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Alternative health care settings and the use of online interfaces are being used to link health care practitioners to patients to provide consumers more options and convenience. Telemedicine is one of many different care delivery models used to provide interactive health care that makes use of new technology and telecommunications. The American Telemedicine Association defines Telemedicine as the use of medicine of medical information exchanged from one site to another via electronic communications to improve patients' health status (Telemedicin Defined, 2009). Telemedicine can be provided in different formats such as, videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and using nursing call centers.
With the focus on improving the quality of patient care and maintaining the integrity of the information being exchanged during teleheath care it's imperative to make privacy and security an upfront and integral part of providing telemedicine services. The barriers to telemedicine are confidentiality and security, liability, licensure and accreditation, legislation, fraud, and reimbursement.
Advances in technology have provided an opportunity for health care to reach consumers in rural areas that have to travel miles to receive care. Licensure and accreditation is a raising legal concern in telemedicine particularly relating to cross-state practice.
Licensure seeks to protect the public by setting standards of qualification, education, training and experience for those who seek to engage in the practice of medicine and to promote high standards of professional performance for those engaged in the profession. State licensure laws are a barrier to the growth of telemedicine in many states. Unlike other states California's legislation allows out-of-state physicians to practice within its borders only in actual consultation with a California licensed practitioner and prohibits the out-of-state practitioner from having ultimate authority over the care or primary diagnosis of a patient located with California (Licensees: Practicing Medicine Through Telemedicine Technology, 2007).
The telemedicine physician should know the patient's state law before providing care because it could be illegal to practice across state lines. Interstate licensure laws vary from state to state. Some states are considered either restrictive, or reciprocal. Many states have no action which allows out of state physicians to practice telemedicine without additional licensure. Tennessee is considered a restrictive state which requires the physician to be licensed by the state of Tennessee to provide care from another state, but there are exceptions that my release an out of state physician from obtaining additional licenses. The exceptions could be if the telemedicine is for educational purposes, used in the service of the U.S. military, and if the service activity is infrequently. The use of telemedicine may face different challenges such as, where a negligent practitioner would be prosecuted in a malpractice claim because the physician practices in a different state where the patient resides. The will be discuss later.
With the adoption of electronic health records patient privacy has become a major focus in health care. Consumers are concerned about identity theft in their everyday life and more than ever they are worried about lack of privacy regarding their health information. While new technology has the capability to enhance health care delivery, they also create questions about who has access to the patient's information and how it is protected. Confidentiality and security becomes an issue when health information is transmitted electronically across state lines. To safeguard health information the American Health Information Association (AHIMA) recommends health care providers ensure that confidentiality and nondisclosure agreements have been signed by all contract and vendor personnel, encrypt the data if possible, employ redundant systems to mirror tape so that both referring and consulting facilities have originals of the media, and incorporate telemedical records in disclosure policies. AHIMA also advise telemedicine physicians to address who can disclose information and establish a method to ensure that only authorized person(s) receive and transmit telemedical information (Welch, 1999).
Patients may be unaware of how their medical records are being disclosured to others. For some procedures and examination they maybe veiwed by unknown parties and records may be sent through different channels used by the telemedicine physician. Computer hacking could be a challenge because hackers can break in the computer system and obtain confidential information. The Health Information Management (HIM) personnel responsbility would be to control the number of persons who have access to the health care information and prevent unwanted disclousre.
Reimbursement is another roadblock when practicing telemedicine due to the inconsistency of comprehensive reimbursement poilices which hinders the growth of telemedicine. The majoirty of health care costs are paid by private insurers, Medicare and Medicaid. Effective in January, 1999, The Balance Budget Act of 1997 (BBA) was the first piece of legislation to mandate that Medicare must reimburse for some telemedicne services. However, the BBA included many constraints (that were unrealistic to the actual provision of telemedicine services) that limited reimbursement (Whitten, 2007). The contraints to telemedicine, limited rebursement in rural areas, fee slpit between the teleconsulting physician and the referring health care provider, and limiting reimbursement to specific CPT codes. In 2000 Congress addressed the limitations placed on telemedicine reimbursement by the BBA. Since 2000 there have been some improvements such as the prohbit of the fee splitting and it now expanded eligible CPT codes. The Benefits Improvement and Protection Act of 2000 expended the geographical locations for eligible orignation sites to include counties that are not located in metropolitan areas.
Private insurers are subject to regulations set by the state. Currently there are eight states that have passed laws regarding reimbursement of telemedicine and private insurers provide some reimbursement for telemedicine services with legislative mandates. Lack of reimbursement inhibits use of telemedicine services. Reimbursement is essential for telemedicine to become practicable on a widespread basis over the long-term.
Telemedicine had been confronted with the same variety of liabilities ranging from malpractice to privacy concerns just like traditional practice of medicine. With more than one physician providing care to patients from different locations this has brought on questions who should be held liable and can a physician-patient relationship be created if the physician never seen the patient. The existence of the physician -patient relationship is important to determine medical malpractice or negligence. Even though a patient may not be in a room with a physician, a relationship may still be formed by the use of telemedicine to diagnose or treat a patient. For example, in Wheeler v. Yettie Kersting Memorial Hospital, the plaintiff was transferred 90 miles away and the patient died when a physician used telephone information provided by nurse (Wheeler v. Yettie Kersting Memorial Hospital, 1993). In Lopez v. Aziz, a physician-patient relationship was not found when a obstetican talked to treating physician by phone. The court noted that since Aziz did not contact or examine Mrs. Lopez directly, and only spoke with her doctor, no relationship existed.
Traditionally, any entity that has responsibility at any time from setting up to use of the clinical device incurs liability. Telemedicine introduces new parties, such as the telemedicine vendor and technical staff. The Federal Food, Drug and Cosmetic Act regulate prescription drugs and medical devices. Some concerns telemedicine practitioners may come across in regards to vendors and the use of telemedicine devices are, breach of contract actions may brought against software vendors who support telemedicine communications, negligence actions may arise against manufacturers of telemedicine devices, and malpractice claims could develop against physicians for improper diagnosis and treatment of patient based on telemedicine data.
Anti-Kickback Statue and the Stark Law have posed a problem to some government funded telehealth programs in the past due to inconsistent statues. Some federal grants, providers have been encourage to provide free telemedicine services, whereas the Anti-Kickback Statue imposes penalties for such relationships. Telemedicine practitioners are encouraged to contact the Office of Inspector General (OIG).
Documentation is another challenge when practicing medicine at a distance. As with any treatment there should be traceable record of care.
Telemedicine is a practice that requires technology, health care and different forms of telecommunication. Telemedicine affect the HIM field because there are policies and strategic plans that are needed to enhance the growth of telehealth. For example, telemedicine is facilitated by access to an interoperable electronic health record (EHR) that allows physicians to review and evaluate all the necessary information about the patient. The HIM professional is the expertise in implementing EHRs and developing organization policies to meet HIPAA standards and regulation. The telemedicine physician and the HIM professional should work together to address to develop some key policies such as, informed consent, release of information, and identifying all required information for a referral or consultation.
Telemedicine is now widely recognized as an essential part of modern quality health care. Not only does telemedicine support long distance clinical care, it also offers a method for health care providers to seek a second opinion, if needed and patients are more involved in managing their care by using internet applications, social media, and remote monitoring devices. Future telemedicine trend include wireless health care, encryption technology to provide security that's consistent with HIPAAs standards.
Ross, L. (2001, August 24). Legal Issues Affecting the Practice of Telemedicine. Retrieved November 18, 2009, from http://www.med.umich.edu/telemedicine/symposium/ross/index.htm
Wheeler v. Yettie Kersting Memorial Hospital, 866 S.W.2d 32 (Texas Court of Appeals January 11, 1993).