The Pulse

Barriers to Telemedicine Faced in the US in 2021

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Telemedicine is a healthcare segment that involves the use of telecommunications to diagnose and treat patients without the need for an in-person visit. With telemedicine, doctors can deliver their specialist expertise to people that are unable to access such services.

The earliest instance of the use of telemedicine has been traced to the late 1950s and the initial period of 1960s. The credit for the use of telemedicine during this period goes to Norfolk State Hospital and Nebraska Psychiatric Institute, which relied on a closed-circuit television link. This link helped the hospitals to connect with each other for psychiatric consultations.

Geographical constraints and technical limitations have been primary reasons for the absence of rapid adoption of telemedicine. But advancements in technology and rapid adoption of such technology are opening up new and hitherto unseen opportunities for telemedicine.

Wide penetration of internet, and explosive use of smartphones with video capabilities, are shifting the focus to telemedicine. The inherent power of the medium in delivering quality medical services is being widely recognized.

With telemedicine, it is possible to take clinical capabilities directly to the patient. Patients requiring general or specialty care can access telemedicine from their homes, assisted living residence, or even workplaces. The remote delivery capability is the allure and the power of telemedicine that continues to be explored for high-quality patient care.

The Current State of Telemedicine

Use of telemedicine has increased, and has in fact become a standard, since the pandemic COVID-19 in 2019. Though originally developed to deliver basic clinical services to patients in rural areas and those in the underserved category, use of telemedicine has now spread across patient categories.

Telemedicine employs both audio and video technology to provide specialty and primary care. This inherent technology makes it possible for doctors to deliver quality patient care from across geographies.

More importance is being attributed to ensuring efficient patient care, maximum patient satisfaction, and reduced service costs. As these factors are being realized in implementation, there has been an increase in the adoption of telemedicine.

But, given the benefits of telemedicine, a widespread adoption though desirable, has not yet been achieved. Legal, regulatory and reimbursement, among others, are seen as major barriers facing telemedicine implementation.

Barriers to Telemedicine Explained

Easy access and cost efficiency of services have been a major reason for the infusion of telemedicine into 50% of U.S. hospitals. Nearly 1 million people in the United States of America are already using telemedicine due to the reasons mentioned above.

It is estimated that telemedicine will grow by 16.8% over the period 2017 to 2023. Despite these positive statistics, telemedicine is far away from a widespread implementation due to the following challenges:

Less than Significant Insurance Reimbursement

A major obstacle faced by physicians and healthcare providers offering telemedicine services is the lack of a streamlined reimbursement process. There is no guarantee that physicians offering telemedicine services will be suitably reimbursed for the services rendered.

The Medicare federal insurance program, for example, offers reimbursement but with heavy restrictions. The program does not follow a fee-for-service reimbursement methodology. In addition, reimbursement advantages are exclusive to specific CPT (Current Procedural Terminology) codes.

Also, Medicare reimbursement coverage mostly applies to nonmetropolitan areas and to specific institutions.

Medicaid and commercial insurance programs too do not offer significant reimbursement for telemedicine. Medicaid programs are controlled by the state and therefore state laws for telemedicine apply to these programs. These laws vary from state to state. Reimbursement coverage for telemedicine services such as live video transmission, remote patient monitoring and prerecorded video sharing, depend on state laws.

In case of reimbursement coverage by private insurance firms, not all companies offer such coverage.

Absence of a Multi-State License

Telemedicine providers such as physicians and nurse practitioners (NPs) are capable of offering their services to patients across geographies. It is also possible for telemedicine service providers to share their expertise with healthcare providers beyond boundaries. But, the necessity for a state-specific license is a major challenge that telemedicine service providers face.

Each state has its own laws and regulations that medical service providers are required to comply with, to practice their profession. Physicians and other medical practitioners must have a license from the respective state and fulfil obligations to continue to hold the license. Some conditions for license acquisition include attainment of specific medical education and completion of financial obligations.

This challenge has been addressed by the licensure portability model introduced by the FSMB (state medical board federation). But license portability is available only for physicians and physician assistants. These medical care providers can offer telemedicine services beyond their state.

But the Interstate Medical Licensure Compact (license portability) does not apply to NPs. This is because NPs obtain their license from respective state boards that cover nursing and not medicine.

Some states may have temporarily modified existing laws to deliver timely medical care during the pandemic.

Lack of a Concrete Basis for Medical Liability

Telemedicine is not immune to the risk of medical malpractice. There are several liability issues including telemedicine protocols, informed consent, and need for supervision in cases involving non-physician care providers. Another major issue is the coverage for telemedicine under professional liability insurance.

Telemedicine implementation suffers from the lack of a streamlined process for ensuring medical liability. Medical liability standards that apply to conventional in-person care-giving methods cannot be directly applied to telemedicine.

An absence of a standard for appropriate care in telemedicine is the reason behind the lack of a streamlined medical liability approach. Coverage must include factors exclusive to telemedicine such as equipment failures, technology disruptions, privacy violations, and out-of-state services.

Concerns about Patient Confidentiality

Patient-provider telemedicine consultations pose a greater risk for patient security than a standard in-person visit to the physician does. Platforms designed for telemedicine need to comply with existing regulations (the HIPPA law) to ensure privacy. Most platforms are encrypted to meet these regulations. However; providers and patients are not ignorant of the fact that no platform is 100% secure from hacker attacks.

It is important for both the patient and the medical service provider to trust the security of the telemedicine platform they are using. Both the parties need to be knowledgeable of the Federal and state laws governing telemedicine to be more confident when using the platform.

Provider Ignorance of Criteria Concerning Patient-Provider Relationship

States define certain criteria before a provider can prescribe medicines for a patient. Such criteria may include a face-to-face meeting between the provider and the patient, or a physical examination. An understanding of such state-specific criteria is crucial before delivery of service using a telemedicine channel. For example, states such as Maryland and Virginia permit remote physical evaluations using telemedicine channel.

Meeting these criteria is crucial to comply with respective state regulations and deliver a well-informed and efficient medical service.

Lack of Technical Knowledge and Patient Education

Technology literacy among patients is key to the success of a telemedicine service. Patients, particularly elderly patients, may show a reluctance to use technology to access medical care. Some common challenges faced by patients include difficulty in handling devices, attending video conferencing sessions, and accessing telemedicine appointments virtually.

Elderly patients willing to the use telemedicine may find navigating around the virtual system difficult. Patients may struggle with aspects such as downloading essential software to get the telemedicine sessions up and running.

Research shows that even technically-literate patients faced technical difficulties such as choosing the best browser for the telemedicine platform. They also found ensuring uninterrupted connection with the virtual system difficult.

Such technical barriers can prevent patients from making the best use of telemedicine. For example, a patient that is unable to download a videoconferencing software is forced to forgo a virtual appointment. In such cases, the provider is compelled to offer medical services via telephone, which may not be efficient.

Research shows that use of video during a consultation improves patient satisfaction and care quality. Lack of technical pre-preparation can prevent patients from receiving the full advantage of telemedicine.

Lack of trust regarding the safety of technology systems is another barrier preventing patients from taking advantage of telemedicine. A patient, for example, may be wary of hacking, which may propel him/ her to forgo a virtual appointment.

Besides technology, a lack of clarity regarding the expectations during a consultation using telemedicine, also contributes to patient dissatisfaction and reduced care quality.

For example, a patient needs to be told what s/he is expected to do before and during a virtual appointment. Ideally, a patient has to attend a virtual appointment at a quiet place and have a medication list in place before the consultation. Such preparation prevents occurrences such as attending a virtual appointment from a grocery or other noisy environments.

It is also important to explain patients the importance of following the pre-appointment etiquette.

For example, attending virtual appointments from home enables the physician to view and assess the patient in the context of his/ her own environment. The provider can gain better insights into the patient’s social, biological and mental relation with health, with such contexts. As a result, the quality of the care and patient satisfaction are both enhanced.

Technical Incompetency

The telemedicine platform must be efficient enough to handle the various requirements of a telemedicine service. For example, the platform must enable integration of electronic patient record or EHR into the system. Without this integration, it becomes impossible to maintain a patient’s record with accurate details and follow-up on the same. This lack of organization affects a provider’s workflow efficiency too.

An inefficiency of the platform to integrate with EHR also impacts a patient’s future virtual visits. For example, a patient may have consulted a specific doctor on the first visit. If he chooses another provider on a subsequent virtual visit, then the provider may have only limited information for diagnosis.

It is important to choose and use the right platform to deliver the high quality of care expected of a telemedicine service.

Lack of Service Awareness/ Hype

These two extremes work against telemedicine. Patients can use a platform only when they are aware of such a platform. Lack of efficient marketing prevents able reach of telemedicine platform, leading to wastage of the platform.

Over-marketing or hype, too, affects the reach of telemedicine to people that need such services. For example, over hype regarding a specific platform leads to people having great expectations from the platform. If the platform does not live up to these expectations, then patients get disappointed. They may discontinue using the platform, or worse, form a negative opinion regarding telemedicine itself.

Broadband Availability

Telemedicine implementation requires wider availability of broadband at affordable costs. With deeper penetration of Internet and cost-effective availability, patients will be able to access essential medical care at the right time.

A need for improved availability of broadband is being seen in rural areas and among population belonging to the underserved category. There have been FCC healthcare programs for rural benefit to improve broadband access to rural areas. Managed by the USAC, some of these rural healthcare programs focused on providing Broadband at affordable prices. Programs also offered mentoring services for projects focused on developing broadband healthcare networks. Unfortunately, there has been no reliable insights into the impact of such programs, according to the U.S. Government.

Risk of Fraud and System Abuse

As more people shift to telemedicine, patients and providers must be aware of the risk of frauds and abuse that such platforms can expose them to.

A common and a grave risk in telemedicine practice is that of fraud arising out of provider referrals to entities where the provider has a financial interest. There are laws such as Stark Law and the

Federal Anti-Kickback statute to safeguard patients against such frauds. Providers indulging in such violations can be sentenced to imprisonment, fined, or excluded from Medicaid and Medicare programs.

Providers too must be knowledgeable of these laws to safeguard themselves against false claims. They must also know fraud laws vary from state to state. They must educate themselves about state-specific laws to prevent abuse.

In Conclusion

Though telemedicine was initially aimed at rural and remote population, this medium of medical care is beginning to find acceptance among varied populations. The inherent benefits of telemedicine, including convenience, affordability, and ease of access, are now widely evident.

Patients are using their smartphones and other electronic devices to access medical care as and when they need it. They are taking advantage of telemedicine channels such as video, audio, email, the Internet, and device connectivity capabilities, to derive maximum advantage of telemedicine.

Patients are able to obtain efficient diagnosis and treatment for a range of chronic and general medical conditions.

Despite the numerous benefits, telemedicine remains inaccessible to many given the challenges in its implementation. These challenges are varied and involve the government, patients, medical care providers, and platform service providers.

Widespread telemedicine implementation requires the continuous and dedicated efforts of all parties involved, including the government, patients, healthcare providers, and technology providers.

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