American College of Physicians supports expanding telemedicine in primary care
The&nbsp;American College of Physicians has published a paper outlining its support for the expansion of telemedicine in primary care settings. The body argues that telemedicine should be held to account to the same standards of practice as in-person medicine, and emphasises the importance of a valid patient-physician relationship, whilst admitting such a relationship can be achieved through real-time audiovisual technology.&nbsp;
Telemedicine can broaden access to care, improve outcomes, and reduce care costs, but risks and benefits must be carefully evaluated for both patients and physicians, say authors of a new position paper from the American College of Physicians (ACP).

The paper, published online September 8 in the Annals of Internal Medicine, offers more than a dozen recommendations — and the rationale behind them — for successful telemedicine, which the ACP says should be held to the same standards of practice as in-person medicine.

Among the most important recommendations is establishing a relationship. "ACP believes that a valid patient–physician relationship must be established for a professionally responsible telemedicine service to take place. A telemedicine encounter itself can establish a patient–physician relationship through real-time audiovisual technology," the authors write.

A physician who is seeing a patient for the first time via telemedicine should either begin a relationship based on the standard of care for an in-person visit or consult with another physician who does have a relationship with the patient.

Reimbursement remains one of the largest challenges for telemedicine, as laws and policies vary widely and some areas provide more incentives than others. For instance, regarding Medicaid, 46 states and the District of Columbia reimburse for interactive or live video, 10 states reimburse for store-and-forward technology, 13 states reimburse for remote monitoring, and three pay for all three types of telemedicine.

The ACP supports payment by public and private health plans whether the telemedicine encounter happens in real time via two-way communication or via transmission of information not in real time, and whether communication is text only or accompanied by voice, video, or device feeds.

Physicians who use telemedicine will need to be proactive in protecting themselves, the organization warns. The ACP advises physicians to make sure their medical liability policy covers telemedicine services. They also support a streamlined licensing process so physicians and other clinicians can provide services across state lines while allowing states to keep their individual licensing and regulatory authority.

The Savings Potential of Telemedicine

In an accompanying editorial, David A. Asch, MD, MBA, from the Center for Health Care Innovation, University of Pennsylvania, Philadelphia, says the savings potential for physicians, hospitals, and other providers is enormous with telemedicine. Time with patients can be shorter, and there is no check-in at a desk and no need to devote space to a waiting room. He notes that in some offices, "waiting rooms occupy nearly one half of usable space."

That is the real potential, he writes. "The innovation that telemedicine promises is not just doing the same thing remotely that used to be done face to face but awakening us to the many things that we thought required face-to-face contact but actually do not."

Among the telemedicine winners, he says, are those patients who are choosing not between in-office care and telemedicine, but between no care and telemedicine. Perhaps a region does not have a neurologist, or an emergency department cannot staff a full-time stroke specialist. Telemedicine grants patients access.

Other winners are patients who can eliminate the travel time, wait time, and parking fees of an in-office visit. Waiting can be done at home or at work where, presumably, they could get other things done at the same time. And some will not have to wait at all, such as patients with a rash, who can send an image to a dermatologist and get results remotely, says Dr Asch.

He points out that some payers worry that making care as convenient as taking a picture will mean people will seek care for things they would otherwise have ignored.

Although he agrees that may happen, he thinks the question should be thought of another way: "Do we really want to ration care by inconvenience, or do we want to find ways to deliver valuable care as conveniently and inexpensively as possible?"

Hilary Daniel, BS, from the ACP in Washington, DC, and Lois Snyder Sulmasy, JD, from the ACP in Philadelphia, Pennsylvania, authored the paper for the ACP Health and Public Policy Committee. The statements represent the official policy positions and recommendations of ACP.

Financial support for developing this guideline comes exclusively from the ACP operating budget. The authors and Dr Asch have disclosed no relevant financial relationships.

Ann Intern Med. Published online September 8, 2015. Article full text, Editorial extract