Broadband Internet for telemedicine

<<March 9, 2000>>

Peter T. Knight <ptknight@attglobal.net>

Prof. and Mrs. Edward C. DeLand <edeland@anes.ucla.edu>

Ms. Mickelle Rodgers <mrodgers@nas.edu>

Dena S. Puskin, Sc.D. <dpuskin@hrsa.gov>

Salah H. Mandil, Ph.D. <mandils@who.int>

Robert J. Rodrigues, M.D. <rrodrigues@paho.org>

Dr. Pablo Pulido <pablopulido1@compuserve.com>

Edward Dodds <dodds@home.com>

Kimberly K. Obbink <kobbink@montana.edu>

Dear Peter:
===========

(1) Many thanks for your msg (ATTACHMENT I).

Dear Ed Deland:
===============

(2) Many thanks for your original info about this press release mtg at the
National Academy of Sciences -- see ATTACHMENT I in "Meeting at the
National Academy of Sciences in D.C. on 2/23 - February 19, 2000" at
<http://www.kagawa-jc.ac.jp/~steve/global-univ-2000.html>.

Dear Dena, Salah, Bob, and Pablo:
=================================

(3) Ms. Mickelle Rodgers told me just a few minutes ago over the phone that
pre-publication copy of this report is still available free of charge.
It is Networking Health: Prescriptions for the Internet" by the
Computer Science and Telecommunications Board of the National Research
Council in Washington, D.C.

You may send your request to;

Mr. Jerry Sheehan <jsheehan@nas.edu>

I highly commend this report to you.

Dear Electronic Colleagues:
===========================

(4) You can also read about it at <http://books.nap.edu/catalog/9750.html>.

Dear Ed Dodds:
==============

(5) Many thanks for your valuable info (ATTACHMENT II). I read it with great interest.

(6) Will see you on 3/15th when I visit your town, Nashville, TN.

Dear Dena and Kim:
==================

(7) This article may be of some interest to you for your Native American community project.

(8) When you fix the date and time of our visit to Dena, pls let me know.

Best, Tak
****************************************

Return to Global University System Early 2000 Correspondence

ATTACHMENT I

Date: Thu, 24 Feb 2000 08:45:25 -0500 (EST)
From: ptkngiht@attglobal.net
To: utsumi@columbia.edu
Subject: Medicine Could Benefit From Internet Improvements, Report Says

This story from The Chronicle of Higher Education
(http://chronicle.com) was forwarded to you from: ptkngiht@attglobal.net

_________________________________________________________________

The following message was enclosed:
In case you didn't get there, Tak. I was too busy to go
myself.

Cheers,

Peter

_________________________________________________________________

Thursday, February 24, 2000

Medicine Could Benefit From Internet Improvements, Report Says

By VINCENT KIERNAN

The federal government should take stronger steps to ensure
that future technical refinements to the Internet include
features that would let medical researchers and physicians
rely on the network, concludes a report released Wednesday by
the National Research Council.

The features include mechanisms to protect the anonymity of
Internet users, to keep patient information secure, to
validate the identities of users participating in confidential
online transactions, and to track users of databases, the report said.

In addition, new network technologies should include
provisions to guarantee the availability of fast,
high-capacity network connections for medical uses, like
long-distance collaboration by physicians or digital
transmission of medical images.

Edward H. Shortliffe, chairman of the committee that produced
the study, said many of the technical improvements that the
report endorses would bolster non-medical uses of the
Internet. But the technical demands for some of the report's
recommendations, such as building privacy safeguards to
medical standards, would require technical specifications to
be more sophisticated than they would otherwise be for
non-medical uses, such as e-commerce, said Dr. Shortliffe, who
is a professor of medical informatics at Columbia University.

The committee recommended that the National Institutes of
Health, which requested the study, take steps to bring
together medical professionals and networking experts so that
medicine's needs would be taken into greater account when
planning improvements to the Internet. "Interactions between
the two groups have been limited in the past," Dr. Shortliffe
told reporters at a briefing here at which the report was released.

The National Institutes of Health could go even further, Dr.
Shortliffe said, by requiring scientists who receive
biomedical grants from N.I.H. to consult with networking experts.
_________________________________________________________________

Subscribers can read this story on the Web at this address:
http://chronicle.com/free/2000/02/2000022401t.htm

_________________________________________________________________

You may visit The Chronicle as follows:

* via the World-Wide Web, at http://chronicle.com
* via telnet at chronicle.com

Date: Tue, 22 Feb 2000 10:42:06 -0500
From: "Ed Dodds" <dodds@home.com>
To: utsumi@friends-partners.org
Subject: HCFA's pay policy hampering telemedicine programs

http://www.acponline.org/journals/news/feb00/hcfa.htm
Ed Dodds
dodds@home.com
http://members.home.com/dodds
ICQ 49457096
========================================

Computers & Medicine

HCFA's pay policy hampering telemedicine programs

Critics say that restrictive Medicare reimbursements are causing some programs
to scale back efforts

From the February 2000 ACP ASIM Observer, copyright 2000 by the American
College of Physicians American Society of Internal Medicine.

By Edward Martin

When HCFA announced that it would start reimbursing physicians for certain
types of telemedicine procedures in April of last year, many predicted that
1999 was going to be a big year for telemedicine. HCFA's new payment policy
would shatter one of telemedicine's main barriers?reimbursement?and give the
technology a boost.

Nearly a year after HCFA introduced its new payment policy, however,
telemedicine programs around the country are worse off than ever. Hospitals
have curtailed their efforts or are shelving programs altogether. And a big
part of the problem, experts say, is the HCFA reimbursement policy that was
expected to convince hospitals and physicians to use telemedicine.

Telemedicine's most recent troubles began with the Balanced Budget Act of
1997, which directed HCFA to pay for the technology in areas with a shortage
of health professionals. While HCFA did begin reimbursing physicians and
hospitals for telemedicine procedures last April, critics say that the agency
has interpreted a poorly worded statute in ways that do not live up to the
legislation's true intent.

Narrow definition

One critical issue is BBA language authorizing reimbursement for
teleconsultations," said Pat Bousliman, a health care aide to Sen. Max Baucus
(D-Mont.), one of the legislation's original sponsors.

Mr. Bousliman and other legislative sources say lawmakers intended to include
a broad range of current procedural terminology (CPT) codes that would allow
telemedicine doctors to be paid for virtually everything they do in person.
But HCFA defines teleconsultation as live, interactive video transmission
between a patient and his physician?or midlevel provider such as a nurse
practitioner?linked to a specialist. That, and nothing else.

"HCFA's doing things we clearly didn't intend and, unfortunately, the result
is doctors don't have much incentive to get involved," said Mr. Bousliman.

"Teleconsultation has become a dirty word," added Jim Reid, director of the
Midwest Rural Telemedicine Consortium, which is based at Mercy Medical Center
in Des Moines, Iowa. The consortium links 38 remote communities such as Algona
and Mount Ary to facilities in Des Moines and Mason City. "HCFA interprets it
very, very narrowly. Can you imagine a doctor with a waiting room full of
patients leaving to accompany a referral to a consultation?"

Physicians agree. "It's totally contrary to medicine in the real world," said
pediatrician Robert H. Cox, MD, medical director of Hays Medical Center, in
Hays, Kan. The center operates one of the nation's oldest telemedicine
programs, founded in 1990.

HCFA's definition of telemedicine prevents physicians from taking advantage of
technology in other significant ways. A good example is store-and-forward
consults, in which physicians can record a patient examination, including
diagnostic images and sound, and forward it to a specialist for later review.
"A cardiologist can come in tomorrow morning, look at his e-mail and have my
patient's history, physical, chest X-ray, ECG and even the cardiac sound that
concerned me waiting for him," said immunologist Jay H. Sanders, FACP, medical
professor at Johns Hopkins University School of Medicine and scientific
director of the NASA Commercial Space Center in Houston.

But because HCFA defines teleconsults only as live transmissions, such

store-and-forward uses of telemedicine aren't covered. As a result, physicians must
make a trip across town?or into another county?to reach a site. "HCFA is
demanding a totally artificial way of doing things," Dr. Sanders said.

The Medicare reimbursement policy also raises administrative and ethical
questions. For example, to streamline billing, the agency requires consulting
physicians to bill Medicare and return 25% of their fee to the referring
doctor.

The policy is problematic on several levels. First, it means that consulting
physicians do not get their full fee. And while referring physicians get a
small rebate, their payment barely makes a dent in the income they lose by
having to physically sit in on teleconsults.

But most ironically, some say the arrangement smacks of the kind of kickback
that the federal government has outlawed among Medicare providers. "If I did
this on my own," said Dr. Sanders, it would be considered fee-splitting and I
could be put in jail."

Not worth the trouble?

Critics say that HCFA's telemedicine reimbursement policy is so restrictive
and onerous that a number of hospitals and physicians have decided to skip
Medicare reimbursement for telemedicine services. They view telemedicine
services as a cost of doing business and simply pay for telemedicine
procedures covered by Medicare out of their own pocket.

MedCenter One Health System in Bismarck, N.D., a system that provides
teleconsults for rural health care systems, pays its physicians who perform
telemedicine procedures for the elderly the same rate they would receive for
in-person visits. Administrators at the system said that physicians would have
to spend so much time working with HCFA's reimbursement policy that it is
simply easier and more cost effective for the health system to foot the bill.

Mayo Clinic similarly pays physicians for telemedicine services out of its
operating budget. "The hospital pays for it like any other part of our
infrastructure," said Mayo cardiologist Bijoy Khandheria, ACP?ASIM Member.

While these systems have decided to fund telemedicine programs out of their
own budgets, their decision to avoid billing Medicare is slowing telemedicine
growth. The Mayo Clinic, for example, which five years ago successfully
demonstrated telemedicine on Indian reservations and other remote sites, today
focuses mainly on an echocardiology program that serves patients within 120
miles of the Minnesota medical center. And while many hospitals continue to
use teleradiology, the most commonly accepted form of telemedicine, only an
estimated 200 have full-fledged telemedicine programs, a number that is
unlikely to grow until the reimbursement issue is resolved.

For hospitals, the HCFA regulations are just the latest part of a long legacy
of payment problems. Midwest Rural Telemedicine, created as a HCFA
demonstration site five years ago, has faced funding woes typical of
telemedicine's slow progress. Although HCFA authorized the program for three
years starting in 1995, two years lapsed before Congress funded it. That
forced Midwest, like Mayo Clinic and others, to cobble together grants from
foundations, government agencies and telecommunications companies, along with
money tweaked from hospital budgets, to get by.

That has often meant relying on volunteer labor from physicians. For example,
physicians performed consults for free for two years at Dakota Telemedicine
System in Bismarck, N.D., which links remote clinics plus nursing homes and
other sites in the Dakotas and eastern Montana to MedCenter One Health System.
"We'd give them a can of Diet Coke," said Carla Anderson, the program's
director. "That was it."

Now the program, which has received national acclaim, funds the program
internally and from grants, but it does not seek Medicare reimbursement
because of its restrictions.

Physicians hold back

That kind of experience, coupled with lingering skepticism about telemedicine,
explains why so many physicians are reluctant to use telemedicine technology,
even when their hospital or health system has decided to pay for their
services. And as many hospitals can testify, if physicians aren't on board
with a telemedicine program, it will wither.

The Konawa Community Health Center in Konawa, Okla., which used a $50,000
grant from Southwest Bell Corp. in 1995 to launch a telemedicine program, has
dropped all but teleradiology. Utilization was low and costs high," said
Casey Anson, the center's director. "We used it twice in two years, at a total
investment of $140,000."

The intent was to link physicians and midlevel practitioners at remote clinics
for quick consults on trauma cases, but few accepted the technology. "The
challenge," added a South Dakota administrator, "is getting doctors to
incorporate telemedicine into everyday practice."

Ronald K. Poropatich, FACP, a Walter Reed Army Medical Center critical care
pulmonologist and telemedicine expert, recently lectured on telemedicine at a
Chicago meeting of chest physicians. "Attendance was miserable, to put it
mildly," he said. "If we can prove to doctors through studies and peer-review
journals that meet all the scientific rigors that this is not a second-class
way to treat patients, then we can make a more convincing argument for
reimbursement."

Added Dr. Poropatich, who is also a director of the American Telemedicine
Association, "I'm afraid we haven't done enough heavy lifting yet to convince
our own colleagues."

The problems of interstate licensure have also contributed to physician
reluctance. For example, North Dakota doctors complain that South Dakota
forces them to drive hundreds of miles to appear before the state medical
board for 10-minute hearings that could be handled by videoconferencing.
Kansas is another state that critics say has similarly strict rules.

Despite such hurdles, longtime telemedicine supporters remain hopeful. They
point out that 14 states that administer Medicaid already authorize
telemedicine reimbursement. Medicaid reimbursement is encouraging, they
believe, because it shows that some government agencies recognize telemedicine
as clinically and financially viable.

"That's because Medicaid has to pay not only for care but transportation, and
we have data that show that 80% of the people seen over telemedicine remain at
their local sites," said Dr. Sanders.

Telemedicine is also probing promising new areas, such as a program at Hays
Medical Center to monitor recently discharged patients with chronic
obstructive pulmonary disease and congestive heart failure. Dr. Cox explained
that by remotely monitoring factors like oxygen saturation and heart rate,
attending physicians can decide whether to bring a patient into a clinic for a
full exam or merely adjust medications.

Nevertheless, telemedicine supporters recognize that to get the serious
attention of physicians and hospitals, reimbursement needs to be changed. That
could happen as early as this spring, when Sens. Baucus and Kent Conrad (D-N.D.)

hope to hammer out new legislation that would expand Medicare
reimbursement to all rural areas, not just areas with shortages of health
professionals, and to cover all CPT codes otherwise reimbursed by HCFA. Sen.
Conrad would specifically permit store-and-forward consults and fund
government studies of efficacy and cost. That legislation would also fund the
critical, peer-reviewed studies of telemedicine's clinical effectiveness that
Dr. Khandheria and others believe is needed to convince physicians of the
technology's efficacy.

Edward Martin is a freelance writer in Charlotte, N.C.
----------------------------------------

For more about telemedicine

For more information about telemedicine, visit the College's Telemedicine
Resource Center on ACP ASIM Online at

http://www.acponline.org/computer/telemedicine.

The center offers an introduction to telemedicine and recent developments. The
center also houses an extensive glossary of technical terms, a list of
telemedicine Web sites and a bibliography with links to abstracts of journal
articles.
----------------------------------------
1996-2000, American College of Physicians-American Society of Internal
Medicine. All rights reserved.
****************************************

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List of Distribution

Peter T. Knight
Knight, Moore - Telematics for Education and Development
Communications Development Incorporated (CDI)
Strategy, Policy, Design, Implementation, Evaluation
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IP for CU-SeeMe: 198.77.80.46
http://www.knight-moore.com/projects/GSTF.html -- about GSTF

Prof. and Mrs. Edward C. DeLand
DeLand Associates
254 Redlands St
Playa Del Rey, Ca 90293
(310)823-7012
edeland@anes.ucla.edu

Ms. Mickelle Rodgers
National Academy of Sciences
2101 Constitution Avenue, NW
Washington, DC
202/334-2605
mrodgers@nas.edu

Dena S. Puskin, Sc.D.
Director, Office for the Advancement of Telehealth
Deputy Director, US Public Health Service
Office of Rural Health Policy, Room 11A55
Health Resources and Services Adiministration
U.S. Department of Health & Human Services
5600 Fishers Lane
Rockville, MD 20857
USA
Tel: 1 301 443 0447
Fax: 1 301 443 1330
dpuskin@hrsa.gov
http://telehealth.hrsa.gov

Salah H. Mandil, Ph.D.
Director-Advisor
Health Informatics & Telematics
World Health Organization
20, Avenue Appia
CH-1211 Geneva 27
SWITZERLAND
+41-22-791-2426 (direct)
+41-22-791-2111
Fax: +41-22-791-4702
ISDN +41.22 791 1132 and 1133
mandils@who.int
mandils@who.ch

Robert J. Rodrigues, M.D.
Regional Advisor in Health Services Information Technology
Essential Drugs and Technology Program
Division of Health Systems and Services Development
Pan American Health Organization
Regional Office of the World Health Organization
525 Twenty-Third Street, N.W.
Washington, D.C. 20037
202-974-3812
202-974-3826
Fax: 202-974-3614
rrodrigues@paho.org
NetMeeting Server: ils.paho.org
http://www.paho.org

Dr. Pablo Pulido
Executive Director
PanAmerican Federation of Associations of Medical Schools
Apartado de Correos 60411
Caracus 1060-A
VENEZUELA
+58-2-945-0857
Fax: +58-2-945-4275
pablopulido1@compuserve.com

Edward Dodds
Association for the Development of Religious Information Systems (ADRIS)
PO Box 210735
Nashville TN 37221-0735
615-429-8744
Fax: 508-632-0370
dodds@home.com
http://members.home.com/dodds
www.ttalk.com

Kimberly K. Obbink
Director
Burns Telecommunications Center and Extended Studies
128 EPS Building,
Montana State University
Bozeman, MT 59717-3860
USA
Tel: +1-406-994 6550
Fax: +1-406-994 7856
kobbink@montana.edu
http://btc.montana.edu
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* Laureate of Lord Perry Award for Excellence in Distance Education *
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* Global University System (GUS) *
* 43-23 Colden Street, Flushing, NY 11355-3998, U.S.A. *
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