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Telemedicine Telehealth Efforts of the U S Government

Table of contentsSectionNumberAbout the editorTe lemedicine medic aid and medicarele medicine at the fedelCommunications Commission (FCC)US

Department of Agriculture ruraDevelopment ProgramsThe National Center fole healthTechno lo gy(2)National center for PtsdThe Food and Drug administrationDigital health initiativeThe us National library of medicineTe le health Enhancement Act of 2013Te lemedicine clinicaltrials gov

recognized"practitioners/providersstate where teTherefore, the general medicaidments of comparability, state widehoice do not apply with re gard to telemedicine servicesCMS Appito Reviewing telemedicine spasStates are not required to submit a(separate) SP A for coverage or reimbursement oftelemedicine services, if they decide to reimburse for telemedicine services the sameStates must submit a(separate)reimbursement(attachment 4 19-B)SPA if they want tofor telemedicine services or components of telemedicinedifferently than is currently being reimbursed for face-to-face servicesStates may submit a coverage SPa to better describe the telemedioose to co ver, such as which providers/practitioners are; where it is provided; howprovided, etc In this case, and in order to a void unnecessary SPA submissions, it isecommended that a brief description of the frame workemedicine be placed in anintroductory section of the state Plan and then a reference made to telemedicine coveragein the app licab le benefit sections of the State Plan

For example, in the physician sectionit might say that dermatol gy services can be delivered via telemedicine provided astate require ments re lated to te le med icine as described in the state p lan are otherwise metLink:https://wwwmedicaidgov/medicaid/benefits/telmed/indexhtmlMedicareWhether expanding Medicare coverage for telemedicine services would increase or decreasefederal spending is difficult to predict, but doing so depends on two main considerationsthe payment rates that would be estab lished for those services, andWhether those services would substitute for (or reduce use of) other Med icare-coveredservices or would be used in addition to currently co vered servic

believed that if all or most telemedicine services substituted for or pre vented the use of moexpensive services, coverage of telemedicine could reduce federal spending If ins teadlemedicine services were mostly used in addition to currently covered services, co veragetelemedicine would tend to increase Medicare spending Many proposals to expand co verage ote lemed ic ine strive to facilitate enrollees access to health care, there fore sucals couldincrease spending by adding payments for new services instead of substituting for existingserviceecause coverage of te lemedicine services in Med icare's traditional fee-for-service program islimited, so is evidence about the effects of such coverage

Thus, Congressional Budget Office(CBO)must often draw inferences from other sources-such as the experience of privatemanaged care plans-when developing cost estimates However, an important limitation of thatevidence is thate plansvays to influe servicesir enrollees use than are available in Medicare's fee-for-service program(which the Department of Health and Human Services and its contractors run) As a result, evencoverage of telemedicine reduced net costs for some private plans, the greater difficultiesinvolved in ensuring that services are used appropriately in the fee-for-service Medicare pro grammean that proposals to e xpand coverage of services in that program could increase feder

Given the substantial intelsals re lated to te le med iCBO has prepareddiscussion below, which further describes the is sues that arise in defining a telemedicine benefiand how cbo ees the bud getary effects of those proposalsTe lemedicine services include virtual visits with doctors or other professio nals, remotemonitoring of patients'conditions, and off- site analysis of medical imaging or test resultshroughalls, video chats, text messages, email, and websites with the varied possibilities, proposals toexpand coverage for telemedicine or telehealth services in Medicare would need to defineseveral factors, includingThe services that would be covered and their allowed methods of deliverythe types of providers and sites of care that could be paid to offer those services, andthe types of patients or beneficiaries who would be eligible to receive such servicesCBOswould take into account how they differed from medoverage of te lemedicine services under current law Now, Medicare providers can be paid tofurnish certain telemedicine services bcified methods and sites of service- but onlyfor patients who live in rural areas

(Those patients generally visit a facilit y that has some staffut that accesses some doctors remotely )In general, Medicare pays the distant doctor or otherprovider of telemedicine the same fee that Medicare would have paid for an in-person officeItfee Medpayments are thus higher for te lemed icine services than for equivalent services deliveredlly Whether similaits would apply for any expatelemedicine depends on the details of legislative proposals

Although offele med ic ine tolees could improve the quality ofhat suchenrollees receive and could be more convenient for them doing so might not reduce medicareg on their care More broadurban enrollees would otherwise not ha veeceived care because of difficulties in obtaining access to doctors, providing telemedicine mightwell increase spending on services Medicare covers instead of substituting for services thatwould have been covered without te lemedicine without other constraints the addedconvenience for enrollees of receiving te le medicine rather than face-to-face care could increasthe ir demand for and use of Med icare-covered services provis ions governing the cost-sharingrequirements that enrollees face for telemedic ine services would also affect the ir demand fcExtracted from a blog post by lori Housman Zoe williams and philip ellis dated9


Telemedicine at the Federal CommunicationsCommission (FCc)The Connect2 HealthFCC taskforce is exp loring the intersection of broadband, ad vancedechnolo gy and health and further charting the broadband future of health care-selumbrella for all FCC health-oriented activities to help enable a healthier AmericaBy identifying regulatory barriers, as weentives, and building stronger partners hips withtblic and private stakeholders in the areas of telehealth, mobile applications, and telemedicine,re seek to accelerate the adoptd vanced health care technologies- leveraging broadbanand other next-gen communications services, highlighting promising health IT and telemedicineinitiatives ac ross the country and abroad, and expediting a vital shift to more ubiquitorbroadband-enabled health care so lutions a long the entire health and we llness continuumVision: Everyone connected to the people, services and information they need to get we ll andstay healthy

This will requireRobust connectionsAnywhereOn-demand and in real timeTrusted and secure(platforms and devices)Integrated and seamless carePatients and care giversHealth systems and cliniciansviders(e g, grocery stores, fitness centerCenters of learning

Research and dataEmpowered and engaged consumersInteractive, healthy decision supportConsumer-generated health dataTargeted digital health and we llness contentMapping Broadband Health in America tool allows users to visualize, overlay and analyzebroadband and health data at the national, state and county le vels The maps are an interactiveexperience, enabling detailed study of the intersection between connectivity and health for everynty in the United States The resulting maps can be used by both public and private sectorsand local communities, to identify opportunities and gaps in connectivity and care Go directly tothe mapping toolIn november 2016

the fccs connect2 health task force and the consumer and governmenta lAffairs Bureaus Office of Intergovernmental Affairs co-hosted a webinar to further explore thepotential of the Mapping broadband Health in America platform for the public sector This onehour deeper dive" webinar was particularly tailored to the needs and interests of state and locsgovernmentofficesandagencies(https://wwwfccgov/news-events/events/2016/11/mappingconnec ted-heaIth-county-countyThe Connect2 HealthFCC Task Force's Mapping Broadband Health in America tool allows usersvisualize, overlay and analyze broadband and health data at the national state and countylevels- informing policy prescriptions and investment decisions

teractilence showing various pictures of the interonnectivity and health for every county in the United States

USers can generate customizemaps that show broadband access, adoption and speed alobesity, diabetes and physician access)in urban and rural areasThese maps can be used by both public and private sectors, and local communities, to identifyopportunities and gaps in connected careYou can exp lore questions likeWhat is the re lationship between connectivity and healtWhat is the chronic disease picture in higher vs lo wer connectivity areasWhere can existing broadband infrastructure be leveraged now -by polic ymakers,entrepreneurs, or other stakeholders--to he hp address physician shortages or high levelsof chronic dwhere do infrastructure gaps and poor hea lth outcomes coincide -both at the naand county level- in order to better target and prioritize market lace solutions andprivate sector investmeKey features of these mapsteractive data visualization toolsEasily accessible statistics about connectivity and health at the national and state levels,to help ground the user experienceCustomizab le zoom levels to state, county, or automatUnique URLs created for each customized map to facilitate sharing and collaborationSupport of open government and open data initiatives through APls and downloadabledata sets

About the editorMichael Erbschloe has worked for over 30 years performing analys is of theeconomics of information techno logy, public policy relating to technology, andutilizing techno logy in reengineering organization processes He has authoredseveral books on social and management issues of information technology thatere published by Mc Graw Hill and other major publishers

He has also taught atseveral univers ities and developed technology-related curriculum His career hasfocused on several interrelated areasTechnology strategy, analysis, and forecastingTeaching andcurrIcelopmentWriting books and articlesPublishing and editingPublic policy analys is and program evaluatiBooks by michael ErbschloeSocial Media Warfare: Equal Weapons for All(Auerbach Publications)Walling Out the Insiders: Controlling Access to Improve Organizational Security(Auerbach PublicPhysical Security for IT(Elsevier Science)Trojans, Worms, and Spyware(Butterworth-Heinemann)Implementing Homela

nd Security in Enterprise IT(Digit al Press)Guide to Disaster Recovery(Course TechnologySocially responsible IT Management Digital Press)Information Warfare: How to Survive Cyber Attacks(Mc Graw Hill)s Guide to Privacy Management(Mc Graw HillNet Privacy: A Guide to Developing Implementing an e-bus iness Privacy Pl(Mc Graw Hill)

introductioelemedicine seeks to improve a patient's health by permitting two-way, real time interactivecommunication between the patient, and the physician or practitioner at the distant site Thiselectronic communication means the use of interactive telecommunications equipment thaat a mininlum,audio and video equipment The imp lementation of telemedicineroutine health services has been impeded in many setting because of a lack of scientific evidenceBut things are changing Based on ad vances in information and communications technologiesmedical professionals as well as other health and care"providers can now offer increasinglybust, remote(from the ir location to another ), interactiumerspatients and caregiversThe terms used to describe these broadband- enab led interactions include te le health, telemed icineand te lecare

Telehealth"evolved from the word te le med icine, Te lecare" is a similar termthat you generally hear in Europe Aof these words are often- but not always-usedinterchangeably They can also have different meanings depending on who you ask And that'sly why yould ask your doctor, your insurance provider, your nurse, anyone whosart of your health and care universeTelemedicine can be defined as using te lecommunications techno logies to support the deliveryall kinds of medical, diagnostic and treatment-re lated services us ually by doc tors Feexample, this includes conducting diagnostic tests, closely monitoring a patient 's progress after

treatment or therapy and facilitating access to specialists that are not located in the same placTelehealth is similar to telemedicine but includes a wider variety of remote healthcare serviceseyond the doctor-patient re lationship It often involves services provided by nurses, pharmacistsor social workers, for example, who help with patient health education, social support andmedication adherence and troub leshooting health issues for patients and the ir care giverselecare generally refers to technology that allows consumers to stay safe and independent intheir own homes For example, telecare may inc lude consumer-oriented health and fitness appssensors and too ls that connect consumers with family members or other caregivers, exercisetracking tools, digital medication reminder systems or early warning and detection technologiesAlthough the terms"telemedic ine"and"telehealth are often used to describe simi lar types oftechno logies, the term "telemedicine has historically been used to refer specifically to bilaterainteractive health cunications wicians on both" ends" of the exchange(e

g, videoconferenced Grand Rounds, x-rays transmitted between radiolo gists or consultations where ate practitioner presents a patient to a specialist ) Whereas, the term"telehealth"incorporatesnot only techno lo gies that fall under "telemedicine, but also direct, electronic patient-toprovider interactions and the use of medical devices(e g, smartphone app lications ("apps)activity trackers, automated reminders, blood glucose monitors, etc )to co llect and transmithealth information, often with the intent to monitor or manage chronic conditions Currentlythere are four basic modalities, or methods, of telehealth

video(synchronous): Live, two-way interaction between a(patient,While these videoconferences had historically and exclusively been provider-to-providertelemedicine encounters, many companies such as Te ladoc and LiveHealth onlinenow video linking patients directly to clinicians on a daily basistore-and-forward (SFT): Transmission of videos and digital images such as x-raysand photos through a secure electronic communications system As compared to a"real-time "visit, this service provides access to data after it has been collected Generallydiagnostic information ( eg, X-rays, CT scans, EEG printouts) are recorded or captured atthe patients site of care, and then sent to a specialist in another location Because of thelag, or delay, between the time an image is sent and when it is interpreted, SFT is oftenferred to3

Remote patient monitoring(RPM): Personal health and medical data collection froran individual in one location, which is transmitted to a provider in a different locationPM is used primarily for the mana gement of chronic illness, using deHolter monitors to transmit information inc luding vital statistics(eg, blood pressblood oxygen le vels) to clinicians4 Mobile health(mHealth): Smartp hone apps designed to foster health and well-beingThese apps range from programs which send targeted text messages aimedencouraging healthy behaviors to alerts about disease outbreaks to programs or appshelp patients with reminders to adhere to specific care regimens Increasinglmartp hones may use cameras, microphones, or other sensors or transducers to capturevital signs for input to apps and bridging into RPMLink:https://wwwhealthitgov/playbook/patient-engagement/#telehealthIn the current environment of a shortage of hea lthcare professionals, greater incidence of chroniconditions, and rising healthcare costs, te ine offers a potential tool to improve efficiency

he delivery of healthcare The needle medfurther compounded by the followinge in the Us population-estimated growth of 20 percent0363between 2008-2030ducted trained and licg incidence of chronic diseases around the world includingNeed for efficient care of the elderly, home-bound, and physicallhallenged patientsLack of spec ialists and health facilities in rural areasAdverse events, injuries and illness at hospitals and phys icians officesNeed to improve community and population healthLink:http:/ita

docgov/td/health/telemedicine_2009pdfThe Connect2 HealthFCC Task force is working to raise consumer awareness about the value ofbroadband in the health and care sectors The fcc 's connect2 health task force and its work ononsumerhealthissuescanbefoundatwwwfccgov/health

Telemedicine: Medicaid and medicareFor purposes of Medicaid, telemedicine seeks to improve a patient's health by permitting twtime interabetween the patient, and the physiciaat the distant site This e lectronic communication means the use of interactivetelecommunications equipment that includes, at a minimum, audio and video equipmentTe lemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way oproviding medical care(eg, face-to-face consultations or examinations between provider andpatient) that states can choose to cover under Medicaid This definition is modeled on Medicaredefinition of te le health services(42 Cfr 410

78) Note that the federal med icaid statute does notrecognize te lemedicine as a distinct serviceTelemedicine TermsDis tant or Hub site: Site at which the physician or other licensed practitioner delivering theservice is located at the time the service is provided via telecommunications s ystemOriginke site: location of the medicaid patient at the time the service beurnished via a telecommunications system occurs Telepresenters may be neededelivery of this serviceAsynchronous or Store and Forward": Transfer of data from one site to another through the usef a camera or similar device that records(stores)an imageis sent(forwarded) viate lecommun ication to another site for consultation async hro nous or store and forwardapplications would not be considered telemedicine but may be utilized to deliver service

Medical Codes: States may select from a vaHCPCS codes(T1014 and Q3014), CPTcodes and modifiers(GT, Ul-UD)in order to identify, track and reimburse for telemedicineehealth(or Telemonitoring is the use of telecommunications and information techno logyprovide access to health assessment, diagnosis, intervention, consultation, supervision andinformation across distanceehealth inc ludes such tec hno lo gies as telephones, facsimile machines, electronic maiystems, and remote patient monitoring devices, which are used to collect and transmit patientdata for monitoring and interpre tation while they do not meet the medicaid definition ofte le med icine they are often considered under the broad umbrella of telehealth services

eventhough such technologies are not considered"telemedicine, " they may nevertheless be coveredand reimbursed as part of a Medicaid coverable service, such as laboratory service, x-ray servicephysician services(under section 1905(a) of the Social Security Act)rovider and Facility GuidelinesMedicaid guidelines require all providers to practice within the scope of their State Practice ActSome states have enacted le gis lation that requires providers using telemedicine technologyacross state lines to have a validlicense in the state where the patient is located any suchrequirements or restrictions placed by the state are binding under current Medicaid rulesReimbursement for Tele medicine

Reimbursement for medicaid coveredluding those with telemedic ine applicatiomust satisfy federal requirements of efficiency, economy and qua lity of care States areencoura ged to use the flexibility inherefederal law to create inno vatmethodo lo gies for services that incorporate telemedicine technology For example, states maymburse the physician or other licensed prac titioner at the distant site and reimburse a facilityfee to the originating site States can alo reimburse any additional costs such as technicsupport, transmission charges, and equipment

These add-on costs can be incorporated into thefee-for-service rates or separately reimbursed as an administrative cost by the state If they areseparately billed and reimbursed, the costs must be linked to a covered Medicaid serviceState Flexibility in Covering/Reimbursing for Telemedicine Services and the application ofGeneral Medicaid Requirements to Co verage of Telemedicine Serviceselemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way ofproviding medical care(e g, face-to-face consultations or examinations between provider andpatient) As such, states have the option/flexibility to de termine whether(or not) to covertelemedicine; what typesemedicine to cover: where in the state it can be covered: hoprovided/covered; what types of telemedicine practitioners/providers may bng as such practitioners/providers are recognized"and qualifiedaccording to medicaid statute/regulation; and how muclas long as such payments do not exceed Federal Upper Limitsthe state decides to cover telemedicine, but does not cover certain prac titioners/providers oftelemedicine or its te lemedicine coverage is limited to certain parts of the state, then the state isresponsible for assuring access and covering face-to-face vis its/examinations by these