Telepsychiatry Leader Responds to AMA Telemedicine Policy

On June 11, 2014 the American Medical Association (AMA) announced its adoption of a new telemedicine policy, acknowledging telemedicine’s role in transforming healthcare. The Federal State Medical Board (FSMB) also released its Model Telemedicine Policy in April of this year. Both policies marked an important step forward in the expansion of telemedicine and both received their share of criticism from the healthcare and telemedicine communities.

Having attended the Institute of Medicine meeting and the CTeL event where most of this information was made public, and having thoroughly read the policy itself, I can safely say that many of the negative headlines I have encountered about the AMA policy could have just as easily taken a positive spin. For example, given the text of the policy, headlines could have just as easily read “AMA endorses real time video as equivalent to face-to-face,” which is huge news in the world of telemedicine.

While I acknowledge that the policy is cautious in its tone, it clearly states that a valid physician-patient relationship can be established via video and that the AMA’s previous policy on telemedicine is outdated. These statements, coming from the AMA, the nation’s largest and most influential organization of physicians, signify noteworthy progress.

The last formal telemedicine opinion issued by the AMA was a 1994 statement that prohibited physicians from using it altogether. Now the association has formal standards and guidelines, recommendations for the future of telemedicine and endorsement of expanding reimbursement for telemedicine services that meet standard criteria. The policy has some caveats that I am less happy about, but, given all of the gray areas surrounding telemedicine, overall I believe that this policy is a positive for the industry.

With that introduction let me highlight some of the points, both positive and negative that jumped out to me.

Positives:

–          Videoconferencing Can Establish a Valid Patient-Physician Relationship: The policy calls for the establishment of a valid patient-physician relationship with a face-to-face encounter before any telemedicine service, but it also specifically states that the initial face-to-face encounter “could occur in person or virtually through real-time audio and video technology.” With AMA validating videoconferencing for initial face-to-face encounters, policy makers across the nation now have a precedent to help define standards for appropriately establishing patient-physician relationships.

–          Call for Expanding Coverage and Payment for Telemedicine: The AMA recognizes that payment inconsistencies and barriers are limiting further adoption of telemedicine. They even state that, “physicians and other practitioners who provide a service via telemedicine must be paid an amount equal to the amount that the practitioner would have been paid if that service had been provided without the use of telemedicine,” and that “CMS should reimburse for telemedicine services in a fashion similar to traditional payments.” While there are certain other aspects of their reimbursement requirements that were not so helpful, from a broad-brush-stroked point of view, these statements from AMA should help to speed up the process of improving payment for telemedicine.

–          Call for Professional Organizations to Create Their Own Clinical Standards for Telemedicine:  The AMA recommended that individual specialty groups and organizations across all medical disciplines work to develop their own telemedicine practice standards and guidelines. I applaud the AMA’s choice to keep this policy broad, rather than trying to create blanket standards that fit all disciplines, and agree that the onus should be on discipline-specific organizations to define clinical best practices for telemedicine. I also appreciate the AMA for validating the work of and recommending further collaboration with the American Telemedicine Association, an organization that I identify as an excellent standard for telemedicine resources and advocacy.

–         Call for Additional Research and Pilot Programs to Expand Telemedicine: The AMA policy also rightfully encourages more research on quality of care and patient safety standards of telemedicine services. In my company’s niche area of psychiatry, for example, there is currently ample evidence of telemedicine’s efficacy in routine care settings, but a huge dearth in research on the health economics of crisis telemedicine, telemedicine’s potential for ED diversion and the potential and growth of in-home services. More verification of telemedicine’s value across multiple populations, settings, and applications will only carry telemedicine’s momentum forward by encouraging future policy amendments. The AMA’s current policy highlights several successful telemedicine programs like the University of Virginia’s successful telehealth system. I hope future iterations of this discussion will include further best practice examples and clinical outcomes.

 –          Focus on Quality Patient Care: Lastly, I commend the AMA’s commitment to supporting telemedicine while ensuring its goals of patient safety, quality of care, privacy of information and patient protection. As the policy states, “the key tenets in the delivery of in-person services hold true for the delivery of telemedicine services.” As such, I believe it is important remain mindful of the fact that quality patient care is the guiding principle behind all health care discussions.

Negatives:          

–          No Solution to the Licensure Debacle: AMA’s policy mandates that providers must be fully licensed in the state in which the patient is receiving the service. The policy also states that AMA “opposes a single national federalized system of medical licensure.” I recognize that an endorsement of national licensure by the AMA would be a significant stretch at this juncture, and I echo the importance of making sure telemedicine providers are appropriately trained and governed, but I am still disappointed that the organization made no attempts to suggest alternative methods for improving the bureaucratic mess that is medical licensure. Licensure complications are a major barrier to the growth of telemedicine and change, like an interstate licensure compact, must happen.

 –          An Overemphasis on Established Medical Homes: The AMA policy mandates care coordination with a patient’s medical home and/or primary care or existing treating physician as prerequisites for a fully covered telemedicine service. The idea that every patient has an established medical home and another physician waiting by the phone to consult with a telemedicine provider is wonderful in theory, but unrealistic in practice. With telemedicine we can leverage the reach of existing providers to make up for shortages and we can share information and provider time between multiple organizations and providers. However, this collaboration is not always readily available in the moment for every consumer. Certainly, continuity of care is of paramount importance, and we should strive for collaboration, information sharing, and warm-handoffs whenever possible. I believe, however, that we must also recognize that some circumstances will require episodic telemedicine intervention and that a consulting medical home may not exist or be accessible. I encourage AMA to be more realistic in this regard.

In today’s rapidly evolving health care environment, we must expect change to develop progressively, and expect that telemedicine policy advocates are going to constantly battle to keep regulations up to date with blossoming trends in technology and care delivery. There will inevitably be gray areas. Given this inevitability, I applaud the AMA for taking the proactive step of accepting telemedicine as a legitimate part of the future of health care.

While its policy does not recommend a revolutionary overhaul of the nation’s healthcare system to accommodate for telemedicine, its guidelines and recommendations signify an appropriate and important example of how the healthcare community can further accept telemedicine as a critical component of healthcare, and not its own separate category of services. I believe that the future of telemedicine will take the “tele” out of telemedicine completely and view it not as its own category of services, but simply as a regular part of the delivery of such episodic, ongoing, and preventative care to support overall wellness.

 Geoffrey Boyce

 geoffreyboyce1Geoffrey Boyce is the Executive Director of the CFG Health Network’s InSight Telepsychiatry. Since 2008, Boyce has advocated for the appropriate use and value of telepsychiatry and has developed unique telemedicine programs within areas of greatest need. Boyce is an active participant in telemedicine advocacy, education and reform initiatives, regularly interacting with state and local healthcare regulators and administrators. Boyce frequently speaks about the potential of telemedicine and the best practices for establishing new programs. Boyce holds an MBA from Terry College of Business at UGA with a focus on entrepreneurship and business planning.

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