The Challenges for Telemedicine

The challenges for the future of telemedicine are going to be complex and require cooperation of government agencies (FAA, FDA, HHS, CMS,) added to some state government departments and state medical boards. This will be a complex web that may prevent some forms of telemedicine from getting off to a good start.


The medical establishment is buzzing about the concepts of telemedicine, telehealth, telecare, and mHealth. The question on everyone's mind is how long will we need to wait before they become a standard way of care and have reasonable guidelines for use. Another and maybe more important question is; how long will telemedicine benefit from the presently low barriers of entry before the regulatory machine limits what telemedicine can accomplish. Even the question should be raised about what impact the Affordable Care Act will have.


Next, we have the emerging mHealth (mobile health) industry, which is presently an undefined area in a fast developing technology climate. This is still waiting for FDA and other regulators to arrive at standards for the approval, market access, and reimbursement of those devices, applications and other healthcare software. Will the FDA, HHS, CMS, and other federal bureaucracies be able to step forward in a timely manner to prevent stifling innovation? Or will they threaten small business and new entrepreneurs that feed the market and delay important technology? To me there is little middle ground and action is needed now.


Here are some of the key issues:


#1. Technology Platform. Currently we do not have a network system that can accept images from CT scanners and MRI devices and transmit them straight to the doctor's smart phones. I have seen a secure computer network in the VA hospital that makes this possible, so I know it can be done on computer networks.


#2. Data Volume and Speed. Since I have seen this accomplished on secure computer networks and done in about one hour, from scan to viewing on the doctor's computer screen, I know it is possible. However, with mobile applications, there are some key points. The volume of data and the priority of moving this data will be huge and software developers need to be aware that the network infrastructure is aligned with the needs. In the diabetic platform similar to the recently launched Cellnovo in the UK (and hopefully shortly in the US), when a patient is hypoglycemic, the cellular bandwidth at which the device sends signals to the mobile phone needs to be somehow prioritized. Moreover, when similar devices come into the market, cellular urgency becomes an issue.


#3. Data Security. Data security is the last concern as it affects all of telemedicine. As more devices come to market, and the public or patient sector considers them, the assurance of privacy and protection of the data will need to be answered. Will HIPAA be able to cover this in advancing technology market? There are some real doubts at present as slowly as Congress is acting.


Yes, in the ever-expanding chronic disease arena and projected physician shortage, mHealth and telemedicine may have a role to play. This will be tested by state medical boards trying to prevent new technologies and there will be many other challenges along to way to a more productive and lasting improvement in medical care. Will efficiency win the day? We can only hope!

The Practice of Medicine Must Change

This blog combines two other blogs of interest to me and helps explain why the practice of medicine must change. No, I am not talking about our broken medical system, but the participants in it and how they can make the change happen. Or at least this is my intent, but the end will determine if I am convincing.


Science has led to many important medical life-saving advances, but it has also led to harmful and dehumanizing medical care. Physicians and hospitals use wasteful and unnecessary tests and treatments. It is sad that about two out of every three families that declare bankruptcy, do this because of expensive medical bills. What is even more alarming is that over 70 percent had medical insurance.


The first blog is this blog by Dr. Leana Wen and I urge you to read it. Her points are very poignant and at the same time revealing about what needs to be accomplished. She does not say this, but I will, we – you and I, need to take charge of our medical care. Doctors are so harried today, that they do not let you tell your story about what is wrong with you.


I do understand that they interrupt many patients because we have too many drama-minded people that do not just state the facts and then let the doctor take over. Then we have the doctors that rely on the “cookbook method” and could care less about what is truly your problem. So both sides may be part of the problem. Patients, we need to just state the facts, forget the drama, and not let the doctor interrupt us until we have finished with the facts. This just may prevent a misdiagnosis.


The second blog is by Riva Greenberg that I am using. I laughed after reading this, but what she describes is happening more and more. Why? I honestly feel this is happening because doctors have lost their comfortable pedestal they want patients to see them atop of and are having burnout to some degree. Yes, some would call it laziness. I see it as being so harried by the lack of time, that they are not able to do their jobs and so drop the ball in many areas. They order tests and procedures just to move to the next patient. The problem is they may not even know why they ordered a test or procedure.


Clinical inertia is what Riva describes - clinical inertia can put a patient in danger, it is a major contributor to inadequate treatment, and it can lead to unnecessary tests and procedures. Riva is talking about diabetes and when this doctor is asleep at the wheel, you as the patient must take charge. Either be prepared to challenge your doctor when he goes on autopilot, or find another doctor. While this may not always be easy if you live in a doctor sparse (rural) area of the US, but it still needs consideration.


The transforming of healthcare does not require more politics, or even more technology. It requires that as patients, we refocus the appointment on us, the human connection – the old fashion form of communications. We need to revitalize the doctor/patient relationship, which is simple and straightforward. Some doctors will appreciate this and some patients will need to move on to a new doctor. This is the simple truth. We are still too far from knowing what the Affordable Care Act will bring, but our health is important now.


Again, I encourage you to read these two blogs and what they are saying.

Pharmacists' Role in Primary Care to Expand

Medical doctors may not be seeing what is happening and soon it will be too late for any action. More states, and especially states with large urban centers and large areas of rural populations that are very doctor sparse, are considering legal actions to confront this doctor shift and in some areas extreme primary care physician shortages.


Recently, the federal government has experimented with success using pharmacists in the delivery of healthcare on the Indian reservations. This project involved diabetes education and the ability to prescribe drugs. This program is probably an introduction of a federal push for greater pharmacist participation in the overall national health system.


California is loosening up their restrictions and they have to. Many doctors are leaving the state's inland rural areas. These areas are beginning to suffer from a physician shortage as primary care doctors migrate to California's wealthier coastal enclaves to generate incomes large enough to offset their medical training debt. Then the California Medical Association said the state could alleviate the looming physician shortage by building additional medical schools, adding medical residency slots, and expanding programs to help physicians pay off student loans in exchange for working in underserved communities.


This is laughable because a big problem for the state is that it lacks the money to build more schools or help medical school graduates pay off their student debt. California's bonding capacity has been downgraded over the past three years from AAA to A, which means the state must pay higher interest rates to attract bond buyers. The state has been flirting with insolvency for several years.


The California State Senate passed SB 493, which is a bill that would give pharmacists broader scope as healthcare providers. This joins SB 491 and SB 492 that expand the role of nurse practitioners and optometrists, respectively in the State Assembly's Business and Professions Committee. This is the latest on this.


In Tennessee, an experiment carried out by the Diabetes Initiative Program followed 206 adult type 2 patients for a year to see if intense collaboration between physicians and pharmacists could lead to a reduction in patient's A1c's. Here pharmacists provided education, ordered lab tests, made referrals, and helped manage drug therapy, including discontinuing it if they thought it appropriate. The study noted an increase in the number of patients whose A1c's were below 7%, from almost 13 percent of participants to nearly 37 percent, and concluded that the doctor/pharmacist collaboration helped produce that outcome.


“Generally speaking, pharmacists are more accessible to patients than their primary care physicians. Those relationships are more informal, rarely dependent on appointments, and often involve more frequent contacts. Greater patient comfort with pharmacists translates into a greater likelihood that they will follow pharmacists' advice and recommendations. Giving pharmacists increased legal authority to deliver certain aspects of primary care would have the advantage of building on an already established set of solid relationships.”


A study from the George Washington School of Public Health and Health Services found that the United States is producing an alarmingly low number of primary care physicians. According to the study, less than 25 percent of newly credentialed doctors go into primary care medicine, and of that number, only 4.8 percent set up practices in rural areas. This shortage sets the stage for including pharmacists, nurse practitioners, and other healthcare providers to help fill the primary care provider gap.


“California's problems serving rural areas with an adequate number of primary care physicians turns out to be a nationwide concern. Along with the conclusions stated in the George Washington University study, there is an increasing likelihood that as the Affordable Care Act comes more into play, it will have two negative impacts on the number of physicians-one absolute and one relative:


#1. Medicine will become an increasingly unattractive field as profit margins are squeezed by regulations. This in conjunction with the rising cost of a medical education, which, like all student tuition costs, has been rising for years far faster than the rate of inflation. Net result: fewer young people entering the medical profession.


#2. Doctors who do not wish to be forced into group practices dependent on government regulation and reimbursements will form independent "concierge" practices where patients pay a set yearly fee, usually in the thousands of dollars, for non insurance-dependent healthcare. These practices work best in densely populated, relatively affluent areas. Net result: fewer doctors among those currently available to practice among patients who either cannot afford non-insured services or live far from urban centers.”


Where will this leave many patients? Without states making it possible for pharmacists, nurse practitioners, and other healthcare providers to practice primary care, the voters may have to insist on this at the federal and state levels.

Will States Allow NPs to Practice?

I can just imagine the physicians on many State Medical Boards choking on their tongues when they read this article in Medscape. The title is “Reducing State Restrictions on NPs Boosts Primary Care Supply.” Unless the Obama administration delays other provisions of the Patient Protection and Affordable Care Act, many states will be in serious problems for lack of primary care physicians. Yet, many of these same State Medical Boards are working overtime to prevent expansion of NPs rights, PAs rights, and limit telemedicine across state borders.


On January 1, 2014, millions more people are expected to gain coverage under the Affordable Care Act, and they will be seeking services from primary care physicians who, in most cases, already have full schedules. One way to meet this supply problem is to relax regulations on nurse practitioners (NPs) and allow them to independently provide basic primary care, as already happens in many rural states that have had difficulties attracting physicians. An additional help would be letting PAs practice with NPs and open the borders for telemedicine.


Arizona, Iowa, Oregon, Maine, and Washington allow the highest levels of NP autonomy, and California, Florida, Massachusetts, Michigan, and Texas have the highest levels of NP restrictions. It would seem prudent for the rural areas of California and Texas that they should reduce the restrictions, but the state medical boards wield a lot of power in those states. Oklahoma, Georgia, Texas, and Louisiana have the highest number of uninsured people and the largest shortage of primary care physicians, therefore how will they be served to take advantage of the ACA.


Then we have this from Medscape, promoted by the Graham Center Policy, and published online in the August 15 issue of American Family Physician. It claims that allowing NPs and PAs will only help a little in the coming physician shortage. Their finds indicate that the data shows that only about half of NPs (52.4%) and PAs (43.2%) work in primary care, with the others choosing subspecialty areas. Even these numbers will help in the physician shortage, if states will relax their restrictions for NPs and PAs to be able to practice. It is unfortunate that the numbers of those that would be available to practice in primary care is not stated.


The authors do indicate that relying on NPs and PAs to solve the problem of a growing shortage of primary care physicians may not be an option. The authors continue that policy makers should not abandon policy solutions designed to increase the number of primary care physicians, NPs, and PAs.


Will state medical boards choke on this as well? Probably, as they do not want NPs and PAs to be able to practice independently.


I was able to receive the full copy of the abstract mentioned in the first Medscape article and it is interesting. I will quote minimally from it, “Several factors contribute to the current and projected shortage of primary care providers in the United States. These include overall population growth, population aging, an expected large increase in the number of people with health insurance, and a decade-long decrease in the number of medical school graduates choosing primary care as a career. Increasing the role of NPs as primary care providers can be an important approach to increasing primary care capacity.


I expect more articles over the next few months as we count down to January 1, 2014. Therefore, I expect to write more on this topic.

Licensing Boards Curbing Free Speech

This is becoming almost a daily occurrence and people are tiring of these zealots. This licensing to create monopolies in different trades, practices, and information is thankfully getting more attention from the media. This it turn is drawing the attention of the Federal Trade Commission (FTC).


The courts are generally ruling in favor of the individuals and this is going to put a damper on state licensing boards and hopefully put an end to their activities. The FTC has investigated the North Carolina dental board over its attempts to monopolize the teeth whitening business. It found that the dental board has illegally thwarted competition through cease-and-desist letters.


The FTC is also stepping in to recommend anticompetitive behavior by physicians of nurse practitioners (NPs). The AMA and other medical organizations are opposing this as they want to continue to monopolize patient care. Two more states have opened the door for NPs to practice independent of physicians.


Even Steve Cooksey is back on track as the 4th US Circuit Court of Appeals held that Cooksey has legal standing in his case that the District Court had thrown out. This allows the lawsuit to go forward against the North Carolina Licensing Board of Dietetics/Nutrition. This is a setback for the Academy of Dietetics and Nutrition.


This article highlights others also going to court and some winners against state licensing boards that are attempting to become monopolies within each state. This is stifling competition and harming the general public because they will not have a choice in selecting who serves them. Yet this licensing conundrum is rearing its ugly head over and over.