Statewide telehealth initiative begins to get off the ground

In June, health-care professionals from across the state and New England met to discuss how to build a telehealth initiative in New Hampshire.

The two-day “Telehealth NH” seminar was sponsored by the North Country Health Consortium Inc., a Littleton-based rural health network that works with health-care providers in the North Country to provide access to affordable health care and services in the region.

“The purpose of the conference was to raise interest, knowledge and awareness of telehealth opportunities and to explore developing a statewide telehealth collaborative,” said Anne Conner, outreach librarian for the NCHC and a coordinator of the conference. “Our game plan is to find partners in a planning process to determine if a New Hampshire telehealth initiative is feasible. We think there is potential for a statewide program with involvement from stakeholders at the state Department of Health and Human Services and the more resource-rich health facilities, such as Dartmouth-Hitchcock Medical Center, and others. If we were to have clinical specialty teleconsultations in the North Country, they could be provided by specialists at facilities in more densely populated areas in the southern tier.”

As a rapidly evolving health-care delivery model, even the definition of telehealth is somewhat vague.

The federal Office for the Advancement of Telehealth defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health-care, patient and professional health-related education, public health and health administration. The American Telemedicine Association defines telemedicine as the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health-care provider and for the purpose of improving patient care.

“Clearly, the types of products and services considered part of telemedicine is evolving,” said Conner.

Several hospitals and care providers in the state are already using telehealth technologies:

• Several hospitals, including Memorial Hospital in North Conway, have a Picture Archiving and Communications System (PACS) for use in teleradiology.

• DHMC and Concord Hospital use videoconferencing to provide continuing medical education to physicians.

• The Lake Sunapee Region Visiting Nurse Association has 50 home monitoring units for patients with congestive heart failure.

• Electronic medical records are used in many community health centers for enhancing documentation, improving reimbursement and efficiency.

• Crotched Mountain Rehabilitation Center employs videoconferencing for evaluations of students who have developmental-behavioral problems. It also uses the technology for statewide training and education seminars.

Major barrier

The NCHC must overcome a number of hurdles to bring about a statewide telehealth initiative, not the least of which is the limited availability of sophisticated telecommunications in the North Country.

“Cable is not available in all communities. There is an initiative coordinated by the New Hampshire Rural Development Council to bring broadband to all communities in northern New Hampshire, but this could take several years to implement,” Conner said.

However, added Conner, advanced telecommunications are available at most of the rural provider sites. “Many of the North Country providers are linked in a wide area network and use virtual private network technology to access their patient databases, for videoconferencing and to share resources.”

While technical considerations will definitely play a major role in defining telehealth in New Hampshire, education about the technology as well as its uses and limitations will be key in moving the initiative forward. Conner said that education for physicians and other providers as well as health-care administrators, legislators, communities and individuals is necessary for the initiative to succeed.

“As with implementing any new technology, adoption rates will be dependent on how successfully providers and others can be convinced of the value of using new technologies. Consumer awareness of the possibilities also comes into play,” she said.

Even if providers and patients are eager to use telehealth systems, state laws may significantly hinder the process. Licensure for physicians and other health professionals becomes a critical issue when medicine is practiced across state lines – and that’s one of the hallmarks of telehealth.

“Congress is increasingly concerned over the restrictive nature of certain state licensure requirements and their negative impact on delivery of telehealth services,” said Conner.

In 1997 and 2001, the Office for Advancement of Telehealth reported to Congress that licensure was a major barrier to the development of telemedicine.

In response, the Federation of State Medical Boards has developed a “special purpose license” model to allow limited practice in states other than the physician’s state of practice. Eight states — Alabama, Minnesota, Montana, Nevada, New Mexico, Oregon, Tennessee and Texas — have adopted plans similar to the FSMB model.

Other states use license reciprocity, or what’s called a Mutual Recognition Model, or an interstate compact. “States that adopt similar legislation grant licenses to practice in all states that have adopted the agreed-upon legislation,” said Conner of the system.

According to the New Hampshire Board of Medicine, an out-of-state doctor using telemedicine or the Internet to diagnose and treat a patient residing in New Hampshire must have a New Hampshire license or be acting as a consultant to a New Hampshire physician who has a bona fide physician-patient relationship with the patient.

“Technology is changing and improving rapidly. Regulatory reforms, however, have not. There needs to be dialogue among providers, patients and regulators,” said Conner.

Reimbursement by insurance companies for telemedicine services is another relatively uncharted area.

“As of Oct. 1, 2001, coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy and pharmacologic management delivered via a telecommunications system,” said Conner. “Private insurers are looking to Medicare as a model for reimbursement.”

And the telehealth technology itself is not cheap, with some of the systems, such as a teleradiology system, costing well over $1 million.

Several presenters at the conference remarked that a telehealth system should pay for itself by maximizing return on investment, such as being used by several hospital departments.

Healthways, a telemedicine service associated with Regional Medical Center at Lubec in Maine, actually generates income by providing statewide videoconferencing grand rounds and other educational programs as well as by having contracts with state prisons for providing clinical consultations.

The NCHC plans to bring the conference planning committee together this summer to review the action items from the conference and further develop the next steps.

“We have to see who else comes to the table. Usually, successful programs start by identifying successful projects and willing partners,” said Conner. “Telehealth is an opportunity for patients, especially from rural, under-served populations, to access care in a cost-effective, efficient manner.”