THE USE OF TELEMEDICINE TO IMPROVE ACCESS TO MEDICALLY UNDERSERVED AMERICAN COMMUNITIES

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1 THE USE OF TELEMEDICINE TO IMPROVE ACCESS TO MEDICALLY UNDERSERVED AMERICAN COMMUNITIES 1 2 Abdulhalim Khan, Salihu Tanko 1 School of Public Health, University of Memphis, TN, USA. 2 Department of family medicine, Aminu Kano Teaching Hospital, Kano, Nigeria. Corresponding Author:- DR KHAN ABDULHALIM School of Public Health, University of Memphis, TN, USA. Tel: abdulhalim.khan@hotmail.com, Abstract The purpose of this paper is to summarize the vast information on telemedicine in the United States and identify challenges and opportunities for improvement. The adoption of telemedicine in American health industry has been slow, and still enshrouded in controversies about telemedicine laws, reimbursement for encounters and services, and overall outcome of implementing telemedicine. However, it is thought that health education, primary care services and specialist services in underserved populations can be provided by telemedicine. In addition, it would be beneficial for developing countries to learn from the experiences and challenges in the US health system as they adopt telemedicine in the near future. Qualitative review of literature was conducted on telemedicine in the US and Nigeria, and summarized to provide the researcher with concise information on the current status of telemedicine, challenges and opportunities. Keywords: Telemedicine, United States, Nigeria, e-healthcare, e-medicine, tele-consultation, tele-education, telephony, EMR/EHR Introduction The United States (US) has a unique health care system because it is the most expensive in the World with 16.2% Gross National Product (GNP) spending on health equivalent to about $2.3 trillion in Despite huge spending on healthcare, indices for American healthcare quality are appalling with more than 50 million Americans having [1] inadequate access to health care. Access to health care is pivotal for achieving quality outcomes. Several efforts made to improve access to care have not been successful because of reasons ranging from inadequate providers to inappropriate geographical distribution of providers. Cost is also a known limitation to accessing health care. T e l e m e d i c i n e i s t h e u s e o f telecommunications to provide health information and health services which may serve as part of the grand scheme to improve access to health care and [2] improving the health of Americans. Literature Review: Definition of Telemedicine The American Telemedicine Association defined Telemedicine as the use of medical information exchanged from one s i t e t o a n o t h e r v i a e l e c t r o n i c communications to improve patients' [2] health status. ARID MEDICAL JOURNAL Vol.2 No.1 January - June,

2 A more comprehensive definition states: the use of advanced telecommunication technologies to exchange health information and provide health care services across geographic, time, social [3] and cultural barriers. The World Health Organization makes a distinction between telehealth and telemedicine. It defines telehealth as the integration of telecommunications systems into the practice of protecting and promoting health, while telemedicine is the incorporation of these systems into [ 3 ] curative medicine. Telehealth is understood to be a broader term to encompass telemedicine, preventive medicine such as health education, training and population health via the use of telecommunication. However, for practical purpose, telemedicine can be as simple as two doctors talking on the phone about the treatment of a shared patient. A standard and acceptable definition of telemedicine is desirable however as regulations are being made on issues such as reimbursement. This would mean that if the regulatory bodies adopt a definition of telemedicine and did not include phone call as telemedicine, it would not be reimbursed. Popular forms of telemedical consultations include telecardiology, teledermatology, telemental health and telemedicine for trauma and emergency situations. These consultations can be doctor to patient, [4] doctor to technician or doctor to doctor. There are two main categories of telemedicine which include the asynchronous and real time. The asynchronous type includes the store and forward telemedicine. This is popularly used in radiology. Real time telemedicine can be fully interactive or simply monitoring the patient via use of closed ARID MEDICAL JOURNAL Vol.2 No.1 January - June, circuit cameras and other monitoring systems. History of Telemedicine In 1924, the magazine Radio News foreshadowed the development of telemedicine. On its cover, a 'radio doctor' was linked to a patient by sound and live television. In 1950, the first mention of telemedicine appeared in literature in reference to the transmission of radiological image over a distance of 24 miles. The first successful use of video communications was documented by the University of Nebraska in In the 1980s, the interest in telemedicine reduced, because it was expensive, and appropriate technology was not available. However, the Newfoundland memorial hospital has been known to use one way video and 2 way audio system for telemedicine since 1977 successfully. Renewed interest arose partly because of newer technologies, reducing costs, improved payment system and incentive from government. Barriers to Telemedicine Telemedicine is critical to modern society and modern health care industry. It has the potential to improve quality of care and increase access by giving the provider and the patient the ability to interact within a short time and over long distance. However, the technology itself poses new challenges. These challenges or barriers have impeded the diffusion of telemedicine in the healthcare industry. Reviews of the literature identified some major barriers which may be categorized as physician licensure, credentialing and privileging, and medical malpractice [6],[7] liability. Other issues include unclear reimbursement models, cost and limited integration of telemedicine into health care.

3 Physician Licensure A strict law on physician licensure is a major restricting factor to the diffusion of telemedicine. A physician is challenged in practicing interstate telemedicine. Every state in the United State has enacted laws relating to the practice of medicine within the state boundaries including laws that delegate authority for enforcing licensing laws. Therefore, the federal government has limited capacity in enforcing any laws on licensure. However, all state licensing boards have different legal structures and rules on licensing. Recently, state boards, the Federation of State Medical Boards (FSMB) and physician organizations have s t u d i e d t h e i s s u e s a n d m a d e recommendations. All states require a doctor to have a full practicing license to practice in a host state with the exception of California. California allows a licensed guest physician from the United States to practice within its borders only if the physician would work with a California licensed physician who makes the final call on patient management. This is called consulting exception, and only applies to states who are listed as eligible by the Board. This may facilitate practicing interstate telemedicine but still not a seamless process. Another way is by endorsement which is the granting of licensure by a state to a physician with a practicing license from a state with similar standards. Most states practice endorsement now but it's a cumbersome process. It requires submission of an application, transcripts, payment of fees, and review by the board before endorsement. Other proposed models include mutual recognition, reciprocity, registration limited licensure and national licensure. Limited licensure is a modification of current licensure system allowing limited scope of practice. National licensure is proposed for professionals in national organizations such as the Veteran Affairs Hospitals. It is noteworthy to state that strict licensure laws are placed by states to ensure safety of patients and maintain the standard of [ 4 ] medical practice. Other health professionals also require licensure to practice and may face similar challenges as the physician in practicing interstate telemedicine. However, many nursing boards have used the 'compact' licensure model since 2000 which allows a nurse to have a license in the resident state and practice physically and electronically in other states subject to the host state [6] regulations. Credentialing And Privileging This is another legal impediment to the successful dissemination of telemedicine services even within the same state. Credentialing and privileging are policies and procedures that health care organizations use to determine whether a health care professional has the qualifications to be employed and p r a c t i c e a t t h e o r g a n i z a t i o n. Credentialing refers to obtaining, reviewing and confirming the credentials of a professional, records of malpractice a n d i n s u r a n c e h i s t o r y. M o s t organizations engage the services of credential verification organizations to do credentialing and is expensive. Privileging is the process whereby a specific scope of health care services is authorized for a health care practitioner by a health care organization. It is conducted by peer-review and may be subjective. The Joint Commission (JC) sets the standards for credentialing and privileging and is regarded as the nationally accepted standard. However, the JC allows credentialing and ARID MEDICAL JOURNAL Vol.2 No.1 January - June,

4 privileging by proxy for telemedicine services. This means that the originating JC accredited hospital (receiving telemedicine service for its patient) could rely on the credentialing and privileging decisions of the distant joint commission accredited facility (where the provider is located). However, the Center for Medicaid and Medicare Services (CMS) requires credentialing and privileging by the originating site. This is a major barrier to several health facilities especially small hospitals that cannot afford credentialing of several physicians, and do not have the capacity for peer review. In light of this, on May 26, 2010, CMS proposed new regulations on credentialing and privileging by proxy under certain circumstances for Medicare participating [6] hospitals. Medical Malpractice Liability Medical professional liability insurance coverage for practicing telemedicine is not widely available yet. The liability risk associated with telemedicine is not well documented yet because the field is still relatively new. This may affect the w i d e s p r e a d d i s s e m i n a t i o n o f telemedicine practice among physicians. Reimbursement There is absence of consistent and comprehensive reimbursement policies for telehealth. The lack of consistent reimbursement policies stems from the nature of multiple payer system in America. Another challenge is that many providers do not bill telemedicine service differently from face to face service. CMS mandated reimbursement for certain Medicare services following the Balanced Budget Act (BBA 1997). Billing of telemedicine service is required using special modifier for the corresponding current procedural terminology (CPT) codes. However, reimbursement is limited to patients in certain geographic locations, and coverage requires the use of real time audio video telecommunications [7] at approved originating sites. Cost Cost may be a perceived barrier by providers because additional cost is i n c u r r e d w h e n i m p l e m e n t i n g telemedicine. This includes dedicated transmission modes that would support a desired data transmission. A common transmission mode used in telemedicine is T1 telephone connection which is a dedicated fiber optic wiring with an average transmission speed of 1.54 megabytes per second. Other costs include telemedicine specific equipment such as digital stethoscopes and high resolution video cameras. A study comparing cost of telemedicine to that of face to face service in Informatics for Diabetes Education and Telemedicine (IDEATel) showed that there was no s i g n i f i c a n t c o s t s a v i n g s u s i n g telemedicine. However, studies of this [8] nature are limited. Other Peculiarities of Telemedicine Informed consent: the practice of telemedicine requires additional information to be provided to patients receiving telemedicine services. The patient needs to be informed that services are being provided by telemedicine and its peculiarities, the possibilities of technology failure and possible alternatives in such events. Privacy and Security: the Health Insurance Portability and Accountability Act of 1996 (HIPPA) spells out the Privacy ARID MEDICAL JOURNAL Vol.2 No.1 January - June,

5 and Security rules. The Privacy Rule requires reasonable safeguards to protect Protected Health Information (PHI). This applies to both electronic and physical protection. The emphasis is on reasonableness, hence, the safeguards applied by a small hospital utilizing telemedicine may not be the same with the providing bigger hospital. The Security Rules do not apply to communications with patients by videoconference, fax or telephone. The Security Rule is technology neutral and emphasizes reasonableness rather than an absolute [7] criteria. Telemedicine to Improve Access to Health Care A large proportion of Americans do not have access to health care for several reasons which include living in medically underserved and rural areas. Health Information Technology for Economic and Clinical Plan (HITECH) enacted under the American Recovery and Reinvestment Act of 2009 provides both incentives for adoption of technology and penalties for non-adoption. Additional incentives are provided by the Federal Communications Commission for implementing telemedicine in rural or underserved areas. A new model of health care education and delivery known as Project ECHO (Extension for community Healthcare outcomes) has documented promising results. This project was established at the University of New Mexico Health Sciences Center to develop the capacity for safe and effective treatment of chronic, common and c o m p l e x d i s e a s e s i n r u r a l a n d underserved areas while monitoring outcomes to ensure quality of care. This model used telemedicine to educate and train primary care physicians to manage common chronic diseases that would otherwise require specialist care (which is not available in rural areas). The focus was on treatment of Hepatitis C in New Mexico. Primary care physicians needed training on staging of patients, treatment protocol and treatment of drug side effects. This was achieved using telemedicine. In addition, specialists were available to the primary care physicians through telemedicine. Project ECHO expanded the scope of health facilities in rural areas of New Mexico to treat patients with Hepatitis C from fewer than 1600 to greater than 10,000. It cost patients less because they got specialist care with the [9] primary care physicians. Other models that used telemedicine successfully include the Indian Health Services (IHS) and Veteran Affairs. The IHS partners with several academic institutions for specialty services via telemedicine including the Brigham and Women's [10] Hospital in Boston Massachusetts. Highlight On Telemedicine In Nigeria, Challenges And Way Forward Adoption of telemedicine is encouraged by the World Health Organization because of it's potential for access and cost [11] saving. Developments in information technology has led to paradigm shifts in how e-banking, e-learning and e- commerce is conducted in developing countries including Nigeria. The healthcare industry is still in the early phase of experimenting telemedicine in [12] Nigeria and some African countries. Broadly, telemedicine may be useful in developing countries for both teleconsultation and tele-education. Based on research data on telemedicine for palliative care in Nigeria, there are two [13] futuristic scenarios for telemedicine. One is real time audio visual ARID MEDICAL JOURNAL Vol.2 No.1 January - June,

6 teleconsultation while the other is lite teleconsultation which includes the use of mobile phones (mhealth) with synchronous telephone and text messaging. The lite version could also use non-synchronous and text [13] messaging. T h e c h a l l e n g e s t o s u c c e s s f u l implementation of telemedicine are in many folds. It requires leadership willingness, stable internet connection and electricity, dedicated equipment, training and awareness. A readiness assessment (RA) is needed for the location [12] of interest. The components of the RA are Need Readiness, Structural Readiness and Acceptance and Use Readiness. A study in Western Nigeria showed that there is a significant gap in structural readiness for the successful [12] implementation of telemedicine. Other challenges include lack of standard policy on reimbursement and regulation and a general lack of electronic health records to [14] support storage of tele-consultation. In 2008, Federal Medical Center, Birnin Kebbi in Nigeria partially implemented a telemedicine program funded by a Federal Ministry of Health grant. However, 92% of staff at the center did not [15] know it was available. It is noteworthy that despite the poverty level in most developing countries, mobile phone technology is widely used which has been helpful in the telemedicine journey. This creates a real opportunity for the healthcare sector to explore lite telemedicine and expand to a more futuristic full version of [ 1 3 ] telemedicine. Another future opportunity may involve exploring programs such as PEPFAR where electronic health record has been e s t a b l i s h e d a n d s o m e f o r m o f [13],[16] telemedicine has been attempted. Conclusion Telemedicine can make specialty care more accessible to rural and medically underserved communities. It's capable of maintaining quality of care, and has the potential for cost savings. Telemedicine can also be used to train providers in underserved communities to manage some common specialty cases while maintaining high standard of care for the patients. References 1. DeNavas-Walt C, Proctor JC. Income, poverty and health insurance coverage in the United States Washington: Current population report, US Census Bureau; Karen AW, Lee FW, John PG. Managing healthcare information systems. Current and emerging use of clinical information systems. San Francisco: Jossey Bass; Darkins RD, Leitner P. The telemedicine industry report. New York: Waterford telemedicine partners; Kramer A. Telemedicine: licensure barriers and solutions. Arizona; Roh CY. Telemedicine what it is, where it came from, and where it will go. Comparative technology transfer and society; 2008, ARID MEDICAL JOURNAL Vol.2 No.1 January - June,

7 6. Rowthorn V, Hoffman D. Law and healthcare programs hosts roundtable on legal impediments to the diffusion of telemedicine. Law and healthcare newsletter; Baker DC, Bufker LF. Preparing for the telehealth world: navigating legal, regulatory, reimbursement, and other ethical issues in an electronic age. Journal APA; 2011 Nov;42(6): Palmas W, Shea S, Teresi JA et al. Medicare payments, healthcare service use, and telemedicine case management with usual care in m e d i c a l l y u n d e r s e r v e d participants with diabetes m e l l i t u s. J A M I A ; Mar;17(2): Arora S, Kalishman S, Dion D et al. Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care. Health Affairs; 2011 Jun; 30(6): Sequist DT, Cullen T, Acton AJ. Indian health service innovations have helped reduce health disparities affecting American indian and Alaska native people. H e a l t h A f f a i r s ; O c t ; 30(10): J u s t i c e E O. E - h e a l t h c a r e / t e l e m e d i c i n e r e a d i n e s s assessment of some selected states in western Nigeria. IJET; 2012 Feb; 2(2): Gurp JV, Soyonnwo O, Odebunmi K et al. Telemedicine's potential to support good dying in Nigeria-A qualitative study. Journal PLosOne; 2015 Jun; 10(6): Akanbi MO, Ocheke AN, Agaba PA et al. Use of electronic health records in sub saharan Africa: Progress and challenges. JMedTrop Sep; 14(1): Monsudi FK, Ayanniyi AA, Oguntunde OO. Awareness and practice of telemedicine among staff of federal medical center at b i r n i n k e b b i, N i g e r i a. JTelemedTelecare; 2012 Oct; 18(7): Chaplain B, Meloni S, Eisen G et al. Scale-up of networked HIV treatment in Nigeria: creation of an integrated electronic medical record system. IJMedInf; 2014 Sep; 84(1): Mayoka KG, Rwashana AS. A f r a m e w o r k f o r d e s i g n i n g sustainable telemedicine in developing countries. JSIT; 2012 Jul; 14(3): ARID MEDICAL JOURNAL Vol.2 No.1 January - June,