Demand Continues for Primary Care Doctors

The demand for primary care doctors is here now and will for many years to come. With the demand for these doctors increasing in many rural or less doctor dense areas, recruiters cannot fill the needs. Merritt Hawkins, a national health care consulting and recruitment firm, speaks to some of the issues, but not all. This firm along with two other staffing companies spans the lower 48 states and includes rural and major metropolitan areas.


As we become more aware of the needs for doctors in the rural areas and many underserved areas of medicine, all three recruiting firms have found that hospitals and medical groups are continuing to seek primary care physicians, nurses, and assistants. However, this is the first year that the request for geriatricians out paced the demand of previous years. This is also the first time that this specialty has entered into the firms' top 20 of the most recruited.


Travis Singleton, senior vice president at Merritt Hawkins, stated that, “It is interesting that our youngest doctors are treating our oldest patients, but I think that some of it is just reclassification, it was happening already.” Other specialties, such as radiology and anesthesiology, despite being among the most competitive and desired positions a decade ago, did not make the top-20 list for 2013.


Dr. Atul Grover, an internist and chief public policy officer at the Association of American Medical Colleges, says, “I think people are starting to look at the market and get nervous, because of Medicare payment changes that impact doctor's pay and the growing emphasis on preventive medicine.”


I think the “growing emphasis on preventive medicine” has many doctors making changes because they are afraid of preventive medicine and know little about it, after having practiced only treating people already ill or in need of treatment for a disease or chronic illness.


I have been made aware of two towns about an hour and one-half distant of recently loosing two primary care doctors because their agreement with the towns had been fulfilled. Both headed for hospitals in larger cities where they will become hospitalists and at a much higher wage and less hours.


Many doctors are taking different jobs to satisfy a work-life balance and not the hectic almost 24/7 hours and paperwork of meeting the needs of their current jobs. According to the three staffing firms, hospitalists ranked third on the top 20 list.


Even with the health care law's attempt to curb the high cost of emergency care, Merritt Hawkins reports an increased demand for emergency department (ED) doctors. With patients finding fewer primary care doctors available to meet their needs, patients will continue to turn to the ED as a last resort or for convenience.


This points out the increasing need for doctors to be trained that will serve in vulnerable communities and the need for incentives for them to continue to practice in these communities. However, the doctors that left these communities for large cities continue to lobby to prevent NPs, PAs, and Pharmacists who have remained in these communities from being able to practice unsupervised.


Therefore, it will be necessary for patients in these underserved areas to lobby their state legislatures in opposition to the state medical boards. Also these same patients in some communities to will need to lobby for restrictions on telemedicine to be lifted. The next decade will be interesting as the powers that exist now may see their popularity disappear and be replaced by the very groups they are muzzling now. And, I feel that the patients may play a large part in this.

Connected Health – Generates Quality Care

This is a take-off of a blog posted recently by Nancy Finn on her site. I read her blog with interest as it was so much different from another article also posted recently on Medscape. Nancy's blog indicates an extremely large dollar savings while the Medscape article reports no savings.


Now before I go further, the UK study was a once monthly telephone conference as a 1-on-1 health coaching session. Nancy covers a broader range of telemedicine. She brings in the internet, telecommunications, video technology, smart phones, robotics, digital sensors and scanners. This is all used to provide patients in remote, medically underserved areas, or those who are homebound, immediate quality care. This makes it easy to understand why the UK study was unsuccessful.


Enough about the UK study, Nancy's blog gives hope. Considering the range of services she is talking about, there is hope that her projected savings is possible and even if not met, large dollar savings should still exist. What I enjoy about Nancy's blog is the fact that her ideas are not limited by technology, but embraces technology to care for patients. From using an interface to hook up patients with appropriate healthcare specialists, speech therapy, and mental health counseling when and where it is needed. Also of interest is the assisting of patients with chronic diseases to manage there care remotely.


Nancy states, “The Center for Connected Health and Partners Home Care did a pilot where over 500 heart failure patients were monitored remotely. Home health nurses collected vital signs, including heart rate, blood pressure and weight, using simple devices in the patient’s home. The information was sent daily to a nurse, who could identify early warning signs, notify the patient’s primary care physician, and intervene to avert a potential health crisis. The program resulted in reduced hospital visits and improved quality of health care for the patients.”


This is the first I have read about a “smart” pill bottle being used to detect when a patient at home did not take their scheduled medication. The pill bottle would send a signal to an ambient orb in the patient's home to remind them to take that medication. I can see that this could reduce the chances of a medical crises and even an emergency room visit. This could alone save big dollars.


Using technology could make the workload for doctors' decrease and provide better care for patients. Now I will need to be alert to see if state medical boards will fight to prevent these technologies from happening and if doctors will welcome these technologies or try to say that it is robbing them of revenue when the Affordable Care Act becomes a reality. There are many areas in the US that could benefit from modern technology.

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!

ATA Calls for USA Doctor Licensure

What are the problems of today that are standing in the path of telemedicine? It is state laws promoted by the different state medical boards. These state medical boards jealously guard the state borders and protect the doctors within their borders so that other doctors must become licensed to practice in that state.

This does not protect patients and often harms patients when they travel or are in another state on business. Can they pick up the telephone and order a prescription if they become sick with something they have been treated for before? No, they must see a doctor in the state they are in. The only exception is if they have a prescription issued by their home state doctor and use the pharmacy chain that fills the prescriptions at home. Example: At home, they have their prescriptions filled at Walgreens and obtain another prescription before they travel and when they have a repeat episode, take the prescription to a Walgreens wherever they are located during their travel. Walgreens can then check the records at the previous pharmacy and once verified they can fill the prescription. Otherwise, under current laws, they would be required to see a different doctor in the state where they are located.

I know of an executive from Minnesota that traveled to Illinois on business and became sick. The doctor there would not take him as a patient and sent him to the local hospital emergency room. There he was misdiagnosed and given the incorrect treatment and ended up almost dying because they would not listen to his wife and contact his doctor in Minnesota. During the transfer to another hospital, his wife recognized the airport they were passing and redirected the ambulance to the corporate jet and flew him home.

Using the jet's communications, she alerted the doctor and he had an ambulance waiting when the plane landed. The records were fortunately with the wife (the ambulance had given them to her), and she handed them to the ambulance personnel and they communicated with the hospital. When he arrive at the hospital, everyone knew what was wrong and they confirmed the correct diagnosis and had to give medications to blunt the previously given medications and then give the correct medications. Not everyone can be as fortunate as him and have this type of service. The hospital where this was started was notified that the diagnosis was incorrect and that they could forget billing for their services unless they wanted to be sued for malpractice.

This is just one more reason to support the American Telemedicine Association (ATA) in their campaign to change the licensure system for doctors in the USA. The U.S. military and Veterans Affairs (VA) Department have already acted to fix licensure barriers. So have the European Union and many other countries.  The American consumers, health providers, and taxpayers are being left behind.

Please read these three articles, two by the ATA, here and here, and this by the

Commonwealth Fund. This is an ongoing battle that the ATA has been trying to get resolved since August of 2011. Apparently, Senator Tom Udall (D-NM) is not interested in following his first promise and others are attempting to have federal legislation passed in the face of stiff lobbying by the different medical groups want to keep licensure for the states.

Telehealth, Telemedicine, mHealth - ????

With the explosion of technology today, it is difficult to see what is in store tomorrow much less five or ten years from now. Yet many people are attempting to predict and declare what will happen in the next five to ten years. This is because of their obsession with having order in their lives and direction in what they do. I can understand and appreciate this, but as I grow older, I just want to wake up tomorrow and then I will worry about what I do and what will happen. Oh, yes, I have plans, live by a budget, but all these dreams are mote if I don't wake up tomorrow.

The definitions of the terms used today are complex and often confusing. I am not sure that I have them right, but I have asked three doctors and received three different answers. And in their own professional groups, each has their points and they all differed. Digital health technology seems to be accepted more than any other term and in some instances, this may be true, but then we need to think about the other terms that are gaining acceptance. And when talking about digital health and digital healthcare, there is not a national organization, that I am aware of existing.

Telemedicine, telehealth, mhealth, (Mhealth, m-health, mobile health all apply to the use of mobile health devices), are just a few of the terms being used widely. In a search of the internet, only one of these terms relates to a national organization and that is the American Telemedicine Association. At present, and I say this cautiously, this is the only group to have a national association and as such I need to consider this the overarching organization for all other terms.

Be careful and don't confuse this with telecommunications as this is represented by at least two national groups – the National Telecommunications Cooperative Association (NTCA) and the National Rural Telecommunications Cooperative (NRTC). The NTCA and the Organization for the Promotion and Advancement of Small Telecommunications Companies (OPASTCO) merged and beginning on March 1, 2013, the new organization will be called NTCA, The Rural Broadband Association.

Back to the use of terms in the health arena. The term “eHealth” is often used, particularly in the U.K. and Europe, as an umbrella term that includes telehealth, electronic medical records, and other components of health information technology. As this is a term more common to the European Union, I will leave it alone.

Another term similar to telemedicine is the term "telehealth," which is frequently used to denote a broader definition of remote healthcare not always involving active clinical treatments. Telehealth and eHealth are at times incorrectly interchanged with telemedicine. Telemedicine often refers only to the provision of clinical services while the term telehealth can refer to clinical and non-clinical services involving medical education, administration, and research.

Telehealth is not popular in some areas, but one company still pushes this. And remember, it does not take a national organization to drive definitions, but it helps.  Reading about the different terms in wikipedia can be of some help, but there is still confusion. I find it interesting just trying to wrap my head around all the terms. I may misuse them, but to me telemedicine will be for me the overarching term and may include some of the other terms as part of telemedicine.

Telemedicine Is Gaining Support - Part 2

Part 2 of 2 parts

Some important history needs to be part of this blog. “The University of Kansas Center for Telemedicine & Telehealth is a recognized world leader in telehealth services and research.” I would not have included this if I did not believe it. I have a distant relative that has been a recipient of this service and he says it was needed and he was thankful it was available when he needed it.

“Beginning in 1991 with a single connection to a community in western Kansas, the Kansas telehealth network now has accessed more than 100 sites throughout the state, has conducted many thousands of clinical consultations for the people of Kansas and has hosted hundreds of educational events for health professionals, teachers, students and the public.”

This is not the total of universities, but none has had the success that U of K has had or the range of population across the state. Other universities are modeling after the University of Kansas and are still developing especially when not blocked by state medical boards.

The benefits of telemedicine in states that are largely rural are more evident than in states that have some large population areas. Rural physicians and clinics can,

• Receive education from the specialist/provider
• Better health outcome for their patients
• Enhanced community confidence in local healthcare
• Attend continuing medical education courses from their clinic

Patients benefit,

• Loved ones remain in their community with family support
• Cost savings from not having to travel extensively
• Immediate urgent care
• Confidentiality of specialty examination or visit (Because the patient visits the general practice doctor, he can be seen for any specialty care without anyone else knowing)
• Patient education courses (nutrition, oncology, etc.)
• Properly stabilize patient prior to transport
• Early Diagnosis prior to escalated medical episode

Rural Patient's Community benefits because,

• Dollars follow the patient
  • Patients that routinely travel to visit doctors in large urban areas tend to purchase their goods and services from those cities,
  • Telemedicine keeps those dollars local.

Telemedicine Providers (hub sites) benefit by,

• Expand patient outreach
• Major surgical procedures resulting from the initial telemedicine consultation
• Reduction in ER visits
• Promotion of Hospital
• Charge tuition for clinician education courses (CME, CNE, etc.)

• How can we give any hospital or clinic immediate access to a vast amount of medical experts, healthcare education/information, and support from other physicians.

These benefits can become powerful benefits for telemedicine in states like Kansas, Montana, Wyoming, and other states. Physicians with access to telemedicine will be more likely to remain in these largely rural states. Residents will be happier not needing to travel for hours to be treated and will welcome and utilize nearby physicians.

Telemedicine Is Gaining Support – Part 1

Part 1 of 2 parts

I know that there are a lot of definitions available to apply to telemedicine. Telemedicine in one form or another has been around for about 50 plus years. Most of telemedicine pre 1990 was by use of telephone or occasionally when publicity could be had, some TV stations would lend their facilities to aid in telemedicine.

Then in 1991, the scene started to change. Computers became the medium for telemedicine. Today there are mobile devices and portable tablets being used for telemedicine. Terminology is expanding and more terms are gaining acceptance. Sometimes even I need to wonder which term(s) to use.

Almost 100 percent of telemedicine today uses telecommunications. We have the term telehealth, mHealth, eHealth, and health information technology (HIT). This is not a complete list as there is others gaining acceptance such as RPM for remote patient monitoring.

A concise and yet simplistic definition is, “Telemedicine is the ability to provide interactive healthcare utilizing modern technology and telecommunications.” I have encountered this usage from several sources and therefore do not know whom the source of the original use should be credited. This is also revealing in that telemedicine is not a separate medical specialty. Many specialists make use of telemedicine and think nothing of it.

Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the reimbursement fee structure, there is usually no distinction made between services provided on site and those provided through telemedicine and often no separate coding required for billing of remote services. However, some state medical boards are lobbying for a different set of billing codes to differentiate and control groups using telemedicine.

Some attempts are being made throttle telemedicine and force patients into a doctor's office, or a hospital and eliminate telemedicine. I hope state legislatures will reverse this to allow telemedicine to expand in not only heavily populated areas, but also especially in largely rural areas where patients would need to travel several hours to see a doctor or have access to a hospital. Some federal programs have stepped into very remote areas to lend assistance to telemedicine.

Is Telemedicine Ready for Prime Time?

Maybe, and there are many aspects that will need to come together for this to happen. I do not agree with the optimism of many writers.  From some of what I am seeing, the legal profession is sharpening their medical skills be hiring some doctors and legal medical specialists. This tells me that something is brewing on the legal front that may affect many aspects of medicine. No, I do not know what is being planned, but there are many possibilities.

Even the HIPAA rules are being expanded and as of yet there is some confusion. Some are saying telemedicine will be exempt for parts of HIPAA and others are saying don't count on it. One video program that is secure is now on the market and this link will give you information. Now, if we could find doctors that would be available and use it.

One problem that may prevent telemedicine from reaching prime time in 2013, is the number of states that have not approved mandatory private insurance reimbursement for telemedicine care. It is surprising that some of the more rural states have not taken action on this.

Another problem is the physical examination requirement (PER) some states have in place and this may prevent telemedicine from being used in a few states. A lot will depend on how the state laws are written.

Two efforts at the Congressional level may be favorable for telemedicine. One piece of legislation – The Telehealth Promotion Act of 2012 (HR 6719) has been introduced by Rep. Mike Thompson (D-CA 1). The proposed legislation fixes the two existing barriers to telemedicine in federal health programs: reimbursement and physician licensure. By eliminating arbitrary coverage restrictions and simplifying licensure requirements within federal health programs, the bill would extend the benefits of telehealth and mHealth (mobile health) to nearly 75 million Americans.

The second has not been introduced, but an aide to Sen. Tom Udall said the New Mexico Democrat is drafting legislation to create a national physician licensing system to operate in tandem with state boards.

Even if telemedicine does not make prime time this year, it is on the thresh hold to potentially receive a boost and gain some important ground.

Telehealth Also Asking Gov't Help

Whether you call it telehealth, mHealth or remote monitoring, the deployment of telemedicine is galloping. In what direction, this is a question to be answered. We should have an answer in 2013 or 2014, possibly. Some state medical boards are so wrapped up in their own self-importance that they are opposing the expansion of telemedicine and vehemently doing this. Other state medical boards are cautious, but moving in the right direction, and some are openly embracing telemedicine.

The state medical board in my state seems to be frozen in the past. They are unable to make a decision on many issues and therefore the state legislature is not acting on several issues that have been brought before it. Fortunately, the US Congress may force the issue and create laws that will force issues to be settled at the state level and create funding problems for those states choosing not to act. Again, patients are being caught in the middle and are the ones that will suffer.

This article is important and does need to be quoted for several issues. “Consider these facts:

• More than five million Americans had their medical images read remotely last year;
• Approximately 10% of all the intensive care unit beds in the U.S. use telemedicine;
• According to MobiHealthNews, there are more than 13,000 consumer health applications for the iPhone;
• One million Americans benefit from remote cardiac monitoring for implantable devices or for checking on a suspected cardiac arrhythmia; and
• The American Telemedicine Association estimates that more than 10 million Americans have directly benefited from some sort of telemedicine service this past year, probably double from just three years ago.

The American Telemedicine Association (ATA) was established in 1993. The ATA says the leading barriers to the development of telemedicine in the USA have been government policies. The Centers for Medicare and Medicaid Services (CMS) is very hesitant to reimburse for telemedicine. Then the ATA lists state-based standards of care and professional licensing as blocking much of what it needed for the advancement of telemedicine. And the list goes on to the FCC and FDA for their dragging of action.

Please take time to read the article in the link above.  It explains what is happening to telemedicine and the reasons they feel that 2013 will be the year of change.

Telemedicine Is Expanding

If you are interested in telemedicine like I am, this map should be of interest. This is the link to check from time to time for changes. Several state legislatures are still in session and thus there may be some more changes.

The Current "State" of Telehealth Reimbursement:

Latest Update April 2013 (referenced from ATAwiki):

States with the year of enactment: Arizona (2013)*, California (1996), Georgia (2006), Hawaii (1999), Kentucky (2000), Louisiana (1995), Maine (2009), Maryland (2012), Michigan (2012), Mississippi (2013), Montana (2013), New Hampshire (2009), New Mexico (2013), Oklahoma (1997), Oregon (2009), Texas (1997), Vermont (2012), Virginia (2010)

States with proposed/pending legislation: In 2013, Arizona (ENACTED), Connecticut, Florida, Illinois, Massachusetts, Mississippi (ENACTED), Missouri, Montana (ENACTED), New Mexico (ENACTED), New York, Pennsylvania, South Carolina, Tennessee and the District of Columbia
*No statewide coverage. Applies to rural areas only. (Arizona)

October 2012: States that reimburse for telehealth services: Maryland became the 13th state to require private sector insurance companies to pay for telehealth services. Maryland joined California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon, Texas and Virginia in mandating that private payers cover telehealth services that are considered medically necessary and would otherwise be covered when provided face-to-face.

The information is from several links to make what is on the image more readable. In addition, this link describes several of the developing programs in telemedicine.

I am concerned about conflicts with some states and their Physical Examination Requirements (PER). And with the federal component of PER, will this prevent telemedicine in some forms. Or will the telemedicine laws allow prescriptions. There is much in the way of legal problems to be resolved.

My state does not have a PER law (failed to make it out of committee again), but the state medical board is opposing the telemedicine bill and it failed to make it out of committee this year.