Telemedicine is being praised, and rightly so, for folding space and time to deliver first-class healthcare to rural populations as well as homebound city dwellers. What we don’t hear so much about are the limitations.
There are gray areas — human, regulatory, reimbursement and technological — that inhibit what can be accomplished via telehealth today.
With its focus on mental health, substance abuse, stress and the like, behavioral health is widely considered a strong suit for telemedicine, requiring little if any hands-on treatment, only the doctor’s eyes and ears. But Robert Cuyler, a practicing psychologist and senior associate for OpenMind, said considerable debate about remote consultations exists even within his field.
A practitioner may not be aware of the potential for domestic violence, for instance, or lack of privacy, suicide risk and other emergencies, Cuyler explained.
Regulatory issues are also at stake, such as whether it's safe to prescribe when someone is at home rather than in a healthcare environment, especially true if the medication is narcotic-based.
Then there are the technology challenges. Cuyler added that when he practices teletherapy he may inquire “a little bit differently,” to make sure that he isn't mistaking what might look like a case of the sniffles from someone who is tearing up.
Indeed, practitioners must be aware of so-called telling micro-expressions that reveal hidden emotions, which may be more difficult to notice over even a high-definition video transmission.
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Paul Ekman, a pioneer in micro-expression research, said that while the physician’s recognition of micro-expressions has proven crucial to a patient feeling that the doctor is empathetic, the expressions won’t be noticed unless the resolution and lighting are good.
Ekman said the face should fill up at least half of the camera view and the therapist has to be able to see, for example, the tightening or tensing of the lower eyelid, “enough to begin to cover the iris.” Even with high-resolution tools, he said, without proper training these cues can be missed.
Joe Navaro, a former FBI agent who is trained in deception, espionage and interrogation, said in an article in Psychology Today that it’s not just micro-expressions via teleconferencing that can be missed if caregivers are not properly trained. Certain facial expressions are so small, like the twitch beneath the eye, and rapid - they pass in 1/15th to 1/25th of a second - that they are extremely difficult to observe.
Despite all the technological issues that need to be met to advance the practice of telemedicine the gating factors for the immediate future are more economic and regulatory.
Cuyler believes the reimbursement climate has lagged way behind what healthcare practitioners know about the effectiveness of telehealth and that this is one of the great inhibitors to its growth.
Private insurers, meanwhile, are slowly coming around to covering telehealth, but it's still far from a common practice. Medicare and Medicaid cover some telemedicine treatment if done in a rural location but do not pay for the same treatment in an urban area. Some treatments have not been issued the golden CPT code at all. In addition, each state has its own reimbursement schedule and telehealth regulations.
Thanks to recent legislation the Centers for Medicare and Medicaid Services (CMS) has laid down early rules on reimbursement for telehealth services. Although quite limited, none of the physicians interviewed for this article doubted the CMS would expand its coverage by offering more CPT codes for a wider range of mobile care.
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At present, CPT codes have been created for psychiatric diagnostic interview examination, individual psychotherapy, end-stage renal disease-related services included in the monthly capitation payment, and neurobehavioral status examination, according to the American Telemedicine Association (ATA).
The codes themselves, however, have limitations that depend on geographic location of the patient, home, hospital, office or clinic, live or store-and-forward video conferencing, and type of health provider, among others.
Consultations, office visits, psychotherapy and pharmacologic management via telehealht are eligible for reimbursement, according to the ATA. And 42 states now offer some form of reimbursement for telehealth, defined by CMS as either live consultation or store-and-forward of images, data, video or audio for the purposes of evaluation. In addition, 17 states are requiring some degree of coverage compliance by private insurers.
This year the CMS is expected to expand coverage of telehealth beyond purely rural locales to the “fringes of metropolitan areas,” according to the National Conference of State Legislators.
Despite all the enthusiasm over telemedicine, the increasing expansion of coverage and the size of reimbursement, Cuyler says he follows one rule of thumb: Where in-person care is accessible, telehealth has a limited role; if it is not improving access or there are comparable procedures in-person, it's best to opt for those.
Ephraim Schwartz is a freelance writer based in Burlington, Vt. He is a recognized mobile expert and columnist, having spent 15 years as Editor-at-Large for InfoWorld, half of them covering the mobile space. Prior to that he was Editor-in-Chief of Laptop Magazine.
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