As the popularity of telemedicine grows, the American Academy of Pediatrics offers guidance on the best ways to use this emerging technology.
Telemedicine is more than a video chat for an antibiotic. In its new policy statement on telemedicine, the American Academy of Pediatrics (AAP) outlines the best uses and ongoing needs for telemedicine, giving pediatricians a roadmap to navigate this growing trend.
The policy statement was written to describe the expected and potential impact of telemedicine on pediatricians, particularly in terms of improving access and workforce shortages, says the AAP.
In some instances, the AAP says telemedicine could improve care models through better communication among clinicians, increased efficiencies, and lower healthcare costs. It also would afford patients in remote areas better access to pediatric specialists, whom families usually must travel long distances to see. Telemedicine has the potential to improve care coordination and improve access to care for patients in isolated communities, the AAP says.
James P. Marcin, MD, MPH, practices in the pediatric intensive care unit at University of California, Davis (UC-Davis) Children’s Hospital and is in charge of the pediatric telemedicine program there. He helped the AAP craft the policy statement and says telemedicine is no longer a tool envisioned for the future.
“I think that everybody would acknowledge that it is a growing trend. The bus has left the station,” Marcin says.
Although telemedicine often has been viewed as a tool for outpatient care, Marcin says telemedicine has a variety of inpatient uses as well, including better care coordination and increased access through remote consultations and continuing education. Still, a lot of barriers exist, Marcin says, such as credentialing and payments.
“Doctors and health systems are paid to treat sick people and not paid to keep them healthy,” Marcin says. “There’s not much incentive for caregivers to monitor kids at home to reduce (other) visits.”
What the AAP does not see telemedicine used for is as a replacement for periodic office visits. “Telemedicine technologies used for episodic care by nonmedical home providers have the potential to disrupt continuity of care and to create redundancy and imprudent use of healthcare resources,” says the policy statement. “Fragmentation should be avoided, and telemedicine, like all primary and specialty services, should be coordinated through the medical home.”
Although the AAP touts the benefits of telemedicine from a perspective of supporting a patient-centered medical home (PCMH)-increasing access to specialists in underserved areas and decreasing emergency department visits-it says sporadic use could threaten the PCMH model.
“The use of telemedicine care by virtual healthcare providers, such as those linked to retail-based clinics, entrepreneurs, or insurers whose business model is to provide healthcare services to patients via smart phone, laptop, or video-consult kiosk without a previous physician-patient relationship, previous medical history, or hands-on physical examination, can undermine the basic principles of the PCMH model,” the AAP says.
Episodic use lacks access to the patient’s history, without timely and comprehensive follow-up, says the AAP. These visits also do not provide the same level of care that would be provided in a hands-on visit, and results in fragmentation of care, incomplete or redundant services, and wasted healthcare dollars.
Some for-profit groups are trying to take advantage of telemedicine, and they see an opportunity to contract with insurance companies on the premise of reducing visits, Marcin adds. However, those providers don’t know the patients and often don’t perform the necessary testing.
“Just seeing you over webcam at home and not being able to do what they should can threaten the medical home,” Marcin says of some telemedicine services. “The pediatrician needs to have this on [his or her] radar, as do parents and insurance companies, so that it is used in the right ways.”
The AAP says that although sporadic care may be tempting for patients and their families, it is not a good substitute for traditional care from their own primary care provider. “Although such novelty care appeals to parents because it can be faster, more convenient, and more affordable than an office visit, the loss of continuity of care, quality of care, and patient safety shows why this telemedicine care model should not be embraced,” the statement says.
As pediatricians adopt their own forms of telemedicine, Marcin stresses that “they have to be comfortable with doing whatever they want to do.” A lot can be done by phone, but pediatricians will have to determine when contact over video adds enough. For a specialty consultation or a follow-up? Perhaps. For diagnosing a cough? Maybe, but maybe not, Marcin says. “It has to be used so that it medically makes sense. Where it helps you clinically,” he adds.
The AAP defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status” and is usually limited to when a provider delivers direct patient health services. A similar term, “telehealth,” is a broader term that includes telemedicine plus other health services using various technologies such as electronic medical records and remote or mobile patient monitoring.
The AAP says telemedicine should not be considered a new or different type of care delivery, but a way to deliver the same or enhanced care over a distance rather than directly. It can help close gaps in care that are caused by distances or cost.
“There is significant disparity in the geographic distribution of pediatric physicians across the country, resulting in many underserved regions. Underserved communities are most commonly found in rural regions, but can include suburban and urban settings,” the policy statement says. “This maldistribution of workforce results in differential access and is at least partly to blame for differential health outcomes between rural and nonrural populations, particularly for those children with special healthcare needs. The literature shows that access barriers related to distance can be partly addressed with the use of telemedicine technologies, which can also minimize burdens of parents and other caregivers missing work, children missing school, and costs and risks associated with travel.”
In terms of clinical benefits, the AAP says that combining models of care that use telemedicine can result in improved adherence to evidence-based guidelines and clinical outcomes. Technology such as mobile patient monitoring also has the potential to improve outcomes, as well as increase the efficiency and capacity of a practice, the AAP says. Additionally, studies have shown that telemedicine can help increase healthcare access, reduce missed appointment times, increase compliance with recommended therapies, and ensure appropriate frequency of physical physician visits.
Reimbursement for telemedicine services remains a bit of an enigma, however.
Marcin says the policy statement does not get into the politics of payment, but explains that physicians don’t have much incentive to take on additional work without reimbursement. California lawmakers introduced a bill last year that would have required payment to physicians for phone calls and e-mails, but it never got out of committee. Marcin says the bill has recently been reintroduced but it is being opposed by insurance companies.
The Centers for Medicare and Medicaid Services (CMS) has set up telemedicine payment policies for Medicare, which the AAP says have been called “restrictive” by some. A proposed rule in 2014 also would give accountable care organizations (ACOs) flexibility to use telehealth services to improve care and lower costs. As for Medicaid, about half of the states pay for subspecialty medical and surgical pediatrician telemedicine consultations using Current Procedural Terminology consultation codes and Healthcare Common Procedure Coding System codes.
“States enjoy tremendous flexibility when developing innovative payment methodologies for services that incorporate telemedicine technology,” the AAP says. “This flexibility, however, can cause confusion when care is being delivered across state lines. . . . However, given the growing evidence that these technologies can improve satisfaction, increase quality of care and health outcomes, and reduce healthcare costs, states and payers are increasingly paying for telemedicine services.”
The AAP also predicts that the transition from volume-based to value-based care models will increase the use of telemedicine technologies.
Financial incentives for using telemedicine to reach underserved populations could be coming in the future. For example, some states have allowed the use of telemedicine technologies to be used to incentivize primary care offices to become certified as a PCMH, says AAP, and incentives for telemedicine should extend beyond tax credits to other models such as loan forgiveness and grants.
Payment isn’t the only obstacle facing pediatricians who seek to use telemedicine. In some practices, the initial investment can be substantial, and there is also the burden of regulatory red tape. Physicians who work across state lines must comply with all state licensure rules in each state whether in-person or via telemedicine.
“In addition, hospital- and practice-based credentialing and privileging policies often do not consider the delivery of care using telemedicine technologies,” the AAP says. “Not all states currently pay for telemedicine services or recognize CMS and Joint Commission rules on privileging by proxy for telemedicine providers.”
The AAP also questions the coverage of telemedicine services by malpractice insurance, urging physicians to review their individual policies.
The policy statement also sets forth several goals related to telemedicine, including knocking down barriers to telemedicine that keep care from reaching underserviced areas. It also recommends equitable payment for healthcare services delivered through telemedicine; restricting episodic telemedicine services to the context of a medical home; stable funding for continued support of telemedicine expansion and development; continued research on the efficacy and needs of telemedicine; financial incentives to physicians who can prove their telemedicine services improved access to care; and regulatory/licensure support to facilitate interstate practice and help physicians overcome administrative barriers to care expansion.