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US Behind the World in Telemedicine


NEW YORK - The American College of Physicians (ACP) has issued a baker's dozen of recommendations intended to guide the effective use of telemedicine in primary care settings.

"The recommendations balance the potential benefits and expanded use of telemedicine with the importance of maintaining the patient-physician relationship and patient safety," Hilary Daniel from American College of Physicians, Washington, DC, said by email.

Telemedicine, the use of technology to deliver health care services at a distance, began mainly in rural communities and federal health programs, but now is used in a variety of medical specialties and subspecialties.

Daniel and colleagues on the ACP Health and Public Policy Committee detail pragmatic recommendations on the use of telemedicine in the primary care setting, physician considerations for those who use telemedicine in their practices, and policy recommendations on the practice and reimbursement of telemedicine in their September 8 Annals of Internal Medicine online position paper.

While ACP "supports the expanded role of telemedicine as a method of health care delivery that may enhance patient-physician collaborations," it also recommends that direct-to-patient telemedicine services should be used only as an intermittent alternative to a patient's primary care physician when necessary to meet the patient's immediate care


These services should take place within the context of a valid patient-physician relationship. Physicians who use telemedicine have an obligation to establish such a relationship based on the standard of care required for an in-person visit or consult with another physician who has such a relationship with the patient.

Physicians should take care to see that financially disadvantaged populations also have access to telemedicine services, where appropriate, as well as ensure that these services comply with federal and state security and privacy regulations while meeting the same standards of practice as if the physician were seeing the patient in person.

ACP supports efforts to reimburse telemedicine communications and telehealth services and supports processes to obtain medical licenses and hospital privileges necessary to support telemedicine across state lines.

The committee also endorses the use of federal funds to support the broadband infrastructure and to establish an evidence base on the safety, efficacy, and cost of telemedicine technologies.

"Telemedicine can be an effective and beneficial tool for physicians and patients to enhance a patient's care," Daniel concluded. "Physicians can take away from this report a greater understanding of the regulatory and payment issues surrounding telemedicine and evaluate how telemedicine may be useful for their patients and practice and augment the care they already provide."

In a related editorial, Dr. David A. Asch, from the University of Pennsylvania's Center for Health Care Innovation, Philadelphia, addressed the hidden economics of telemedicine. He said by email, "I think it is a trap to think that the only promise of telemedicine is the opportunity to do something remotely that used to happen face to face. The real opportunities will come from doing health care in a different way because of this remote technology."

"An important question is, 'If there are so many opportunities from telemedicine, why doesn't more of it happen?'" Dr. Asch said. "I think there are a lot of reasons for that but one important reason is that insurers, in particular, worry that if they make telemedicine payments easy, then they will open up the floodgates of demand."

Dr. Laura Markwick, from Wegmans School of Nursing, St. John Fisher College, Rochester, New York, said by email, "I would like to apply these to all health care providers and not just physicians. Of note, they do mention that they recommend a relationship already be established with the patient, which I do not feel is an absolute must. When we did our telemedicine program, we did not have a previous in-person relationship established and we were able to provide high-quality care that improved access for the patients."

"All health care providers should be reimbursed for telemedicine care, at levels similar to what is reimbursed currently," Dr. Markwick said. "This should be a covered service from the person's insurance, depending upon the care needed. If it is just someone who does not feel like making it to an appointment but otherwise could with little difficulty (social issues included in this decision), then perhaps the patient should contribute toward this reimbursement."

Dr. Manish N. Shah, from the University of Wisconsin School of Medicine and Public Health, Madison, said by email, "It is important to know that the U.S. is behind the rest of the world when it comes to telemedicine. In Canada, the Ontario Telemedicine Network has existed for years. In the UK, telemedicine has been also available."

"Reimbursement for telemedicine is a complex issue, particularly because the entire provider payment system is changing," Dr. Shah said. "However, without funding, telemedicine will not be made available to patients despite increasing evidence showing that patients want to use it, that care can be effectively delivered via telemedicine, and that telemedicine is cost effective."

The authors reported no external funding or disclosures.

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