In Telemedicine Recommendations, ACP Advises Caution

The American College of Physicians outlines when and how telemedicine can be used appropriately in primary care and what's needed to make it better.

Telemedicine is good, when it's an appropriate use of the technology, but there are still some hurdles to jump along the way to make it as good as it can be.

Those are the main takeaways from the American College of Physicians' position paper outlining its policy recommendations for using telemedicine in primary care settings.

"Telemedicine is probably here to stay," says Wayne J. Riley, MD, MPH, president of the American College of Physicians, and clinical professor of medicine with the Vanderbilt University School of Medicine and adjunct professor of healthcare management with the Owen Graduate School of Management at Vanderbilt University. "We see a lot of potential good that can come from telemedicine, but it has to be done right."

Riley says the ACP heard from many of its 143,000 members who had questions about the role of telemedicine in their practice and their community, and who wanted to be thoughtful and appropriate in their use of it.

The position paper includes 13 main recommendations, which were developed after a review of studies, reports, surveys, and the legal landscape of telemedicine "through our very rigorous policy process," Riley says.

The recommendations can be broken down into two categories: Those pertaining to the immediate use of telemedicine and those calling for future action.

Telemedicine Today
On the immediate-use front are recommendations that discuss when and how telemedicine should be used. For instance, ACP believes that telemedicine should "enhance patient–physician collaborations." Rather than using telemedicine exclusively, it's best used to either supplement an existing, in-person relationship or in consultation with another physician who does have an existing relationship with the patient.

The organization also advises that physicians exercise caution if they've never treated a patient in person before seeing them via telemedicine by either taking "appropriate steps to establish a relationship based on the standard of care required for an in-person visit," or consulting "with another physician who does have a relationship with the patient and oversees his or her care."

"We worry about the initial telemedicine encounter that is only established through telemedicine or a video link," Riley says. He acknowledges that some emergency situations require quick triage decisions via telemedicine, and suggests that  follow-up care be done in person with the patient's regular doctor.

Another recommendation calls on physicians to "use their professional judgment about whether the use of telemedicine is appropriate for a patient." Riley says nothing can replace the exam room for a patient-physician encounter.

"It's not sufficient just to have telemedicine," he says. "You really have to get in to see your doctor."

He points to managing chronic conditions as a good example of the judicious use of telemedicine; instead of seeing a patient in-person once a month, perhaps some of those visits can be done via video chat.   

In addition, not every condition is appropriate for telemedicine.

"You can't diagnose a brain tumor by video link," Riley says. "It's probably not a good idea."

Calls to Action
Other recommendations include calls to action, such as the need for developing "evidence-based guidelines and clinical guidance" for telemedicine's appropriate use.

In addition, because "telemedicine is an appropriate medical encounter," the ACP believes it should be reimbursed as such.

"We do advocate for appropriate reimbursement for telemedicine service," Riley says. Although encounters may not occur in-person, "it is still using the cognitive skills" of physicians and is therefore should be compensated.

The guidelines call for "reimbursement for appropriately structured telemedicine communications, whether synchronous or asynchronous and whether solely text-based or supplemented with voice, video, or device feeds in public and private health plans, because this form of communication may be a clinically appropriate service similar to a face-to-face encounter."

Reimbursement for telemedicine today is "all over the map," Riley says, and varies by state. Because of this, telemedicine is "going to be very diverse in its penetration through the country."  Similarly, "there's no one federal standard for telemedicine," he says, because the practice of medicine is governed by states and territories.

Interstate Licensure Agreement Adds Two More States

To those ends, the ACP also calls for:

• A streamlined process to obtaining several medical licenses that would facilitate the ability of physicians and other clinicians to provide telemedicine services across state lines while allowing states to retain individual licensing and regulatory authority
• Allowing hospitals and critical access hospitals to give "privilege by proxy"
• Lifting geographic site restrictions that limit reimbursement of telemedicine and telehealth services by Medicare to those that originate outside of metropolitan statistical areas or for patients who live in or receive service in areas where there is a shortage of health professionals

Riley says physicians and healthcare leaders who are interested in the future of telemedicine should pay attention to what's happening in their states, because that's where the "action really is."

"You have to be very attuned to what's going on in your statehouse," Riley says. "That's where it's appropriate for our members to participate in the rule setting."

HealthLeaders Media LIVE from Mercy: Telemedicine; Healthcare's Nerve Center, will be broadcast on Thursday, October 22, 2015, from 11:00 to 2:00 p.m. ET. Mercy Health System reveals underlying reasons for their successful implementation of telemedicine. How telemedicine has enabled them to improve outcomes, reduce costs, provide their clinicians better quality of life, and made them an increasingly attractive value proposition to payers.