A Missed Opportunity


Telemedicine use for treating substance use disorder remains low, despite unmet need

Looking over a doctor's shoulder, we see a patient video conferencing on the doctor's laptop.

Despite the enormous unmet need for treatment of substance use disorders and the promise technology holds for filling some of the gaps in care, telemedicine remains woefully underused, according to research led by investigators from the Blavatnik Institute at Harvard Medical School.

The study, published in the December issue of Health Affairs, analyzed patterns of telemedicine use and showed that overall use remains low despite some increase in the use of this tool.

“The low rates of telehealth visits for substance use disorder that we found represent a missed opportunity to get people the help they need, especially in the context of the ongoing opioid epidemic,” said study author Haiden Huskamp, the 30th Anniversary Professor of Health Care Policy at HMS.

In what is thought to be the first study of telemedicine for the treatment of substance use disorder, the researchers used insurance claims from 2010 to 2017 to identify characteristics of telehealth users and patterns of use.

Specifically, the analysis showed that the rate of telehealth visits for substance use disorder increased quickly during the study period: from 0.62 visits per 1,000 diagnosed (97 visits) in 2010 to 3.05 visits per 1,000 diagnosed (1,989 visits) in 2017. Despite this increase, telehealth visits for substance use disorder remained dismally low, representing just 1.4 percent of telehealth visits for any health condition. The number of telehealth visits for substance use disorder accounted for only 0.1 percent of all substance use disorder visits.

Approximately 21 million Americans have a substance use disorder related to alcohol, opioids or other drugs, according to the 2016 National Survey on Drug Use and Health. Deaths from opioid overdose nearly quadrupled from 1999 to 2016, according to the U.S. Centers for Disease Control. There are several treatment options for substance use disorder, including medications and psychotherapy or counseling, but fewer than one in five people struggling with the disorder receive treatment, the researchers said.

Experts have deemed telemedicine to be one way to improve access to substance use disorder treatment, particularly for people in remote and underserved communities. While telehealth is not a substitute for in-person care, its use could increase treatment engagement and outcomes by helping patients overcome transportation, distance or stigma barriers to treatment for substance use disorders, the study authors said.

The study also showed significant geographic variation in use of telemedicine for substance use disorder. While per capita rates of telehealth for substance use disorder treatment were higher among rural residents, the vast majority of people receiving telecare were in urban areas. Targeted interventions to increase access to telehealth in rural areas are needed to address the significant unmet need for substance use disorder treatment options outside urban areas, the researchers noted.

The researchers also found that telehealth treatment for substance use disorder is being used almost exclusively as a complement to in-person care rather than as a standalone treatment. In these cases, telehealth may ease access to follow-up care for some patients or provide access to a particular type of service that may be unavailable in their community.

There are a number of barriers that preclude the wider use of telehealth for substance use disorder, the researchers said. Important among them is the shortage of substance use disorder providers, particularly in rural areas, the researchers said.  Other barriers include regulatory and reimbursement hurdles. While it’s possible to do telehealth visits from just about anywhere with a fast internet connection, rules for reimbursement and restrictions on prescribing controlled substances, including those used for substance use disorder treatment, often require patients to come to a qualified facility like a clinic or a hospital which has a telehealth facility that they can use to meet remotely with a clinician at another location.

The SUPPORT for Patients and Communities Act, a new opioid law which was signed in October 2018 and to be implemented in 2019, includes some key features that are intended to ease some of these restrictions.

With growing interest in using telehealth to deliver care for mental health and substance use disorder, the researchers said their study would provide an important baseline for understanding how telehealth is being used now and for monitoring whether efforts to encourage the use of telehealth are having the intended results.

“Many experts believe that mental health conditions and substance use disorders may be particularly well-suited to telemedicine because their treatment doesn’t require an in-person exam,” Huskamp said. “I think more and more providers are getting interested in delivering telemedicine for these conditions in part because they view it as a way to expand access and possibly improve engagement in treatment for these conditions where access is a real problem.”

A robotic doctor is gearing up for action


A new robot under development can send information on the stiffness, look and feel of a patient to a doctor located kilometres away. Image credit: Accrea

A robotic doctor that can be controlled hundreds of kilometres away by a human counterpart is gearing up for action.

Getting a check-up from a robot may sound like something from a sci-fi film, but scientists are closing in on this real-life scenario and have already tested a prototype.

‘The robot at the remote site has different force, humidity and temperature sensors, all capturing information that a doctor would get when they are directly palpating (physically examining) a patient,’ explains Professor Angelika Peer, a robotics researcher at the University of the West of England, UK.

Prof. Peer is also the project coordinator of the EU-funded ReMeDi project, which is developing the robotic doctor to allow medical professionals to examine patients over huge distances.

Through a specially designed surface mounted on a robotic arm, stiffness data of the patient’s abdomen is displayed to the human, allowing the doctor to feel what the remote robot feels. This is made possible thanks to a tool called a haptic device, which has a soft surface reminiscent of skin that can recreate the sense of touch through force and changing its shape.

During the examination, the doctor sits at a desk facing three screens, one showing the doctor’s hand on the faraway patient and a second for teleconferencing with the patient, which will remain an essential part of the exchange.

The third screen displays a special capability of the robot doctor – ultrasonography. This is a medical technique that sends sound pulses into a patient’s body to create a window into the patient. It reveals areas of different densities in the body and is often used to examine pregnant women.

Ultrasonography is also important for flagging injuries or disease in organs such as the heart, liver, kidneys or spleen and can find indications for some types of cancer, too.

‘The system allows a doctor from a remote location to do a first assessment of a patient and make a decision about what should be done, whether to transfer them to hospital or undergo certain treatments,’ said Prof. Peer.

The robot currently resides in a hospital in Poland but scientists have shown the prototype at medical conferences around the world. And they have already been approached by doctors from Australia and Canada where it can take several hours to transfer rural patients to a doctor’s office or hospital.

With the help of a robot, a doctor can talk to a patient, manoeuvre robotic arms, feel what the robot senses and get ultrasounds. Image credit: ReMeDi

With the help of a robot, a doctor can talk to a patient, manoeuvre robotic arms, feel what the robot senses and get ultrasounds.

‘This is to support an initial diagnosis. The human is still in the loop, but this allows them to perform an examination remotely,’ said Prof. Peer.

Telemedicine

The ReMeDi project could speed up a medical exam and save time for patients and clinics. Another EU-funded project – United4Health (U4H) – looks at a different technology that could be used to remotely diagnose or treat people.

‘We need to transform how we deliver health and care,’ said Professor George Crooks, director of the Scottish Centre for Telehealth & Telecare, UK, which provides services via telephone, web and digital television and coordinates U4H.

This approach is crucial as Europe faces an ageing population and a rise in long-term health conditions like diabetes and heart disease. Telemedicine empowers these types of patients to take steps to help themselves at home, while staying in touch with medical experts via technology. Previous studies showed those with heart failure can be successfully treated this way.

These patients were given equipment to monitor their vital signs and send data back to a hospital. A trial in the UK comparing this self-care group to the standard-care group showed a reduction in mortality, hospital admissions and bed days, says Prof. Crooks.

‘The human is still in the loop, but this allows them to perform an examination remotely.’

Professor Angelika Peer, University of the West of England, UK

A similar result was shown in the demonstration sites of the U4H project which tested the telemedicine approach in 14 regions for patients with heart failure, diabetes and chronic obstructive pulmonary disease (COPD). For diabetic patients in Scotland, they kept in touch with the hospital using text messages. For COPD, some patients used video consultations.

Prof. Crooks stresses that it is not all about the electronics – what matters is the service wraparound that makes the technology acceptable and easy to use for patients and clinical teams.

‘It can take two or three hours out of your day to go along to a 15 minute medical appointment and then to be told to keep taking your medication. What we do is, by using technology, patients monitor their own parameters, such as blood sugar in the case of diabetes, how they are feeling, diet and so on, and then they upload these results,’ said Prof. Crooks.

‘It doesn’t mean you never go to see a doctor, but whereas you might have gone seven or eight times a year, you may go just once or twice.’

Crucially, previous research has shown these patients fare better and the approach is safe.

‘There can be an economic benefit, but really this is about saving capacity. It frees up healthcare professionals to see the more complex cases,’ said Prof. Crooks.

It also empowers patients to take more responsibility for their health and results in fewer unplanned visits to the emergency room.

‘Patient satisfaction rates were well over 90 %,’ said Prof. Crooks.

Top Five Digital Transformation Trends In Health Care


Technology is changing every industry in significant ways. To help frame how, I’m starting a new series discussing top trends in various markets. First up: health care.

No one can dispute technology’s ability to enable us all to live longer, healthier lives. From surgical robots to “smart hospitals,” the digital transformation is revolutionizing patient care in new and exciting ways. That’s not all. National health expenditures in the United States accounted for $3.2 trillion in 2015—nearly 18% of the country’s total GDP. It’s predicted that the digital revolution can save $300 billion in spending in the sector, especially in the area of chronic diseases. Clearly there is value—human and financial—in bringing new technology to the health care market. The following are just a few ways how.

Telemedicine

Even back in 2015, 80% of doctors surveyed said telemedicine is a better way to manage chronic diseases than the traditional office visit. Why? Telemedicine offers patients and health care providers both a new wave of freedom and accessibility. For the first time, a patient’s care options are not limited by geographic location. Even patients in remote areas can receive the highest quality of care, providing they have an internet connection and smart phone. Telemedicine can also save both time and money. Patients no longer have to schedule their days around routine follow-up visits (and long office waits). Instead, they can hop on a conference call to get the prescription update or check-up they need.

Nowhere has telepresence been more useful than in the mental health field. Now, those seeking emotional support can find access to a therapist or counselor at the click of a button, often for far less than they would pay for a full office visit. Internet therapies, for instance, “offer scalable approaches whereby large numbers of people can receive treatment and/or prevention, potentially bypassing barriers related to cost, location, lack of trained professionals, and stigma.” Telemedicine makes it possible.

Mobility And Cloud Access

Have you ever played phone tag with your doctor while waiting for important test results? It’s so nerve-racking! That’s why mobility and cloud access have been such a tremendous help in increasing accessibility for patients and doctors alike. By 2018, it’s estimated that 65% of interactions with health care facilities will occur by mobile devices. Some 80% of doctors already use smartphones and medical apps, with 72% accessing drug info on smart phones on a regular basis. Gone are the days of paper charts and file rooms. Hospitals, insurance companies, and doctor’s offices are now storing patient medical records in the cloud, with patients able to access test results online 24/7.

Given HIPAA laws relating to patient privacy, it’s probably no surprise this has also led to an increased focus on data protection and security. According to one report, “the black-market value of medical data is greater than even that of financial information.” Believe me when I say: No industry is more focused on virtualization security right now than health care.

Wearables And IoT

I remember the days when going into the local grocery store and getting my blood pressure read at one of those prehistoric machines seemed exciting. Imagine: A machine that helped me manage my own well-being without setting foot in a doctor’s office. Now, mobile devices as small as my cell phone can perform ECGs, DIY blood tests, or serve as a thermometer, all without even leaving my house. With help from automation, patients can even be prompted to check their weight, pulse, or oxygen levels, and enter results into mobile patient portals. Even better: They can transmit the results to my doctor in real time. Those details, when entered regularly, can help predict one’s risk for heart disease and other illnesses, ultimately saving lives. This is far more than cool. It’s life-saving.

Artificial Intelligence And Big Data

Big data is king in the digital world, and health care is no exception. Yes, it can be gathered to measure customer satisfaction. But perhaps more importantly, it can be used to automatically identify risk factors and recommend preventative treatment. Even more exciting: with the rise of the Internet of (Medical) Things (IoMT), mobile and wearable devices are increasingly connected, working together to create a cohesive medical report accessible anywhere by your health care provider. This data is not just useful for the patient. It can be pooled and studied en masse to predict health care trends for entire cultures and countries.

Empowered Consumers

All of the above have led to an entirely new trend in healthcare: patient empowerment. While many of us have come to associate health care with high costs and long waits, patients are now in the driver’s seat, with better access to higher-quality doctors, and higher satisfaction rates overall. It’s a healthy new way to look at health care, and one that holds promise for all of us with easy access to the digital landscape. My blood pressure is already lowering just imagining the possibilities.

AAFP Still Searching for Right Stance on Telemedicine


Most family physicians support its availability, but uneasy with lack of structure

  • Family physicians couldn’t agree on whether “responsible medicine” should require telemedicine to be strictly limited to established physician-patient relationships or open to new patients in an effort to expand healthcare access and affordability.

But the vast majority of doctors who gave testimony in support of telemedicine also asked the reference committee on practice enhancement at the American Academy of Family Physicians’ 2015 Congress of Delegates to provide tools and research to help them provide high-quality care in this uncharted territory.

Ultimately, the committee decided to refer the resolution back to the Board of Directors for further investigation by the Commission on Quality and Practice and the Telehealth Member Interest Group.

A resolution supporting reimbursable and malpractice-protected telemedicine as part of an established patient/physician relationship hinged on the word “only” — which, if included in the resolution as written, would limit telemedicine to patients established within a practice.

“Saying the word ‘only’ established physician-patient relationship greatly limits us in our ability to reach all the hundreds and thousands of people that we live with, drive by everyday, that have not had access to a physician,” a delegate from Iowa said. “Often times they don’t see a physician for money, time — they’re working too hard, they have fears — they don’t want to know something about their health. This [telemedicine] may be their only entry to see a doctor.”

The delegate urged her colleagues to embrace telemedicine without the designation of ‘only established,’ as it will certainly be part of the future.

“Telemedicine does have great potential in primary care,” a delegate from Mississippi, and author of the resolution, responded. “But it also has the potential to disrupt quality of care.”

The Mississippi delegate agreed that telemedicine is the way of the future and physicians should incorporate it into their practices, but in order to ensure the medical care is of the highest quality, “it must be part of an established relationship.”

This should become an extension of family medicine “instead of a kiosk in Walgreens,” he added.

A delegate from Maryland noted that telemedicine started 15 years ago, but with the recent explosions, “it’s now become a franchise institution where I am regularly recruited to become part of somebody’s telemedicine incorporation.”

The delegate said she supported the resolution, but with expanded wording that didn’t isolate patients forcing them to “utilize care the way we want them to.”

“We have reservations in regards to the words ‘only’ and ‘recent,'” the Resident section delegate said. “Patients are demanding care in new and flexible ways, particularly the younger patient populations and we as a specialty need to meet them where they are as opposed to being extremely rigid and inflexible.”

 The Resident delegate agreed that there’s nothing that can take the place of the physical exam room, “however, I think in 50 years, we’re going to be looking at a very different scenario.”

Another delegate, who warned against narrow views not recognizing the full scope of potential for telemedicine, spoke of an “e-long-term care support mechanism” to monitor nursing home residents who’ve experienced a change in condition and wouldn’t be able to go into a physician’s office in a timely manner. “This is very important to prevent a return to the hospital.”

“Telemedicine is a fact of life and we all practice it all the time,” a delegate from Massachusetts said. “But when we know the patients, we make better decisions. Everything we can do to support long-term relationships should be done, including in this area.”

Several other delegates told the committee that telemedicine is the future and it’s important for family physicians to embrace it to stay cutting-edge and increase their market of patients.

The Alaska delegate suggested using state licensure to help keep tabs on quality care. And the Texas delegate made mention of his state’s medical board being sued by a telemedicine company. “It is here to stay, and it needs to be done right — done by physicians, not by corporations.”

5 Things to Know About Telemedicine


You may have recently heard of the term telemedicine. So what is telemedicine? It’s more than just a buzzword or a word to describe using FaceTime or Skype with your doctor. Telemedicine is the use of technology to connect patients with physicians or other health care providers outside of the traditional office visit. National Kidney Foundation President Jeffrey S. Berns, MD, breaks down what telemedicine means and how it can be used for people with kidney disease.

Telemedicine is defined as exchanging medical information between different sites. This means that instead of being treated in the same room, a patient can be located in a different city, or even country, from a doctor or other health care provider. The telemedicine appointment is conducted through electronic communications to provide diagnoses, treatment recommendations and health care education to improve patients’ health status. Here are 5 key details you should know about telemedicine:

  1. Telemedicine “visits” are typically conducted using special internet technology to transmit voice, images (including the patient and doctor), and sound. There is even a digital stethoscope and other tools available that can be used to transmit heart and lung sounds from the patient to the provider.
  2. For patients with kidney disease, telemedicine has been used to monitor blood pressures measured at home and has been shown to improve control of BP. Telemedicine has also been used successfully to provide resources and information to patients. For example, this information sharing could include providing information about how to best reduce dietary salt intake and how to take high blood pressure medications correctly.
  3. Another use of telemedicine is to help connect two doctors together. For instance, an internist, family doctor, or nurse practitioner could talk with a nephrologist to discuss a patient and coordinate care. This model has been used very successfully in the U.S. Indian Health Service.
  4. Telemedicine has also been used to allow nephrologists or nephrology nurses to interact with patients who are being treated with home dialysis (both home hemodialysis and peritoneal dialysis), to provide “visits” in-between regularly scheduled office visits. This could provide a great deal of comfort for patients to know that someone is available when concerns arise without requiring that patients travel to the dialysis center.
  5. For now, telemedicine is mostly limited to “virtual visits” for patients living in rural parts of the U.S. Before telemedicine, these patients would otherwise have to travel long distances to see their doctors or their doctors would need to travel long distances to see them.

So whether for diagnosis, treatment, doctor-to-doctor consultations, or just “keeping an eye on a patient when needed,” telemedicine may have a lot to offer in the future as technological advancements make this a more common medical model. It would not be surprising if in the near future, the reach of telemedicine increases significantly, changing the way we think about medicine, and bringing doctors and patients together more often, without the need to travel (and sit in a doctor’s waiting room).

Iowa Supreme Court ruling on abortions could lift telemedicine


The Iowa Supreme Court on Friday struck down a rule prohibiting doctors from administering abortion-inducing drugs remotely via technology, a decision with potential implications for telemedicine nationwide.

In a unanimous decision, the court said the rule, which requires doctors to be physically present when an abortion-inducing drug is provided, is unconstitutional at the state and federal levels.

Planned Parenthood has been performing the telemedicine abortions in Iowa since 2008. Under the procedure, a trained staff member takes a patient’s medical history, checks vital signs, collects blood for testing and performs an ultrasound. A doctor in a different location then reviews the information and, via videoconferencing, talks with the patient and remotely releases a drawer in the same room as the patient with the medications. The physician and staff member then watch the woman take the drug.

The Iowa Board of Medicine, however, passed its rule in August 2013, citing patient safety.

Planned Parenthood has argued the rule’s true purpose was to limit women’s access to abortions.

The Iowa Medical Board’s executive director, Mark Bowden, said in a statement Friday the board adopted the rule to address what it saw as “the unsafe practice of medicine, and not to place an undue burden on women who choose to terminate their pregnancies.” The board had said it was concerned about the “quality and sufficiency” of the physical exam being performed before a medical abortion.

Bowden said the board will discuss the ruling at its meeting in July to fully determine how to apply it. A spokesman for Iowa Gov. Terry Branstad said Friday the governor was disappointed by the ruling but it was too early to speculate as to whether there will be an appeal.

“After receiving petitions from medical professionals from all across Iowa that raised concerns about the quality of care women were receiving under these webcam procedures, the Iowa Board of Medicine provided a standard of care for webcam abortions,” Jimmy Centers, a spokesman for Branstad, said in a statement. “Although the Court upheld parental notification, the governor is extremely disappointed that the Iowa Board of Medicine’s action, which ensured women received the high standard of care that they deserve, was reversed by the Iowa Supreme Court.”

Suzanna de Baca, CEO of Planned Parenthood of the Heartland, applauded the court for protecting “women’s access to safe, legal abortion.”

“Medical experts opposed this law because it harms women by blocking access to safe medical care,” de Baca said in a statement Friday. “When it comes to healthcare, politics should never trump medicine.”

In its opinion, the court said the rule places an undue burden on a woman’s right to terminate her pregnancy.

Also, the court said, the medical board didn’t seem consistent in its views over telemedicine abortions versus other telemedicine activities.

“Whenever telemedicine occurs, the physician at the remote location does not perform a physical examination of the patient,” the court wrote. “It is difficult to avoid the conclusion that the Board’s medical concerns about telemedicine are selectively limited to abortion.”

The case has potential ramifications for telemedicine abortions, and the broader, growing field of telemedicine in general, across the country.

Nathaniel Lacktman, a partner at law firm Foley & Lardner in Chicago, said the ruling may send a message to other states, particularly because the court found the “undue burden” test established by the U.S. Supreme Court.

He also noted that the ruling cited studies showing that telemedicine abortions don’t pose any more risk of complications than those done in person.

“This is a great win in support of telemedicine services,” Lacktman wrote in an e-mail.

Joseph McMenamin, a lawyer in Richmond, Va., who focuses much of his work on telemedicine, said the fact that the Iowa Supreme Court saw no problem with telemedicine abortions may suggest a level of acceptance of telemedicine that advocates couldn’t necessarily claim five or 10 years ago.

“What’s perhaps most helpful about it is the Supreme Court of Iowa seemed to make pretty clear telemedicine is a standard way of providing healthcare, which advocates of telemedicine have argued for a long time,” McMenamin said.

McMenamin noted, however, that the national implications might still be somewhat modest given that the American College of Obstetricians and Gynecologists already has a position that telemedicine is a safe and effective means over which to carry out a medical abortion.

In fact, ACOG president Dr. Mark DeFrancesco released his own statement Friday saying that abortion via telemedicine can be particularly helpful to rural women who otherwise might have to travel hundreds of miles to receive care.

“Telemedicine is widely regarded as an important and promising technology in medical care, and its potential benefit to American patients’ access to care is significant,” DeFrancesco said. “Singling out and restricting one particular use of telemedicine care is wrong, and we are pleased that the Iowa Supreme Court has recognized that.”

Sixteen states require that clinicians be physically present when prescribing abortion-inducing drugs, according to the Guttmacher Institute, which works to advance sexual and reproductive health and rights. Minnesota is the only other state where telemedicine abortions are allowed, according to Planned Parenthood of the Heartland.

Telemedicine Is The Future Of Health Care: On-Call Docs To Examine, Diagnose, And Treat Patients Remotely


Smartphones and tablets are used for just about everything, from monitoring your bank account to ordering a cab, so it would only make sense that health care become part of this technological advancement. Telemedicine is the union between technology and health, and many believe it is the future of health care in the U.S.

On Monday, at the American Telemedicine Association’s trade show in Los Angeles, American Well, a telemedicine provider, announced “Telehealth 2.0” — a broad sweeping list of telemedicine products and services. These include live “video visits” on your phone and the web, real-time patient data, and the ability for doctors to review and accept/decline visits on their mobile phone.

“We [want to] take telehealth that was used as a convenience measure for patients and put it in the hands of physicians,” said American Well CEO Roy Schoenberg, as reported by Forbes.

American Well’s move has further strengthened the prediction telemedicine is not a passing phase but here to stay. The technology needed for telemedicine as well as the demand for its services has been around for decades, but it’s not until fairly recently that this idea of “virtual check-ups” began to be taken seriously by health professionals.

Telemedicine is highly convenient, a factor that is helping in its rise in popularity. American Well’s new app for physicians will include integrations with Apple’s biometrics to allow patients health records available at the touch of a finger. American Well also has an app which matches patients with doctors within two minutes. According to Forbes, American Well foresees doctors eventually easily shifting between their virtual and physical waiting room patients, a skill which will allow them to see more patients than ever before. Allowing doctors to deal with minor health concerns, such as flus and colds in a virtual setting would theoretically make more space in actual waiting rooms for more seriously ill patients.

Beyond the cold and flu, Schoenberg explains, telemedicine has potential to treat more complex conditions, such as cancer and heart disease. Large hospital systems like the Cleveland Clinic and Massachusetts General are currently using American Well technology to treat patients, he said.

Wired reported that UnitedHealthcare, Oscar, WellPoint, and some BlueCross BlueSheild plans have adopted telemedicine programs in recent years.

While telemedicine does sound exciting, it’s not without its hurdles. For example, making access to a doctor that easy may lead to patient-overuse, a problem which could overwhelm the already inundated health care system. There’s also the fact that old habits die hard and although it may be possible to have a virtual doctor’s appointment, for now, doctors and patients alike may prefer the old-fashioned face-to-face check-up.

Regardless of these hurdles, it’s clear that telemedicine is here to stay and bound to only become more popular. And while there is a long way to go before we’re all able to have 24/7 medical help at the touch of our fingers, this latest announcement from American Well is certainly a step in that direction.

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