related to patient safety, quality measurement, and data flow. There is also promising preliminary telehealth data from the pandemic, but the gateway to sustainable change is effective management of the multidimensional chronic illness population in America. This population contains some of the oldest, most socioeconomically disadvantaged, least technologically involved, and most vulnerable individuals in our health system.

With the involvement of CMS, the potential benefits of a more connected healthcare system, improved patient outcomes, and lower acute episode costs can be amplified. CMS should modify RPM fee rules for patients with chronic illnesses, expand their reimbursement criteria for telehealth by home health, and enable open-ended e-prescribing requirements for MAT except for acute care settings.

References

1. Taskforce on Telehealth Policy (TTP) Findings and Recommendations. NCQA; 2020.
2. Nouri S, Khoong, E.C., Lyles, C.R., Karliner, L. Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic. New England Journal of Medicine. 2020.
3. Kent J. Chronic Conditions Account for $8.3B in Avoidable ED Visits. Health IT Analytics 2019.
4. Auerbach J. Prevention efforts can ward off many chronic and expensive conditions. So why aren’t we investing in them? Stat News 2017.
5. Frandsen BR, Joynt, K.E., Rebitzer, J.B. Care Fragmentation, Quality, and Cost in Chronically Ill Patients. American Journal of managed care. 2015; 21(5).
6. Remote Patient Management: Technology-Enabled Innovation And Evolving Business Models For Chronic Disease Care. Health Affairs. 2009;28(1):126-135.
7. In-home care for optimizing chronic disease management in the community: an evidence-based analysis. Ont Health Technol Assess Ser. 2013;13(5):1-65.
8. Beadles CA, Voils CI, Crowley MJ, Farley JF, Maciejewski ML. Continuity of medication management and continuity of care: Conceptual and operational considerations. SAGE Open Med. 2014;2:2050312114559261.
9. Sambamoorthi U, Tan X, Deb A. Multiple chronic conditions and healthcare costs among adults. Expert Rev Pharmacoecon Outcomes Res. 2015;15(5):823-832.
10. Khanna G, Chang, C. New Research Shows Promise of Telehealth in Treating Opioid Use Disorder. In. AHRQ 2020.
11. Mehmet Sofuoglu, M.D. , Ph.D., Elise E. DeVito, Ph.D., Kathleen M. Carroll, Ph.D. Pharmacological and Behavioral Treatment of Opioid Use Disorder. Psychiatric Research and Clinical Practice. 2019;1(1):4-15.

Published 3.9.2021

Under Recognition of the Potential Role of Telemedicine to Speed Data Dissemination and Communication in Veterinary Medicine in the Netherlands

Jack Gommers, Dongen, The Netherlands, jcjgommers@gmail.com

Telemedicine can enhance information exchange in veterinary care. It provides triage, and, of particular importance for this post, timely follow-up regarding results of laboratory testing of livestock. Through the use of a case history, the focus here is on the author’s frustration with the current lack of remote communication and the potential role of telemedicine to speed sharing of essential information regarding risks to human and animal health.

In practice, a farmer maintains dialogue with the veterinarian who visits at least weekly. If an unknown disease strikes and analysis and diagnosis remain unclear, samples, often from dead animals, are sent to the laboratory for additional testing. In the Netherlands, this is conducted by the Animal Health Service, which sometimes forwards samples to accredited laboratories for further analysis. Based on test results, prescriptions are issued for collective treatment of the livestock or individual animals via oral or injected antibiotics.

If, as was experienced here, there is an unexpected lockdown by a governmental agency on suspicion of feed contamination, it is essential to know the diagnosis that made this action necessary. It must be remembered that family and children are at risk of unintentional contact with contamination. For rapid decision-making and to ensure public health, this is where telemedicine can be used for timely sharing of data.

In spite of the lockdown of my farm, gaining access to essential data was denied, for unclarified reasons. The Dutch government simply refused to forward laboratory results from tests carried out on my own animals. After asking the European Commission for guidance, they indicated that as a livestock farmer, I was certainly entitled to the test results of my farm. Yet, my government continued to refuse!

Despite zero tolerance required in European directives, the Dutch government tolerates finite concentrations of hormonal contaminants and pharmaceuticals in Dutch food, exported or not. According to the World Health Organization, chemical contamination might lead to acute poisoning or long-term diseases, such as cancer. Foodborne diseases might lead to long-lasting disability and even death.¹

Another problem is mutation of bacterial and viral pathogens, e.g., coronaviruses.²

Coronaviruses are a large family of viruses that mutate easily. It is known for decades that they can be present in pigs, chickens, and minks in areas of intensive livestock farming. SARS-CoV-2 is the most recent virus variant of the Corona type, with dozens of mink farms infected. Millions of these animals have been killed already, to eradicate this source of infection (also in Denmark, by the way). Furthermore, SARS-CoV-2 is reported to a limited extent in pigs, chickens, dogs, and cats.

Another well-known zoonosis is the Q fever that flared in the province of North Brabant (in the south of the Netherlands) in 2007. It resulted in dozens of deaths and hundreds of people chronically ill for life. Q fever is a bacterial infectious disease that is mainly transmitted to humans by goats. Hundreds of thousands of goats were killed in the Netherlands because of this outbreak.

Officials of the European Commission pointed out to the Netherlands that all described risks to human health are unacceptable. In a parliamentary debate on this subject, with the responsible Ministers of Agriculture and Public Health, it was concluded that the Netherlands is indeed not following European guidelines 96/22 and 96/23 /EG for public health.

It is not my purpose to debate unacceptable policies at a political level here. As a farmer “in the field” my focus is on the health of my animals and the health of my family and others, by minimizing contamination risks. To this end, recognition of telemedicine is of utmost importance, as a valuable tool to facilitate the instantaneous provision of critical information and achieve the objectives advocated by the European Commission.

References

1. Food Safety. 2020. Available at URL: https://www.who.int/news-room/fact-sheets/detail/food-safety
2. Knobler S, Mahmoud A, Lemon S, et al., editors. Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. Washington (DC):National Academies Press (US); 2004. Available at URL: https://www.ncbi.nlm.nih.gov/books/NBK92442/

Published 1.29.21

TMT "Best of" Gold Open Access Articles

Posted 1.20.2021

Transforming Health Care in the Wake of a Global Pandemic

Tory Cenaj, Publisher, Telehealth and Medicine Today

Some of the world’s top leaders and influencers in healthcare delivery transformation and health technologies, including blockchain in health tech and telehealth, converged at the 4th Annual ConVerge2Xcelerate (#CONV2X) 2020 Symposium held virtually from November 10th-12th, to exchange perspectives and solutions to shortfalls in global patient care exposed by COVID-19. The theme of this year’s symposium TMT hosted was “US-World Health Transformation.”

Impact of COVID-19 on health care

The global COVID-19 pandemic showed how vulnerable healthcare delivery is to patients around the world. Healthcare systems in every country have been challenged – not only in treating patients with coronavirus, but in trying to maintain optimal care for non-COVID patients at the same time.

As a result, new advances in digital health technologies, including telehealth, blockchain, AI and others, are transforming patient treatment models on an international scale. What this event proved is that healthcare transformation, via technology and new global models for greater access and more efficient and effective delivery of healthcare services to patients, is much closer to reality than ever before.

Many of the sessions over the two-day event focused on two main topics: healthcare interoperability, digital health, adoption, scale and equity.

Healthcare interoperability

On Day 1 of the event, this topic was highlighted by speakers from the UK, India, North America and the European Union. Interoperability is the ability of different healthcare systems and processes to communicate and share information with other healthcare systems and processes, either within or across organizational borders, in order to advance the effective delivery of healthcare. The consensus was that patients will enable interoperability through trust – a pivotal facet of adoption and scale.

Technology players will have to continue to grow in partnership with healthcare systems, which will be required for both the systems and for consumers.

Digital health

According to Keynote speaker, Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, “Digital health is a new reality that will bridge disparity and access to those with lower income and the underserved.” Other Keynotes from Teladoc Health and Mayo Clinic Digital Platform emphasized transforming health care with digital health and virtual care delivery systems, which would make care affordable and equitable, decrease disparities among income levels and geographies, and create global standards and regulations for citizens and health systems around the world.

But digital health is a broad term, one that encompasses several technologies, including telehealth, virtual care, and digital tools and services, and requiring integrations that make health care delivery broader, easier and more flexible.

A Keynote session titled, “Virtual Health: The Next Frontier for Healthcare,” with Alex Harris, Partner, McKinsey & Company and moderated by Lyle Berkowitz, MD, FACP, FHIMSS, CEO of Back9 Healthcare Consulting discussed he radical digitization of health care with supply and demand factored in. Healthcare has lagged behind other industries in terms of digitization. But on the consumer (patient) side, mindset and behavior changes have moved the needle on telemedicine visits, and it is projected that 60% of those over age 65 will avail themselves of this technology in the near future.

Physicians question the effectiveness of telehealth visits and financial compensation, and they wonder about adoption and when it will stabilize. Telehealth visits were high in April, but decreased, perhaps due to restrictions in movement as things shut down.

The challenges to adoption that still exist include funding and parity for certain services and long-term reimbursement. Fee-for-service vs. value-based is still unclear. So while providers are still wondering about financial implications, consumers are starting to feel more comfortable.

It is clear that this past year has presented both many challenges to healthcare delivery and opportunities for innovations. The manner in which health care is delivered is occurring at a time when traditional physical interaction between patient and provider has basically been a “cease and desist order” for the safety of both parties.

To learn more and get access to the agenda and program, visit https://conv2x-2020-ondemand.eventcreate.com/

For a top line introduction and select presentations visit TMT at https://telehealthandmedicinetoday.com/index.php/journal/ConV2X2020

Posted 11.20.2020

Building Telemedicine into the Post-COVID-19 U.S. Health Care Delivery System

Stephanie J. Zawada, M.S.

Affiliations: Mayo Clinic School of Medicine and Science, Yale University Sherwin B. Nuland Institute, American Medical Students Association

During the COVID-19 public health emergency, interest in telehealth soared to an all-time high. Specifically, telemedicine, the delivery of clinical health care services to remote patients using telecommunications tools, is seen as the most promising mode of health care delivery in the near future, with investor capital flowing into telemedicine platforms.

Regulatory waivers provided by the Centers for Medicare & Medicaid Services (CMS), executive orders issued by state governors, and mandatory social distancing measures fueled the widespread use of telemedicine during the pandemic. Healthcare stakeholders should keep the following telemedicine issues in mind as we prepare for the 2020-21 flu season:

• Defining the services offered. The distinction between telemedicine and telehealth is critical. The Oxford dictionary defines telemedicine as “[t]he remote diagnosis and treatment of patients by means of telecommunications technology”; telehealth as “[t]he provision of healthcare remotely by means of telecommunications technology”. Telemedicine is the offering of established health care services, appropriate in scope and frequency, to remote patients - this can include remote monitoring. Telehealth describes “the wider range of ancillary health-related services and less-than-comprehensive virtual health options”.

Today, the methodological frameworks for the clinical validation of digital health technologies are still being developed. Separately defining telemedicine and telehealth services is critical to ensuring patient safety and promoting innovation. If telehealth is regulated like telemedicine, innovation will be limited. (Think about the potential of requiring artificial intelligence to pass licensure exams to deliver care.) If telemedicine is regulated like telehealth, patient safety could be compromised. (Think about online surveys where you can fill out questions to get a lifestyle drug without a doctor’s prescription. A heart attack patient in the ER who does not have this prescription in his EHR might then be prescribed drugs that lead to harmful drug interactions.)

• Using consistent documentation. Providers should select a documentation process for telemedicine services and consistently adhere to it. One example of such an approach is in Massachusetts, where providers “include a notation in the medical record that indicates that the service was provided via telehealth [and] the technology used”. Not only will consistent documentation practices streamline the reimbursement process, but they also provide a baseline for data generated by telemedicine for research purposes.
• Tracking drugs prescribed. The Drug Supply Chain Security Act (DSCSA) calls for an “electronic, interoperable system to identify and trace certain prescription drugs as they are distributed in the United States...to enhance FDA’s ability to help protect consumers from exposure to drugs that may be counterfeit, stolen, contaminated, or otherwise harmful”. Spurred by telehealth deregulation during the pandemic, new supply chain models for pharmaceutical compounds have emerged, such as the remote prescribing across state lines with same-day delivery. With the expansion of telemedicine, an interoperable drug tracking system, particularly for opioid prescription tracking in state prescription drug monitoring programs (PDMPs), is needed. Blockchain, a peer-to-peer (PRP) public ledger software maintained across a distributed network of computers, is one application that demonstrates potential in addressing this need.
• Reforming policies restricting patient access. State and federal policymakers should eliminate patient location requirements, freeing patients to access telemedicine care from home. CMS’s temporary waiver allowing Medicare patients to access telemedicine care at home for the duration of the pandemic should be made permanent. In addition to removing location-based restrictions for patients seeking telemedicine care, states should follow the American Medical Association’s guideline for removing pre-existing patient-physician relationship requirements by defining the formation of said relationship when “a physician affirmatively acts in a patient’s case by examining, diagnosing, treating, or agreeing to do so”, whether in person or online.

 States should address licensure reform that allows out-of-state physicians to practice telemedicine with in-state residents. Many states temporarily implemented this approach for the duration of the pandemic. This would allow patients in rural areas with a physician shortage to access doctors in near-by states and enable patients in states without a world-renowned medical center to access telemedicine care rendered by top-ranked specialists.

• Addressing reimbursement policies. At the start of the pandemic, many states and the federal government established temporary reimbursement parity for clinical health services delivered via telemedicine [9] [11]. Reimbursement parity for health care services levels the playing field for telemedicine as an alternative mode of health care delivery. For health care services established to be safe, appropriate in scope and frequency, and equally as effective as in-person visits, telemedicine reimbursement parity is vital to allowing physicians to offer more patient-centered care, enabling patients to choose either an in-person or telemedicine visit. Otherwise, providers will need to encourage patients to schedule in-person visits to meet revenue targets, even if a telemedicine visit would be more appropriate.

Additionally, as rural hospitals face ever-increasing financial challenges, telemedicine reimbursement parity offers them an opportunity to restructure their services. Mercy Virtual Hospital is a blueprint for adapting the delivery of health care services to meet the needs of the digital age.

• Preparing for tax reporting. The Internal Revenue Service (IRS) has yet to update its definition of “patient”, which currently does not consider services rendered by providers at non-profit hospitals to remote patients as medical expenses. For these patients who are not admitted to the non-profit hospital, telemedicine payments may be classified as unrelated business income (UBI). When providers render telemedicine services to patients across state lines, other UBI-related rules could apply. To address these issues, the IRS definition of patient should be updated to include telemedicine-only patients and state departments of revenue should issue guidance on telemedicine-relevant UBI rules.

Business expensing for telemedicine is possible. For instance, technology investments for telemedicine practice, such as “software, hardware, or hosting fees”, may be deductible. Even 3D-printed medical devices may qualify for R&D tax credits. For telemedicine doctors using a home office, the “space and the equipment that [they] use to work from home are all part of [their] tax deduction…[as well as] part of [their] home’s utility costs, internet costs, and even mortgage” [16].

  Posted 7.31.2020

Telemedicine use amid COVID-19 outbreak: A global perspective

Affiliations: Md Azharuddin¹, PhD, Mohammad Adil², PhD, Prem Kapur³, MD, Pinaki Ghosh⁴, PhD, Manju Sharma², PhD

¹Department of Pharmaceutical Medicine, Division of Pharmacology, School of
Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
²Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia
Hamdard, New Delhi, India
³Department of Medicine, Hamdard Institute of Medical Sciences and Research, Jamia
Hamdard, New Delhi, India
⁴Department of Pharmacology, Poona College of Pharmacy, Bharati Vidyapeeth, Pune, India

Contact: msharma@jamiahamdard.ac.in

In December 2019, several unidentified pneumonia cases were reported in Wuhan, China, caused by β-coronavirus, a novel strain of coronavirus (2019-nCoV). On 11 February 2020, WHO officially announced “COVID-19” as the name of this new disease.¹ It is steadily rising by human-to-human transmission and has confirmed 26,31839 cases worldwide, till April 24, 2020.² The WHO declared the outbreak a global public health emergency on January 30, 2020.² COVID-19 pandemic has put most of the countries under public health as well as economic strain.³ Several measures have taken by different countries to cope with COVID-19 outbreak. Now the global health crisis continues to escalate, telemedicine critically stepped into the spotlight in health care system to slowing the COVID-19 outbreak.

Telemedicine is the use of electronic information and telecommunications technologies including, videoconferencing, internet, store-and-forward imaging, streaming media, telephone calls and wireless communications.  It promotes and improve the vast distances patient and clinical health care by the means of interactions between patients and clinicians or between two or more consulting practitioners.⁴ Additionally, interactions of telemedicine have a different role in patient care. Synchronous interaction, where patients and consulting practitioners interacted in real-time. It is a two-way communication using audio-visual technology (e.g., video call). It may use to diagnose a disease, and provide treatment. Asynchronous telemedicine not providing the direct patient care, the shared information can be reviewed and answered in a delay of time between patients and consulting practitioners (e.g., e-mail).⁴ It may use to provide a patient care and healthcare opinion.

As the COVID-19 contributing higher fatalities among immunocompromised people like chronic diseases and comorbidities, it can be used to avoid virus exposure by the means of reducing hospital visits.⁵ In addition to, it can reduce the risk of COVID-19 transmission among health care professionals those working tirelessly in the frontlines by keeping all the significant infected patients out of hospital. ⁵ Televisiting and teleconsultation can be used to triage more patients, screen and diagnose remotely.⁵  

According to Infectious Diseases Society of America (IDSA), it also supports cost effective care by keeping patients to unlikely visit to emergency department and face to face consultations.⁶

In recent, due to wreaks havoc of COVID-19 virus, the Centers for Disease Control and Prevention (CDC) a Federal agency urging the public and healthcare professional to use telehealth programs for communication in an effort to reduce the burden of unnecessary emergency rooms and clinics visits.

The World Health Organization (WHO), CDC, as well as several state public health agencies have suggested that telemedicine service must considered as an essential part of healthcare provider in “strengthening the Health Systems Response to COVID-19” policy. In addition, according to a new WHO policy, within the adequate service delivery action, it should be considered as one of the alternative models for clinical services and clinical decision support.

A survey carried out among U.S. patients have shown that 84% are more likely to choose those providers who offers telemedicine. In Israel, a TytoCare’s telehealth solution has launched a TytoHome^TM kit to examine COVID-19 patients in quarantine wards, as well as to monitor patients in isolation stays and home quarantine.⁵

TytoCare’s partners is all set to emerged the solution and expanded their use in the US and Europe.  In recent March 25, 2020, the American Medical Association (AMA) launches telemedicine during COVID-19 outbreak, where physicians and experts can discuss the several issues and share the experiences over the ongoing pandemics. Also, the Government agencies are associated with industry leaders in virtual care. Ro is a patient-driven virtual telehealth company launched a digital health clinic, now it became a part of the White House’s Tech Task Force for coronavirus, aims to be the patient's first call for all of their healthcare needs.⁷

On March 25, 2020, the Indian Ministry of Health and Family Welfare (MoHFW) with NITI Aayog and Board of Governors (BoG) Medical Council of India (MCI) launched the official guidelines for telemedicine practices to prevent transmission of virus.⁸ Advised all the registered medical practitioners and doctors to provide and support healthcare services remotely via phone or online communication consultation where citizen go on nationwide lockdown for 21 days. Under this consideration, doctors can write prescriptions based on receiving telephonic, textual or video conversations-chat, images, messaging, emails, fax and others.⁸

This is a crucial step for digital health, and the decision has been lauded by current digital healthcare solutions, who believed that this is the need of the hour especially when the world is facing unprecedented challenges with the coronavirus pandemic.

Furthermore, there are several online health services such as Practo, 1mg, Medlife, mFine, significantly stepped in online    consultations during the COVID-19 pandemics, where 1mg claimed a 300% rise in e-consultations for flu and fever-related illnesses since the beginning of March 2020. The telecommunication received from across the country, nearly 600 cities and towns. In addition, Practo, an online doctor-consultation service reported that, it sharply increases in telemedicine calls after a week since the first confirmed case of COVID-19 in India.⁹ Additionally, the USA, Israel, UK, Nordics and France are amongst the leading countries with established telehealth providers, and their cumulative experience is helping to respond to the current situation.¹⁰

This study briefly addressed the global perspectives towards use of telemedicine, in order to deliver and ensure the patient health and safety of health care professionals. Therefore, all countries are suggested to use telemedicine during this pandemic and set up an infrastructure for the next inevitable, infectious disease, if emerge.

Acknowledgement

Sun Pharmaceuticals, India, for providing assistantship for this project under the joint collaboration for the Ph.D. programme with Jamia Hamdard, New Delhi, India.

References:

1. World Health Organization website. Novel Coronavirus (2019-nCoV) Situation Report-1 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200121-sitrep-1-2019-ncov.pdf. Accessed April 12, 2020.
2. World Health Organization website. Coronavirus disease (COVID-19) Pandemic. https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Accessed April 25, 2020
3. McKibbin WJ, Fernando R. The global macroeconomic impacts of COVID-19: Seven scenarios. SSRN Elec J. 2020.
4. American Telemedicine Association. Telemedicine glossary. Available at: https://thesource.americantelemed.org/resources/telemedicine-glossary. Accessed April 12, 2020.
5. Telemedicine during COVID-19: Benefits, limitations, burdens, adaptation. HealthcareITNews. Bill Siwicki. March 19, 2020. https://www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitations-burdens-adaptation. Accessed April 12, 2020.
6. Young JD, Abdel-Massih R, Herchline T, McCurdy L, Moyer KJ, Scott JD, Wood BR, Siddiqui J. Infectious Diseases Society of America position statement on telehealth and telemedicine as applied to the practice of infectious diseases. Clinical Infectious Diseases. 2019 Apr 24;68(9):1437-43.
7. Apple releases COVID-19 screening tool, resource guide. Mobihealthnews. Laura Lovett. March 27, 2020. https://www.mobihealthnews.com/news/apple-releases-covid-19-screening-tool-resource-guide. Accessed April 12, 2020.
8. Telemedicine Practice Guidelines. Board of Governors in supersession of the Medical Council of India. https://www.mohfw.gov.in/pdf/Telemedicine.pdf. Accessed April 12, 2020.
9. Telemedicine takes spotlight in season of flu. The Economic Times; Healthcare. Alnoor Peermohamed. Mar 16, 2020. https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/telemedicine-takes-spotlight-in-season-of-flu/articleshow/74642448.cms?from=mdr. Accessed April 12, 2020.
10. Telehealth in the time of COVID-19. Mobihealthnews. Marianna Imenokhoeva. March 31, 2020. https://www.mobihealthnews.com/news/europe/telehealth-time-covid-19. Accessed April 12, 2020.

 Posted 5.19.2020

Why Veterinary TeleHealth is Critical to Keeping Our Pets (And Ourselves) Healthy During - And After - the COVID-19 Crisis

Hannah Cheng Lau, DVM 

I have been very lucky to work almost exclusively in the field of veterinary telemedicine for over a year. I see patients over video and phone consults for a myriad of issues that can be managed at home. Planning, implementing, and troubleshooting a well-rounded telemedicine program in our large 30-veterinarian hospital has been exciting, new, and intimidating for everyone involved. A year ago we had no idea how extensively the program would be put to the test with the public health crisis that is COVID-19. Telehealth has a whole new purpose in this new reality. We have realized that while trying to ride the wave of current events, many of our colleagues are just dusting off their surfboards - or even more concerning, are still sitting on the beach.

I believe strongly that telehealth is an essential organ in the veterinary beast - and it has been for years. Telehealth has always been a part of any veterinary business, and it happens every day in every practice around the world. Like any untrained muscle, it can be challenging and uncomfortable to intentionally strengthen it - but it ​has ​ always been there. When I speak to my colleagues about telehealth, the first thing I remind them of is that they are already doing it. Granted, a big portion of this is done by paraprofessional staff: mainly client service representatives, veterinary nurses, and assistants. Teletriage and teleadvice is being regularly performed over the phone, either when the client first contacts the clinic, or as veterinary nurse consults. Continuing care is also done daily on the phone, through email, or with voicemail tag. All of these communications, when done well, take hours of employee time and require years of professional and on-the-job training. Although the medium of multiple phone calls and voicemails feels familiar and therefore comforting, they are inefficient to document, confusing for a third party to interpret, and difficult to monetize.

With the continuing effects of COVID-19 stretching out with unknown horizons into the future, likely resulting in a society that is forever changed, it is naive and perhaps negligent to assume life will return to “normal” and telemedicine will become a dying fad. COVID-19 has underlined the importance of telemedicine to the general populace by helping clients and providers socially distance and reduce unnecessary travel. However, this has always been and will continue to be a concern for many of our clients even without a worldwide health crisis. COVID-19 has opened all of our eyes to the dangers and anxieties of navigating the world as someone who is immunocompromised. However, those concerns will continue to exist for our community members who are battling illness, differently abled, do not have acces