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Calling Mr. Watson

By Kim Bellard, October 24, 2011

I was going to write something about the recent controversies about the PSA test or Pap test, but the effort by the U.S. Preventive Service Task Force to use documented evidence in determining the value of periodic testing seems almost certain to be overcome by the combination of tradition, emotional responses, and self-interest by impacted parties, so I’ll let that go for another day. 

Instead I’ll turn my attention to one of my favorite topics, the use of technology to improve the delivery of health care services. 

I’m enough of a science-fiction fan to believe that I should be able to get medical advice and consultation whenever and wherever I am, from an appropriate expert (or at least a qualified person with real-time access to any necessary expertise), using real-time biomedical and other readings.  I’m glad to say that this is rapidly moving from science fiction to reality.

Earlier this month, California passed AB 415, the Telehealth Advancement Act.  The bill updates California’s prior telemedicine law, and makes various improvements to allow wider use of telehealth in California.  It allows broader use by more types of providers, removes rules requiring documentation of barriers to in-person visits, and eliminates restrictions on reimbursement for services provided by email or telephone, among other things.  The bill’s proponents claim it should save up to $1.3 billion per year to the state’s Medi-Cal program, much of which comes from electronic home monitoring programs for patients with diabetes or potential heart failure. 

Several studies (e.g., University of Texas Medical Branch and UnitedHealth Group) argue for telehealth’s particular value in care delivery for rural populations, where access to in-person services may be especially problematic.  Again, closer monitoring of patients with chronic conditions is cited as an opportunity for improved care and lower costs. 

Meanwhile, the Mercy health system has announced plans for what it calls the nation’s first “virtual care center”.  It will bring together a variety of existing and planned telehealth programs, such as the Mercy SafeWatch program.  This program is an electronic ICU, monitoring 400 beds in 10 Mercy hospitals to provide around the clock support from specialists and ICU nurses to the bedside practitioners.  Mercy plans to spend $90 million on building the center and another $590 million in technology to support their multiple initiatives. 

Similarly, Washington Health Center, in Washington D.C., announced CodeHeart, a mobile application it developed in conjunction with AT&T.  It allows cardiologists to view video and test results while a critical care patient is in transit, allowing them to better prepare for the patient’s arrival in the emergency room, where time is usually of the essence.

It’s no surprise that telehealth is a hot topic.  Manhattan Research claims that 75% of physicians own an Apple mobile device – iPhone, iPad, or iPod – and 26% of U.S. adults have used their mobile phones for health information and tools.  Mobile is rapidly becoming crucial to telehealth, supplementing prior video-conferencing capabilities.

The barriers to telehealth are no longer technological, since the increased availability of broadband connections and more robust mobile platforms have made possible a wide variety of options.  The real barriers are artifacts of historic practices, especially related to reimbursement and licensing.

Reimbursement for telehealth remains uneven.  Medicare, for example, covers some telehealth services, and is expanding its rules for 2012, but still does not do so uniformly.  For example, it is more favorable to beneficiaries in rural areas than in urban areas, and only covers live interactions, not so-called “store-and-forward” methods used for images and certain other patient information.  Fourteen states require private payors to cover telemedicine, but the rules are not consistent across states, nor do they necessarily speak to reimbursement equivalence. 

Licensing is an issue because health care practitioners are licensed by the state in which they practice.  Telehealth, of course, is not bound by geographic location, but under current laws providers in one state cannot treat patients in another state unless they are licensed in that state.  Practicing in multiple states thus is onerous

Both of these issues can be overcome, but it will not be easy.  Most private payors follow Medicare’s lead in reimbursement policies, so if and when Medicare makes progress in how aggressively it wants to use telehealth, the private sector should follow.  The reluctance of payors is understandable; the practice of telehealth is still in a relatively early stage, and many payors are concerned that paying for telehealth could lead to an explosion in costs.  In an ACO world, where ACOs have strong incentives to live within a global budget or budget target, employing the use of cost-effective telehealth services should seem entirely logical.  In a predominantly fee-for-service world, perhaps not, or at least not necessarily. 

As for licensing, state licensing agencies are not surprisingly reluctant to cede oversight.  They can justifiably claim that patients could be at risk by treatment from practitioners over whom they have no control and no assurance of competence.  While valid, we seem to be able to conduct inter-state commerce in other fields without abandoning consumer protection.  It argues for more uniform licensing practices and reporting across the states, lessening any particular state’s concerns.  Indeed, the American Telemedicine Association has launched an initiative – – to make licensure more appropriate for 21st century capabilities and practices, including telemedicine.  E.g., why should my access to the best doctors be subject to my physical location?

Licensure will become even more problematic with the evolution of expert systems or artificial intelligence.  This is starting to become real; take, for example, the recent collaboration between Wellpoint and IBM’s Watson technology.  For readers not familiar with Watson, it is the system that beat the Jeopardy champions of champions.  Wellpoint plans to use Watson to help suggest treatment options and diagnoses to doctors.  With so much medical knowledge, and with that knowledge increasing exponentially, such assistance seems inevitable, not to mention highly desirable.  Still, at what point will that kind of assistance be considered practicing medicine?

History buff may recall the apocryphal story that Alexander Graham Bell uttered, “Mr. Watson, come here – I need you” into the first working proto-telephone, launching the era of electronic voice transmission.  It seems ironic, yet somehow fitting, that Watson may again be critical to launching of another technological revolution.

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