Telehealth continues drive change as an innovative alternative to traditional brick-and-mortar medicine. And what works on land can work in the air.
The airlines have upgraded their communications technology and mobile device policies so that nearly every plane is equipped with Wi-Fi and other technologies, allowing both crew and passengers to communicate in real-time with persons on the ground. Moreover, new data compression algorithms are allowing high-definition transmissions to consume lower bandwidth, resulting in faster and more manageable connections.
Thanks to these advancements, a passenger can consult with a physician mid-flight and pick up a necessary prescription at a local pharmacy once the plane lands or have the medication mail-delivered right to his/her hotel. Some companies have begun to offer certain contracted telehealth services for airline crews and emergencies.
With millions of people flying on thousands of flights each day, there is a real opportunity for provider expansion, bringing telehealth to passengers across the country and the world. Focusing on U.S. domestic flights, here are three potential business models a health system or telehealth provider interested in airline-related telehealth could consider:
Model 1: Contracting with airlines to provide services to the crew. Airlines employ a vast number of in-flight personnel who regularly work long shifts consisting of time spent in the air and layovers in unfamiliar cities. They are exposed to hundreds of potentially sick passengers each flight and are constantly located a great distance from their primary care provider.
Telehealth is an obvious convenience for this population. The airline would benefit from telehealth services with increased presenteeism and fewer sick days (and therefore fewer workforce scheduling challenges), improved customer service provided by a healthier crew, a potentially lower cost alternative to other forms of healthcare that the airlines already provide (or a supplemental employee benefit), and promotion of healthcare triage and urgent care from a single source telehealth provider.
Model 2: Offering in-flight telehealth services directly to passengers. Now that nearly every flight is equipped with Wi-Fi, airlines can start offering in-flight services to passengers. This model takes the same business approach as existing on-ground direct-to-patient offerings, but brings it in-flight. This is particularly attractive for "road warriors" who often fly for business and have little down time to fall sick. Similarly, families headed on vacation could see the benefit of having an issue addressed before they land at an unfamiliar destination and struggle to locate a suitable walk-in clinic (a less than ideal way to spend the first day of vacation).
Model 3: Contracting with airlines to provide emergency services to crew and passengers. "Ladies and gentlemen, this is your captain speaking. Is there a doctor on board?" This may be heard more often in films, but by offering telemedicine-based emergency consult services to all persons on board (crew and passengers), an airline can ensure this question will never be met with silence. Under this model, the telehealth physician would be available to provide expert consult and oversight of the trained airline crew to better triage and manage the patient until the plane lands. The patient benefits with the greater care oversight a telemedicine emergency physician can offer. The airline benefits by promoting this innovative health and safety measure to its passengers and crew. And the telehealth provider benefits by, for example, having its name and logo listed in the in-flight materials, to be seen by millions of unique passengers each day.
Furthermore, none of these potential models are mutually exclusive, and the telehealth provider could build an arrangement combining all three elements.
Regardless of the business model chosen, there are two initial regulatory considerations.
Licensure. In-flight telehealth presents a unique question: Of what state should the doctor hold a license? The general rule in the U.S. is that the physician must be licensed to practice medicine in the state where the patient is located at the time of the consult. There has been some progress in the FSMB interstate medical licensure compact, but that continues to develop and is not yet nationwide (currently approximately 10 states have signed on). One possible, reasonable approach to this is that the doctor should be licensed in one of the following: 1) the state from which the plane takes off; 2) the state in which the plane lands; or 3) the patient's home state (particularly if the telehealth service is a follow-up to a pre-existing doctor-patient relationship).
An alternative – and entirely impractical – approach would require the doctor to be licensed in the state over which the plane is traveling at the time of the consult. Cruising at 30,000 feet at 550 miles per hour, this approach is illogical and too burdensome from an operational standpoint (to say nothing of state medical board enforcement). As a point of comparison, airlines are not generally required to follow the law of every state over which they are flying. For example, Federal Aviation Administration regulations on service of alcoholic beverages do not expressly establish a minimum drinking age when the plane is in the air. As a matter of policy, airlines typically do not serve alcohol to anyone under the age of 21. Thus, there are at least three simple, reasonable approaches available to overcome the hurdle of state licensure.
Privacy and security. Maintaining the privacy and security of patient health information is required under state and federal law. A patient sitting in the middle seat of a commercial jet may feel less comfortable than if he or she were communicating with a doctor from the privacy of his or her home. Nonetheless, the patient has the right to contact the doctor in-flight and consent to the telehealth consult. Of course, the electronic communication transmission and patient record data storage must be private and secure. As the provider should be doing that already, an in-flight telehealth consultation presents no more of a legal concern than a telehealth consultation conducted on the ground. Again, as with licensure, an examination of this apparent "complex regulatory barrier" reveals itself to be mostly an operational decision, solvable with the right combination of legal understanding and business modeling.
With more people traveling, longer flights and advancements in technology, the opportunity for in-flight services will continue to increase. Taking telehealth to the airline industry is just one of limitless opportunities innovative providers of healthcare services can disrupt current models of care and bring the doctor to the patient.
(Evan Malloy helped to prepare this article)
Nathaniel Lacktman is a healthcare regulatory, compliance and business lawyer with a particular focus on telemedicine, telehealth and innovative healthcare arrangements and offerings in the U.S. and Internationally. A Partner at Foley & Lardner LLP, he is listed in 2013, 2014 and 2015 Chambers USA:America's Leading Business Lawyers. He is the co-chair of the AHLA Telemedicine and eHealth Affinity Group, a frequent speaker and author, and member of the American Telemedicine Association. Follow him on twitter @Lacktman
