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Telemedicine 101

It is easier for us to undertake an overview or primer on a subject by starting with the context of why something must be or became the item to be understood, and tell it from the view of the major proponent. We will have plenty of time to shape the topic with our vision later on in your tour of this subject. For now, this is a fair presentation of this subject to start your journey.

t the outset let me briefly state that there is a difference between telehealth and telemedicine beyond the fact that the former is mostly not reimbursable for Medicaid and Medicare except in specific limited situations. The key difference is telemedicine is strictly defined and requires a two way real time interactive high speed broadband communications connection between the origination site and the destination site where a currently licensed medical professional is there directing the medical or mental health session, and where the patient must be present at the origination site.

Telehealth is undefined and can be anything from you using a personal webcam over the Internet and talking to anybody about health subjects. Hence, while many experts use these two words as if they are the same, telehealth is usually meant to be inclusive because distance and communications is viewed in common with the term telemedicine which is laser straight specific. Still you should know the difference as you will hear the term often and read explanations like that we offer in this website below.

Obviously you wont want your precious private medical data and streaming medical video jerking along on a public accessible communications path where no assurance of a licensed medical professional is on one end to give you specific advice, or where that data can be lost in normal interchange traffic and never reach its destination. Finally, there are so many health professional scarcity areas in the world, including many urban and rural areas in the US, where there just is not enough or absolutely no dentists, primary care doctors, secondary health care professionals, nurses, therapists, mental health professionals to meet the demand. The following material puts this scarcity in context as an important driver for telemedicine.

Why are Telemedicine and Telehealth so Important in Our Healthcare System?

Telemedicine is emerging as a critical component of the healthcare crisis solution. Telemedicine holds the promise to significantly impact some of the most challenging problems of our current healthcare system: access to care, cost effective delivery, and distribution of limited providers. Telemedicine can change the current paradigm of care and allow for improved access and improved health outcomes in cost effective ways.

Telemedicine increases access to healthcare:

Remote patients can more easily obtain clinical services.

Remote hospitals can provide emergency and intensive care services.

Telemedicine improves health outcomes:

Patients diagnosed and treated earlier often have improved outcomes and less costly treatments.

Patients with telemedicine supported ICU's have substantially reduced mortality rates, reduced complications, and reduced hospital stays.

Telemedicine reduces healthcare costs:

Home monitoring programs can reduce high cost hospital visits.

High cost patient transfers for stroke and other emergencies are reduced.

Telemedicine assists in addressing shortages and misdistribution of healthcare providers:

Specialists can serve more patients using telemedicine.

Nursing shortages can be addressed using telemedicine.

Telemedicine supports clinical education programs:

Rural clinicians can more easily obtain continuing education.

Rural clinicians can more easily consult with specialists.

Telemedicine improves support for patients and families:

Patients can stay in their local communities and, when hospitalized away from home, can keep in contact with family and friends.

Many telehealth applications empower patients to play an active role in their healthcare.

Telemedicine helps the environment:

Reducing extended travel to obtain necessary care reduces the related carbon footprint.

Telemedicine improves organizational productivity:

Employees can avoid absences from work when telehealth services are available on site or when employees can remotely participate in consultations about family members.

These examples illustrate the some improved outcomes and cost savings being achieved by telemedicine and telehealth programs:

Home monitoring of chronic diseases is reducing hospital visits by as much as 50% by keeping patients stable through daily monitoring.

The national average for re-admission to hospitals within 30 days following a heart failure episode is 20%. Telehealth monitoring programs have reduced that level to less than 4%.

Timely provision of treatments that effectively reverse the consequences of a stroke have risen from 15% to 85% due to the availability of telestroke programs.

Telemedicine support to Intensive Care Units (often called eICUs) is reducing mortality rates by 15 - 30% and substantially reducing complications and length of stay.

Telemedicine retinopathy screening programs support early identification of serious eye disease and reduce the incidence of blindness in diabetic patients.


Position Statement and Recommendations from the America Telemedicine Association

Approved March 2007

A number of recent reports indicate that the United States is facing shortages of health care providers nationwide. This U.S. problem is one aspect of a world-wide shortage of providers that seriously affects the health of the global population. If the problem is not addressed, it is likely to have significant consequences for the health of U.S. citizens, including reduced access to scarce care resources and an increased cost for those services.

The problem is documented by the following quotes:

“… There are 77 million people known as “baby boomers” in the United States. These are people defined as being born in the years 1946 through 1964. This group represents the majority of the people that have earning power and are supporting the economy. The majority of the present doctors, nurses, and other health care providers and staff come from this group. The number of retirees from this generation will be growing rapidly in the coming years.​

Members of Generation X born between 1961 and1981 are essentially the children of the

baby boomers. There are only about 50 million people in the Generation X group. Comparison of these two generations raises a serious question for the health care industry: If today’s health care workers are primarily from the 77 million baby boomers generation, how will there be enough health care workers from a 50 million population in Generation X to provide services for the aging baby boomers, their own Generation X, and the generations to follow?”

“The Council on Graduate Medical Education (COGME), a national advisory body that makes policy recommendations regarding the adequacy of the supply and distribution of physicians, predicts that if current trends continue, demand for physicians will significantly outweigh supply by 2020. It recommends that medical schools expand the number of graduates by 3,000 per year by 2015.”

“… Dr. Peter Buerhaus and colleagues found that "despite the increase in employment of nearly 185,000 hospital RNs since 2001, there is no empirical evidence that the nursing shortage has ended. To the contrary, national surveys of RNs and physicians conducted in 2004 found that a clear majority of RNs (82%) and doctors (81%) perceived shortages where they worked."

“The statistics are clear that the current shortage of pharmacists exists and will not be quickly resolved. Unless the problem is addressed immediately, the demand for pharmacists will continue to outpace the supply, and the nation’s health care delivery system will suffer. Addressing these issues will require a significant increase in the number of people who enter the pharmacy profession

“The lack of pharmacists in the U.S. has spawned Congressional action, private studies and public concern. Today, more than 8,000 vacancies exist in retail pharmacies, hospitals, clinics, and other industry sectors, and the problem is only expected to worsen over time.”

“The health care labor shortage in the United States has been widely documented and expected to last through 2050. Almost half of the health care workforce will be 45 years or older by 2008. . . . By 2010, 40% of all registered nurses will be 50 years old or older; . . . the U.S. will need 1.7 million nurses but only 635,000 will be available. One of the most prevalent obstacles rural

Americans face in accessing timely and appropriate primary health care services is the maldistribution and shortage of health professionals to provide needed services. Workforce shortages are especially serious in remote frontier communities, many of which are located in the western region of the United States.”

“There are still serious mal-distribution problems—one in five U.S. residents is

medically underserved.”

“More than 35 million people now reside in rural counties with a community of at least 2,500 but no town as large as 20,000, [and are] presently served mostly by family physicians. If these people are to have a personal physician responsible for 1200 patients, more than 29,000 family physicians would be required. With projected population growth the number of family physicians required for this population increases in 2010 to 30,824, in 2015 to 32, 824, and in 2020 to 37,503.”

There is a growing consensus that the supply of health care providers across the

professions is going to be inadequate to meet the expanding needs for health care of the

U.S. population - both in the short term and in the long term. Telehealth, while not the

entire solution to the problems presented by the shortage and maldistribution of health

care providers, can make important contributions to alleviating those problems.

First and foremost, telehealth methodologies by their very nature are designed to address

the problem of provider maldistribution through providing clinical care at a distance in

either rural or urban settings.

The problem is characterized by a distribution of providers that is not uniform across geographic areas. In particular, the ratio of providers to patients tends to be lower in rural areas than in metropolitan areas. With fewer providers to serve a given size population in rural areas, access problems are exacerbated and the quality and safety of care may suffer. In simple terms, the providers, whether they are nurses, physicians, dentists or pharmacists, are not located where the need is greatest. Solving the problem requires that the patients be brought together in some manner with health care providers.

Telehealth methodologies provide such a solution through various forms of telemedicine to make better use of scarce resources. The live interactive videoconference uses telecommunications technologies to bring the patient together with the provider in a virtual visit that has been demonstrated to be effective in numerous situations. Physician specialists located in large urban practices can diagnose and treat patients in rural health professional shortage areas using videoconferencing.

Pharmacists located at large 24/7 staffed hospitals can provide pharmacy services to small rural hospitals that cannot justify the cost of full-time pharmacist coverage. Retail pharmacists can provide medication services to small rural communities through supervision of a medications dispensing technician. Diabetic nurse educators can work with diabetic patients who do not have local access to such services because the geographic demand is insufficient to support such a practice. Rural providers can share their expertise across a broader geographic area and serve as consultants to their rural colleagues using telehealth methodologies. It is important to recognize that this solution to maldistribution will only be effective if urban providers have the time available to provide such care. In all too many situations, needed specialists are already fully booked and do not have the time or resources to provide any additional services via telehealth or otherwise.

Telemedicine consultation models allow the local rural provider to present their patients

to a specialist via videoconference and to be more involved in the consultation than is

possible when patients are sent to see a specialist at a distant location. In most cases,

when a generalist refers a patient to a specialist in another location, the patient is seen and

the local provider will be sent a written report.

Telemedicine allows for the local provider to both present the patient at the beginning of the consult and to participate in a case conference at the end of the specialist’s virtual visit. Over time, the local provider becomes more knowledgeable and can manage patients without requiring specialists as often. This has been demonstrated in e-mental health programs where psychiatrists in urban tertiary medical centers have been able to diagnose and treat mental health patients in rural areas where there are either limited or no available psychiatric services.

Use of the consultation liaison model where the rural provider presents and then at the end can

participate in a case conference about his/her patient has allowed the rural provider to learn how to manage mental health issues for their patients. This is not intended to eliminate the need for mental health specialists entirely but to provide access to mental health services locally and simultaneously provide training for rural providers.

Telehealth methodologies can promote more efficient care so that the same provider can

service more patients in a given day within a broader catchment area. This has been

amply demonstrated in the field of home health. Nurses performing three to five physical

home visits during a given day can now conduct virtual visits using videophones and

other means and visit with many more patients during that same period of time with

travel time and costs greatly reduced. While such virtual visits cannot and should not

completely replace in person visits, they provide a valuable supplement that has a proven

benefit for patients. By significantly improving the productivity of a health professional,

the shortage in terms of units of service delivered can be diminished without the need for

so great an increase in the number of providers.

Another highly effective role for of telehealth is the use of store and forward telemedicine

(SFT). SFT consults rely on asynchronous transfer of still digital images of a patient, or clinical data, such as blood glucose levels or electrocardiogram measurement, from one site to another for the purpose of rendering a medical opinion or diagnosis. Common types of SFT include radiology, pathology, dermatology, ophthalmology, and wound care. SFT has been proven to resolve access to care issues in both rural and urban areas and provides a more efficient use of specialist time.

Telehealth can not only improve the productivity of individual providers but can also lead

to a reduced demand for services. Numerous examples exist in the home monitoring

literature of studies that demonstrate reductions in emergency room visits and

hospitalizations that have resulted from the use home monitoring equipment. One of the

best know examples is the work of the Veterans Administration in the state of Florida

that indicated a 50% reduction in hospital admissions and 11% reduction in ER visits

using home telehealth and care coordination.

These reductions free up resources, including physician time, which can be productively used for other purposes such as providing medical services that are otherwise unavailable. While increases in productivity and reductions in demand can be of some assistance in meeting the growing need for health care providers, it is important to recognize that there will be a continuing need to increase the number of providers simply to keep up with population growth and changing demographics that require care.

Telehealth methodologies can be of assistance in several ways. First, telehealth methodologies extend the geographic scope of an educational program by supporting the training of students at a distant site from a central location or multiple locations. There are a significant number of persons who would avail themselves of the opportunity to become medical professionals if they could stay in their home community to continue jobs and family support during training periods. Once trained, many of these new professionals would stay in that same community and provide a career of support.

Thus, telehealth can assist in expanding the pool of individuals who are willing and able

to pursue a health professions career. The technology, through multipoint videoconferencing can supply educational programs to many remote sites much less expensively than putting an instructor “on the ground” at each location. At the same time, it does provide of a degree of interactivity which is very important to the teaching process. It is a well known and proven principal of education that students who are active in their learning achieve mastery more quickly and demonstrate a better understanding of what they have learned. Telehealth has a particular

advantage over most distance learning in that it already has connectivity to health care

locations such as hospitals, clinics and other settings and can be used for training in those

locations for little additional cost.

Telehealth also facilitates other kinds of teaching besides lectures and group discussions.

In particular, it can promote remote mentoring where a student practices a certain skill

under the supervision of a master tutor at another location. Surgeons have engaged in

remote mentoring in minimally invasive surgery for some time. Since the surgery is

conducted by a surgeon viewing an image captured by a video camera introduced into the

patient’s body through a small opening, that image can be readily shared with others. By

viewing this image, an expert surgeon can provide real-time advice to a surgeon in

training as they carry out the procedure. With high bandwidth telecommunications, the

surgeons could be a half a world apart and still interact with each other in an effective


A problem facing health professions students in medicine, pharmacy and nursing is the

lack of clinical training sites – locations where students can work with patients and

develop their skills in patient care. While telehealth methodologies cannot by themselves

create new training sites, they can foster better communications among those sites and

facilitate the supervision of students located at those sites by a central educational

authority. Since professional schools are responsible for the quality of training at their

clinical sites, the greater ability to communicate and supervise students at these remote

sites should enhance the ability and desire to include training sites beyond those within a

small geographic radius of the training facility – medical school, pharmacy school or

nursing school.

Finally, telehealth may assist in addressing the shortage of health care providers by

promoting new models of practice that improve the effectiveness and efficiency of the

care process. For example, telehealth methodologies could promote high quality care

supplied by lower cost and, theoretically, more numerous and available personnel who

can be trained and closely supervised by higher level providers. The model for this is the

physician’s assistant (PA) who provides care under the supervision of a licensed

physician according to established protocols. In effect, the physician is “handing off”

certain aspects of patient care to the PA under carefully controlled conditions.

A vital and critical component of controlling and improving the quality of such care is the timely

and effective communication between the physician and the PA. Telehealth methodologies promote and facilitate such communication and can further broaden its geographic scope so that effective communication and supervision can be carried out over sizable geographic distances without compromising the quality of care. The efforts of the Alaska Federal Health Care Access Network (AFHCAN) in Alaska are perhaps one of the best examples of this type of work. AFHCAN addresses the need for health care in remote Alaskan villages, where there are no physicians, by using store-andforward telehealth to “hand off” health care to health aides located in those villages The health aides then provide care under the supervision and advice of physicians at centrally located sites.

In summary, telehealth and its associated technologies have an important role to play in

addressing the maldistribution and shortages of physicians, dentists, nurses and

pharmacists. Appropriate uses of telehealth provide the promise of a greater geographic

scope of services that will address the needs of underserved populations, improve the

efficiency of care, facilitate professional education and promote new models of care,

making health care more accessible to those in need.

Participatory Health: Online and Mobile Tools Help Chronically Ill Manage Their Care

Jane Sarasohn-Kahn, THINK-Health

September 2009

Of the $2.2 trillion in total U.S. health care spending in 2007, 75% ($1.7 trillion) went to care for patients with chronic conditions. Despite this staggering expenditure, there are pervasive problems with the quality of chronic disease care.

Chronic disease is most effectively managed through frequent, near continuous monitoring. Yet many patients spend only a few minutes a year with their clinicians. According to the National Council on Aging, a third of all chronically ill people say they leave a doctor's office or hospital feeling confused about what they should do to manage their disease, and 57% report that their providers have not asked whether they have anyone to help implement a care plan at home. New technology tools are emerging to bridge these gaps.

This report describes some of the online and mobile platforms and applications that can assist patients in managing their health care -- not only at home, but almost anywhere else outside their clinician's office. Sources include extensive interviews with stakeholders in the field, whose experiences and views are presented throughout the report.

The complete report is available under Document Download below.

Document Download

Participatory Health: Online and Mobile Tools Help Chronically Ill Manage Their Care (821K)

Reports & Initiatives

Delivering Care Anytime, Anywhere: Telehealth Alters the Medical Ecosystem

Carlton A. Doty, Forrester Consulting

November 2008

Health plans, providers, and IT vendors are all using telehealth applications to increase quality of care, reduce costs, and increase access for the underserved. Sometimes referred to as e-health or telemedicine, telehealth encompasses a variety of formats, including:

  • Live videoconferencing;
  • Store-and-forward systems for transmitting digital images and other data;
  • Remote patient monitoring through the use of home-based devices; and
  • E-visits or "virtual house calls."

Several technologies and services are used to enable or complement telehealth applications: satellite networks; phone services (such as 24/7 call centers); high-speed Internet (such as physician-patient portals); streaming media (such as health education videos); and wireless communications (such as mobile devices and radio frequency identification [RFID]).

This iHealth Report -- a commissioned study conducted by Forrester Consulting on behalf of the California HealthCare Foundation -- examines emerging uses of telehealth and describes the market drivers and challenges that will impact its future growth.

The complete study is available under Document Downloads below.

This report complements another CHCF iHealth Report, titled Right Here Right Now: Ten Telehealth Pioneers Make It Work, which is available under Related CHCF Pages below.


Understanding Medicaid Medicaid - Cost and complexity tax reform efforts By Pamela M. Prah, Staff Writer

March 6, 2005 - When Medicaid first came into being in mid-1965, the now gigantic government health care program went largely unnoticed. The federal-state policy commitment to provide for the medical needs of the poor was so overshadowed by passage of sweeping Medicare health care guarantees for every American over age 65 that President Lyndon B. Johnson gave Medicaid only passing mention at an Independence, Mo., bill-signing ceremony.

Related Story New York Medicaid Changes Praised by HHS Secretary: May Be Signal to Governors March 17, 2005 – The effort in New York to “modernize” the Medicaid program drew praise yesterday from Health and Human Services Secretary Mike Leavitt. It may signal a direction for the states to move, after appeals to President Bush by the governor’s failed to produce additional federal funding. Forty years later, Medicaid has evolved into a policy nightmare whose ever-growing costs overburden the federal treasury and threaten to swamp state budgets.

At a February meeting of the National Governors Association in Washington, D.C., it was the dominant issue, sparking much discussion of possible budget cuts and proposed reforms.But like so many policy debates these days, many well-informed people probably found the discussion incoherent; the governors and federal officials used often-confusing, ever-changing frames of reference in talking about the program. As Pennsylvania's Democratic Gov. Edward Rendell observed resignedly in a hallway conversation, Medicaid is so complicated it’s hard to explain.In hopes of bringing some light to this important discussion, set out to better define the Medicaid program and point you to resources that might give you a greater understanding of what the politicians are talking about.

You will find a great deal of basic information on a web site maintained by the U.S. Department of Health and Human Services; click on Medicaid. The Henry J. Kaiser Family Foundation offers help at and Kaiser Report . The Nelson A. Rockefeller Institute of Government has compiled still more information at Rockefeller research. will list other helpful sites as we find them. This "Backgrounder" is a work in progress and will be updated as warranted. Here are some facts at a glance in FAQ form:

What is Medicaid? In reality, Medicaid is not one program, but 50 different programs that states administer using=20 broad federal guidelines and federal funds. Washington picks up about half of the tab, states pay the other half. In 2005, Medicaid will serve 53 million people -- more than any other single health care program in America, including Medicare.

Is Medicaid the same as Medicare? No. Medicare is a federal program that provides health care for some 41 million senior citizens and retirees over 65 years of age. Until recently, states had no role in Medicare. Starting Jan. 1, 2006, Medicare will provide a prescription drug benefit for the first time, but unlike all other Medicare services, states will partly pay for this benefit.

Is Medicaid associated with welfare? No. Almost half (48 percent) of Medicaid recipients are children. Adults, primarily low-income working parents, make up nearly a third (27 percent). Disabled Americans make up 16 percent and the elderly 9 percent, according to the Kaiser Commission on Medicaid and the Uninsured. The 1996 welfare law no longer links Medicaid to welfare. Today, most Medicaid beneficiaries are not on welfare, a striking difference from 20 years ago when three-fourths of people on Medicaid also received welfare.

Who does Medicaid cover? The federal government tells states which groups of people they must cover and the kind of services they must provide. "Mandatory" groups include: > Poor pregnant women, low-income, uninsured children and some parents of low-income families.

> Low-income elderly, blind and disabled people, and

> Certain low-income Medicare recipients.

> States have broad authority to cover other "optional" groups if they want. In 2004, for example, 40 states covered pregnant women at income levels that exceed the federal poverty ceiling.

What does Medicaid pay for? Medicaid pays for a variety of mandatory benefits in every state including: > Doctor's visits

> Inpatient hospital services

> Laboratory services and X-rays

> Outpatient hospital services that are preventive, diagnostic, rehabilitative

> Nursing home care

> Family planning and pregnancy-related services

> Home health care

> Nurse-midwife services

> Periodic screening for children under 21What are some optional benefits that many state

Medicaid programs cover? States can -- and often do -- go beyond required benefits. Among the most popular "optional" services are:

> Prescription drugs

> Dental services

> Eye glasses and hearing aids

> Medical equi pment and supplies, such as wheelchairs

> Ambulance services

> Intermediate care for the mentally retarded

> Hospice care

Even though prescription drug coverage and ambulance transport are listed as optional, all states offer both.

How much does Medicaid cost? Together, state and federal governments are expected to spend nearly $330 billion on Medicaid in 2005. Medicaid accounts for 22 percent of state budgets, when factoring in federal funds. That's up from just 8 percent in 1985. That means the growth of Medicaid spending is crowding out funding for other programs that states deliver, including education, corrections and transportation.The federal government each year tinkers with its formula for calculating how much money it gives each state. Generally, the richer the state, the less it gets. The federal matching rate is based on states' average per-capita income and is always at least 50 percent, but could be as high as nearly 80 percent. In 2005, 12 states got the minimum 50 percent rate (California, Colorado, Connecticut, Illinois, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Virginia and Washington) while 10 states got matching rates higher than 70 percent (Alabama, Arkansas, Idaho, Louisiana, Mississippi, Montana, New Mexico, Oklahoma, Utah and West Virginia).

Because Medicaid is the biggest source of feder al revenue to the states, even the slightest variation of the federal match can have a big impact on a state's budget. The changes for fiscal 2006, for example, will require that states pony up an additional $527 million, according to the Federal Funds Information for States (FFIS), a joint subscription service for NCSL and the National Governors Association that tracks budget issues affecting statesStates hardest hit by this change in matching formulas include New Mexico, which could lose some $82 million, Alaska (potentially losing $76 million) and Louisiana (potentially losing $70 million), according to FFIS.

Why are states' Medicaid costs going up? It was no surprise that Medicaid enrollment went up in the last few years when the economy took a downturn. As more people lost their jobs and income, they turned to Medicaid. But the dramatic and sustained increase has surprised some state budget and health officials. Enrollment jumped by one-third from 2000 through 2004. If recent state estimates are on target, enrollment will grow another 5 percent in 2005, making the rise in overall enrollment for 2000-2005 nearly 40 percent, according to the Kaiser Commission. Higher enrollment means higher costs for states. Medicaid spending jumped by more than 50 percent between 2000-2004.But even as the economy rebounds, Medicaid costs still are expected to eat up state budgets.

Rising health care costs, particularly prescription drugs, plays a huge role, but so do demographics. As Americans gets older, many will need more long-term care and nursing home care. Medicaid already is the nation's primary long-term care program, accounting for 43 percent of total long-term care spending and paying for nearly 60 percent of nursing home residents.Changes in the U.S. workplace also are a reason for the spike in Medicaid enrollment. More employers are opting not to provide health care insurance for their employees, forcing some working poor to turn to Medicaid. Experts say the Medicaid safety net prevented the number of uninsured Americans, which recently hit a record 45 million people, from growing substantially higher.

Who are "dual eligibles" and why are states so upset about them? In any debate about Medicaid, state officials are certain to use the term "dual eligible," referring to 7 million elderly people who are on the rolls of both Medicare and Medicaid. These people account for more than 40 percent of total Medicaid spending because they tend to be very poor and frail and have substantial health problems.States not only pay for their long-term needs and prescription drugs, but help pick up the tab for their Medicare premiums and cost-sharing. The states argue that the federal government should shoulder more of the cost of caring for this group.

What is S-CHIP? Commonly called "S-CHIP," the State Children's Health Insurance Program was created in 1997 to expand health insurance coverage to children in low-income families that did not qualify for traditional Medicaid but could not afford to pay for private insurance. It's largely hailed as a successful program, but it also suffered economic woes during states' budget crises.