Part 2: Telemedicine: Terminology

In this post we’ll cover some of the telemedicine terminology which might be new to the reader, and provide resources for learning more about the telemedicine terminology. 

I know I said I’d include technology in this post, but I’ve decided to save the technology portion until next week.  There’s a lot to cover and I try to keep my posts short so it’s a quick read. 

The terms I’m listing here are ones which I think might not be so obvious to a physician or practice manager.  For a more comprehensive terminology listing, particularly very technical terminology, two excellent sources are CMS LINK and the American Telehealth Association LINK.

I’m attempting to list terms in a relational order, keeping related terms near each other, for example synchronous is followed by asynchronous.

Telemedicine and telehealth

Telemedicine is the provision of medicine service by a provider in one location to a patient in a distant location, and their communication is via some electronic means.  Telehealth is generally considered the same as telemedicine, though sometimes it is thought of in a broader context.  For example, telemedicine might mean a direct patient/doctor interaction, whereas telehealth might refer to a patient interacting with a pharmacy tech regarding a prescription, or with a dietitian on a meal plan.

Originating/Spoke site

The originating or “spoke” site is the location of the patient at the time of service.

Distant/Hub site

The distant or “hub” site is the location of the provider at the time of service.

Presenter/Patient presenter

The presenter or “patient” presenter is a person, typically with a clinical background, who is with the patient and assists in the encounter.  They assist the patient with the communication aspects of the encounter, and may collect and transmit diagnostic data to the provider.

Synchronous communication

This means there is real time, two-way interactive communication between the provider and the patient, or the spoke and the hub.  We typically think of this as audio/video communications.

Asynchronous communication

This mean communications are one directional, as contrasted with synchronous communication.  For example, a provider may electronically receive an MRI, then later send back an opinion.  See Store and Forward below for more information.

Store and Forward (S&F)

 A store and forward (S&) encounter refers to an encounter where a provider electronically receives some diagnostic information (patient picture, MRI, ECG, blood glucose level)  then provides an opinion or diagnosis.  It utilizes asynchronous communications.

Bandwidth

In simple terms, bandwidth is a measure of the information carrying capacity of your communications channel (Internet connection, office network).  Video and large pictures (think radiology) take more bandwidth.  Simple voice communication takes less.  Picture bandwidth as a highway.  The more data trucks that travel it, the more lanes you’ll need to keep traffic moving freely.

CODEC

Short for coder-decoder, this is simply the videoconferencing device which converts audio/video at both ends of your connection (both spoke and hub sites).  Device manufacture names you may be familiar with include Polycom and Cisco Telepresence.  More on this in the technology section.

The reason we use a CODEC is that audio/video information must be compressed in order to more quickly and orderly transmit it over the internet or phone line.  Also, the audio/video information must be converted from analog to digital, and digital to analog.

Encryption

Encryption is process of scrambling a digital stream of data, then unscrambling it when it reaches its intended user.  The way this works is the source (sending) computing device scrambles the data.  The receiving computing device has a special “key” which can put the pieces back together again.  Without the key, the data is a useless string of zeros and ones.  This explanation is greatly simplified, but you get the idea.  While not a new word for most of us, I include it because we’ll revisit this in the technology section.

In the next post, we’ll look at telemedicine technology.  I’m a techno geek, so I’m really excited about this next post.

Sources:

http://www.umtrc.org/

http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3333

http://en.wikipedia.org/wiki/Telemedicine

http://www.apapracticecentral.org/update/2011/03-31/reimbursement.aspx

http://blog.asha.org/2012/03/01/telehealth-regulatory-and-legal-considerations-frequently-asked-questions/

http://www.medicallicensedirect.com/telemed.html

http://ctel.org/

http://www.medcitynews.com/2012/03/3-regulatory-and-financial-barriers-to-telemedicine-and-possible-solutions/

http://www.bricker.com/publications-and-resources/publications-and-resources-details.aspx?Publicationid=2165

http://www.acr.org/SecondaryMainMenuCategories/GR_Econ/FeaturedCategories/state/state_issues/TelemedicineLicensingProvisionsbyStateDoc8.aspx

http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html

Part 1: Telemedicine: Hmm, and it seemed so simple

The subject of telemedicine has been sprinkled in many of my conversations the past few weeks.  I didn’t plan it that way, but it just seems to pop up.  But it got me to thinking about the whole subject, so I did some thinking and investigating.  Here’s some of what I came up with.  For those of you attuned to telemedicine, you won’t find anything here particularly striking, but if you haven’t been following this topic I hope you find it informative.

So just what is telemedicine?  In the simplest form, it’s a doctor in her office looking at a screen with a camera pointing back at her, and a patient in a remote location, doing the same.  They talk, look at each other, and have a standard encounter. 

Simple, right?  Well, yes and no.  Let’s look at that goes in to making this situation possible. The topics I’ll cover include: Regulations, Payments, Terminology, Technology, Medical Specialties, and Type of Patient Visits. 

 

Regulations

Federal - HIPAA

I’m guessing you’ve already thought about HIPAA and protecting patient information.  The video and audio, and resulting data must be protected from prying eyes.  That would mean some sort of encryption for an Internet-based communications system, or a dedicated phone line.  In short, think of security and privacy, just as you would with in-clinic medicine.  We’ll revisit this when we discuss technology in a later post.

State Licensing

The location of the patient dictates licensing requirements.  Most states require a physician to hold an unrestricted license from that state in order to practice telemedicine on patients in that state.  A very few states, such as Alabama and Minnesota, have a telemedicine license available for out-of-state telemedicine physicians.   Currently there is a patchwork of state regulation or non-regulation with regard to telemedicine.  However, there is movement on this and it appears increased Federal involvement in the healthcare system is slowly bringing clarity to telemedicine practiced across state lines.  Though it is outside of the domain I’m covering, I will mention that the Department of Defense and Veterans Administration have their own policies on telemedicine when conducted on federal property.

Hospital Credentialing

Most hospitals still require physicians to be credentialed by them.  They typically won’t accept the fact that the physician is credentialed by another hospital.  Telemedicine proponents encourage “hub and spoke” credentialing.  In the hub and spoke model, a hub hospital credentials a doctor, and the spoke hospitals accept that credential.  For example, in Iowa a physician would be credentialed by Iowa Health System’s Iowa Lutheran Hospital-Des Moines, and that credential would be accepted by St Lukes Hospital in Cedar Rapids, Iowa as well as Methodist Medical Center in Peoria, Illinois.

Payment

Private

Payment for telemedicine services varies from payer to payer.  Physicians and practice managers need to check with potential private payers to see what their policies cover.  This issue is one which has hampered the promotion of telemedicine as it creates uncertainty for doctor and patient alike.  Twelve states (California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas, and Virginia) have regulations requiring private payer coverage for telehealth services.  But they don’t necessarily require the same reimbursement rate as for face-to-face services. 

Medicare

Medicare provides coverage for some telemedicine services.  In March 2012 they further clarified coverage for telemedicine services  LINK.   They provide a list of CPT and HCPCS codes which qualify for telehealth services, as well as guidance on modifiers (i.e. GT for “via interactive audio and video telecommunications system” and GQ for “via asynchronous telecommunications system”)  

Medicaid

Medicaid allows for payment for telehealth services, but since it is administered by each state, physicians will need to check with their state Medicaid office for reimbursement policies and rates.

Next post we’ll dive into telemedicine terminology and technology.

Disclaimer:  I’m not an expert on telemedicine,  I’m just looking at the landscape and trying to learn.  If I’ve missed something important, or I’m (gasp) wrong about something, please let me know. I'll give you credit, incorporate changes and note it at the beginning of the post.

[Note:  at the end of each post is a complete list of sources.  This list may grow with each post in this series, so for the most complete listing refer to the final post in this telemedicine series.]

Sources:

http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3333

http://en.wikipedia.org/wiki/Telemedicine

http://www.apapracticecentral.org/update/2011/03-31/reimbursement.aspx

http://blog.asha.org/2012/03/01/telehealth-regulatory-and-legal-considerations-frequently-asked-questions/

http://www.medicallicensedirect.com/telemed.html

http://ctel.org/

http://www.medcitynews.com/2012/03/3-regulatory-and-financial-barriers-to-telemedicine-and-possible-solutions/

http://www.bricker.com/publications-and-resources/publications-and-resources-details.aspx?Publicationid=2165

http://www.acr.org/SecondaryMainMenuCategories/GR_Econ/FeaturedCategories/state/state_issues/TelemedicineLicensingProvisionsbyStateDoc8.aspx

http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html

Next week: Telemedicine-Hmm, and it seemed so simple

The subject of telemedicine has been sprinkled in many of my conversations the past few weeks.  I didn’t plan it that way, but it just seems to keep popping up.  It got me to thinking about the whole subject, so I did some thinking and investigating.   

Starting next week I’ll have a series of posts on telemedicine.  For those of you attuned to primary care  point-of-care telemedicine, you won’t find anything particularly striking, but if you haven’t been following this topic I hope you find it informative.

WSJ: Innovations in Health Care

Today's Wall Street Journal "The Journal Report" section has an interesting series of articles titled "Innovations In Health Care."   LINK  This is a great read to get you motivated if you're experiencing the Monday blues.

Seth Godin: The end of the diva paradox

Interesting post today from Seth Godin's blog. LINK.  If you're a surgeon, well, I'm sure he didn't mean it personally.

Seth Godin is a bestselling author opining on topics including, and I quote,  "the post-industrial revolution, the way ideas spread, marketing, quitting, leadership and most of all, changing everything."  I prefer to listen to his audio books instead of reading the printed versions. The enthusiasm in his voice seems to bring more life to his works.  Plus they're good airplane listens.

Straight ahead,
Bob

What I Learned From The Masters

I had the joy in 2011 to attend The Masters golf tournament at Augusta National with my father.  We’d arrive at Augusta National early, grab some coffee, and then stroll around the dewy, manicured course in the early morning sunlight.  It was my favorite part of each day. 

We’d watch the grounds crews set the cups, literally take the course’s temperature, and otherwise tend to the magic green carpet.  As we strolled, my father would stop and explain where various memorable shots had taken place. 

“In nineteen such-and-such”, he’d start, “so-and-so had a lie right here.  At that time there was a limb overhanging the fairway, so he had to hit a slice like so,” he’d explain while making a wide arc with his arm.  “On that day, the cup was front right, so he had to land the ball back left but before the back ledge, and the ball had to roll like so, but not too much otherwise it would fall off the false front.  And do you know he rolled it to within five feet of the cup?  Amazing shot.” 

As we made our way along the fairway gallery crossings, we’d try to figure out where the players would place their tee shot, and what their approach to the green would be based on the cup placement we watched earlier. 

The actual golf was amazing as well as it turned out to be one of the really memorable Masters.  Tiger made a late run, Rory McIlroy was in-charge until experiencing an historic collapse, and young Charl Schwartzel won by holding off a bevy of young upstarts with an improbable run of four birdies on the final four holes. 

One of the really interesting things I observed was the quiet.  At golf tournaments it's customary for the gallery to fall silent as a player addresses and hits the ball.  But in true Masters form, quiet seemed to take on new layers of perfection.  I actually discovered three levels of quiet taking place at The Masters.  The first this was Player Quiet.  That’s when a player is addressing the ball, ready to hit, and the patrons (fans are called patrons at The Masters) in the immediate area stop talking and generally stop rustling around.  You hear birds chirping in the tree line and the dull buzz of patrons beyond.  The next level of quiet is Contender Quiet.  This is reserved for players who actually have a chance at winning the tournament.  In Contender Quiet the quiet zone extends to about double the diameter of Player Quiet.  You can now hear the echoes of chirping birds in the woods beyond, and only slight echos of patrons milling around the course.  The third and most intense quiet zone is Tiger Quiet.  This is reserved for only Tiger Woods.  During Tiger Quiet, you can still hear birds chirping in the distance, but nothing else, except occasionally an echo of a police siren in the far, far distance.  It's actually a sort of strange effect.

So what did I learn from The Masters?  The Masters does everything so well, but what it really does well is the details.  For example, I never saw any dirt at The Masters.  I spent three days walking outside over acres of golf course.  But I never saw any dirt.  I only saw green grass, sand neatly raked in traps, pine straw methodically spread beneath trees, and manicured shrubs.  Oh, and black water.  They must put some sort of black covering at the bottom of the water hazards so they appear black and therefore reflect the beauty around them.  But never any dirt.  The final day, Sunday, I did notice that in areas of heavy foot traffic the magical grounds crew pixies had methodically placed a green mix of sand and grass seed.  But the mix was the exact same green color as the short cut grass, so to the casual observe it looked like grass.  I could go on and on, but attention to detail is what I think The Masters organizers do best.

The interesting paradox of this is that because The Masters creates such a cocoon of comfort and expectation of excellence for patrons, that when some detail is missed, it stands out in stunning relief.  For example, in the real world the familiar beep-beep-beep of a utility vehicle backing up is a minor annoyance at best.  But at The Masters, I heard the beep during Contender Quiet and even Tiger Quiet.  It didn’t seem to bother Tiger, but I expected him to back off the ball and throw the unseen vehicle a nasty glare.    

The other thing I noticed was The Masters inability to mute the familiar “thwack-thwack” made by the closing door of a portable toilet.  Admittedly I didn’t see many portable toilets.  In fact, I think the only ones I spied were partially hidden away in strategic locations meant for players use only.  But watching Fred Couples address his ball, then hearing “thwack-thwack” in the distance kind of kills the moment.

Now, my examples may seem petty in the world that is not Augusta National, but in the context of The Masters they seemed like glaring omissions. 

So what does all this have to do with your medical practice?  Well, I think it points to the fact that no matter how good your practice is run, or how incredible the patient care and patient experience is, is that there is always something you can do better.  Your patients will always find something they dislike about your practice.  It means you can always be better managed, or more efficient, or have better working conditions for your staff.  If you can’t think of anything to improve, you’re probably not taking care of the details.

Fore!

Bob Oakley