COMMENTARY

The Global Rise of Telemedicine

Andrew N. Wilner, MD

Disclosures

February 12, 2016

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Andrew N. Wilner, MD: Hello. I'm Dr Andrew Wilner, reporting for Medscape. Today I have the pleasure of speaking with Jonathan Linkous, who is the chief executive officer (CEO) of the American Telemedicine Association (ATA) in Washington, DC. Jon, thanks for joining us.

Jonathan Linkous: Thank you for having me.

Dr Wilner: I have actually started to do a little bit of telemedicine myself. I was browsing the Internet and discovered that there is an American Telemedicine Association that I did not know existed. I said, "Oh, this is cool. This is something that is going to help me." What does the ATA do?

Mr Linkous: First of all, I'm glad that you reached out, and I can assure you that you are not alone, unfortunately, in not knowing about ATA, but certainly not alone in using telemedicine. We are a 22-year-old organization. We have witnessed the growth of telemedicine from something that was unheard of—I've had to define what telemedicine means to a lot of hospitals—to today, where it is really a booming way of providing healthcare services. Our mission is to transform the way healthcare is provided, both in the United States and all over the world. Our members include individuals—we have about 10,000 individuals now that are located in every state and all over the world—and we also have medical institutions and societies as members. There are probably about 200 or so hospitals and health institutions. There are also companies that are members. We have about 200 companies that are providing a lot of the services and products that we use in telemedicine.

We are kind of a conglomeration, meaning part professional society and part trade association. We do provide education, do a lot of meetings, and do a lot of work with the government to help them understand some of the issues and the regulations around this new institution of telemedicine. We do a lot of work with medical societies, and we even do a little bit of work designing standards and practice guidelines in the field as well. It's a booming field, and we find ourselves happily very busy these days.

Dr Wilner: I am a neurologist. Why would I want to be a member?

Mr Linkous: Neurology is a very fast-growing part of telemedicine. As you probably know, the use of neurology in emergency departments (EDs) is particularly critical because there are so many EDs that do not have a full-time neurologist, and when you have things like a patient with a stroke who comes in, it is really critical that you get those services to them. This year, about 125,000 patients who have suffered some form of stroke or symptom of stroke will be seen by telemedicine in EDs.

The ATA is very busy. We are actually in the process right now of developing practice guidelines for telestroke with many of the societies and groups that are active in providing care. We are developing the standard practice guidelines with neurologists who are doing this on a daily basis, and we are also networking with other neurologists. A lot of the companies or institutions that are providing the services look to us not only to help provide education but because they are looking for staffing for other medical professionals who are in this field—it's still relatively small, but we are growing rapidly. As you probably have already discovered, there is an increasing demand for people like yourself who are knowledgeable and have an interest in working in this growing space.

Dr Wilner: One of the issues that is dear to my heart regarding telemedicine is the current requirement that one must be licensed, not only in the state in which one is physically but in the state where the patient is physically. Most telemedicine setups that I am familiar with work with multiple states, and this requires multiple licenses. That's a much bigger job than anyone who has not done it can possibly imagine. I had read something about a bill. Are you making any progress with a national telemedicine license?

Mr Linkous: Again, you have put your finger on a really important issue and one that we have been working on for a long time. It is not an easy issue to crack because, in many cases, we are talking about states' rights. In many cases, we are talking about medical boards and those who would like to protect the interests of the physicians who are in the state. Licensure rules are—and you described it well—unique to every state. In some cases, they are there to really protect the patient; but in some cases, they are also there to protect the physicians who are in the state. As telemedicine grows from something that was once in a community or in one state but is now something that is increasingly regional or even national in scope, it puts a real pressure on the licensing system—not only for doctors but licensing for nurses, physician assistants, and the whole gamut.

We are moving to a different world. I put this in light of what has happened to other industries like banking. Those of us who have been around for a while may remember that each bank was unique to that state, and if you wanted to cash a check, you had to go to your local bank and have your local teller do it. Now we have ATMs, we have banks that go around the world, and certainly the banking laws have been changed. We now have to do the same thing with licensing for physicians.

There are a number of bills that are out there to try to create some change. There is also the Federation of State Medical Boards (which represents each of the medical boards in each of the states), which is under a lot of pressure to create change. They have actually proposed a compact within each of the states to try to make this a little easier. We have worked with, and sometimes against, the Federation in this whole area. I must say that they are trying to create some change.

What we would like to see is a little bit different from the compact. We would like to see reciprocity among the states. It is kind of hard to get a national license because you are talking about such an important political issue. We would like to see some reciprocity where if you are licensed in one state, the other states agree to it. It is not exactly what the Federation has in their compact, but whatever the solution is, and we really don't care, we want to get to the point where a doctor like yourself can get a license in another state very quickly without a lot of additional cost or red tape and can start providing services to patients, no matter where they are located, so that they can get access. Frankly, it's in the patients' interest to do telemedicine so that they can get access to medical care as soon as possible.

Dr Wilner: I don't think Al Capone had his fingerprints taken as often as I have. Let's switch gears for a minute. I understand that you just returned from a telemedicine meeting in China, and this was the second annual meeting. China is a big place, so maybe it lends itself to telemedicine. Why was the meeting in China, and what did you accomplish there?

Mr Linkous: That is a very good point. Telemedicine is growing not only in the United States but all over the world. We actually have a chapter in Canada, another chapter in South America, and a chapter in the Pacific Islands, all of which are looking at the same issue. It's not surprising. China is actually close in geographic size to the United States but many times our population. Most of that population in China is in the large urban cities like Beijing—and what is considered a small- to medium-sized city might have 8 or 10 million people.

They are operating on a different scale from the United States, but they still have similar problems with trying to reach out and provide medical expertise to patients in rural areas and between cities. We find ourselves with very common issues in dealing with the medical community and health services delivery. We even have the similar issues of barriers to adoption of telemedicine and resistance by the physician community. It makes sense that we have a dialogue with China to really open up a good deal of cooperation between the countries. That is why we had our second meeting there—because we hope to do a lot more work with them, not only in terms of meetings but working with the central government in terms of their policies as well as the medical societies and many of the institutions there.

There is also a great interest in more of a relationship between US and Chinese institutions because China needs a lot more medical expertise, and US institutions are a wealth of great interest and expertise that can be exported to other countries. A little bit of this is diplomacy—medical diplomacy, as I call it—and a little bit of this is opening up new markets. But a lot of this is also just expanding the delivery of healthcare using telecommunications that is just as worthwhile in China as it is here.

Dr Wilner: I know the military has been a pioneer with telemedicine. Are there any telemedicine setups now where physicians in the United States are actually reaching out to other countries?

Mr Linkous: Certainly the military is one area—and not surprisingly the military in China is a major consumer of telemedicine. There is a lot of work on humanitarian grounds with nongovernmental organizations. Certainly in areas of disaster like in Haiti and some of the other areas where they have faced major disasters, there has been increasing use of telemedicine. Another example of the increasing use of telemedicine might be an older physician who does a lot of work in areas like Africa to volunteer their services—they will actually go to a country to provide those services. They come back and think: "Well, you know, a lot of these services—certainly the consultation—I can provide pretty easily using telemedicine." The last time we checked, there were about 100 medical institutions in the United States that are using telemedicine to provide humanitarian assistance to another country.

Dr Wilner: One hundred?

Mr Linkous: It's not surprising. There's also a big interest among medical institutions to reach out, especially to the wealthy countries of the world, to attract patients who would come in often paying cash and get medical services. It's a pretty easy next step to say: "Hey, let's use telemedicine to provide some of our services over there."

Most of the leading medical institutions in the United States are actively looking to expand their business to other countries, including areas like the Middle East with a lot of money, but also to areas like China that have a large population. How can we work out an opportunity for us to get into that market to provide some of these services using telemedicine to provide actual assistance to some of the people there?

There are other developed nations that are also working to develop relationships with other countries as well. We are finding that a global network is being developed. It's still in its rudimentary forms, but I think very soon we will be looking at a global marketplace for providing healthcare. An association like ours is very important, not only in seeding that effort and helping that to grow but also in providing some of the guidelines in some of the joint work we can do with developing standards so that, at some point, any person in the world can get access to healthcare from any other part of the world. That is kind of the global thinking as to where we are going with this.

Dr Wilner: Even the astronauts were pioneers with telemedicine, beaming back their heart and respiratory rates, so they could be tracked on how they are doing up there.

Mr Linkous: We have done a lot of work with the National Aeronautics and Space Administration (NASA) headquarters over the years. One year we had a presentation at our meeting from onboard the space station that was quite exciting. One of our immediate past presidents, Dr Bernard Harris, was also an astronaut and did some of the first work in outer space. He has done quite a bit of work both as an astronaut and a provider of telemedicine here in this country. So we've had long ties with NASA as well as with the military. The other part of the government that has done a lot of work in telemedicine is the US Department of Veterans Affairs. They probably are the largest provider of telemedicine services of any single healthcare system in the world right now.

Dr Wilner: I am glad you are there. It sounds like something that can only grow into the future, and I think right now it's a little bit of the Wild West if I understand what I read—that there are institutions like Mayo Clinic or the Cleveland Clinic that are developing programs. There are also individuals that are setting up a system of hospitals and just hiring their own telemedicine docs and providing an independent service not necessarily affiliated with any academic center. Is that right?

Mr Linkous: Certainly the academic centers have been the pioneers in telemedicine, in part because there is government grant money that has helped them do that. But now, it's a natural transition that the doctors who have their own patients are now developing patient portals for them to be able to go online and pay their bills or make an appointment. The next step is to do something electronic. You have been able to provide after-hours services to your patients, usually with weekend coverage of a colleague. Well, there is no reason why you can't use video as part of that, and what we are finding is that the regular primary care doc now is starting to get into the world of using telemedicine, and we have some exciting work that we are doing with the American Medical Association to help educate a lot of the doctors who are in their own practices so that they understand—they are not so much afraid of what this represents, but this is actually a tool they can use to expand their practice and provide better care.

Dr Wilner: Well Jon, it sounds like you have a busy day. I want to thank you for sharing these insights into telemedicine with Medscape. I learned a lot, and I am sure our viewers did too. I look forward to speaking with you again to learn more.

Mr Linkous: Thank you very much.

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