Telehealth: A Skill to be Mastered and a System to Be Optimized

Testimony by Thomas J. Kim, MD, MPH

Committee on Public Health on Telemedicine in Texas

Feb. 10, 2016

Good morning, Chairwoman Crownover and members of the committee. My name is Dr. Thomas Kim. I’m an internist and psychiatrist here in Austin who develops, evaluates, and practices telehealth care solutions. Today I’m testifying on behalf of the Texas Medical Association (TMA) representing 48,000 physicians and medical students across our state.  My hope is to offer you some insight into my daily practice experience as a telehealth provider. I further hope you will excuse my preferred use of the term telehealth which for the purpose of these proceedings can been considered synonymous with telemedicine.  

So far this morning we have listened to some excellent testimony from some of my friends and colleagues who clearly share my vision of a health care system that delivers on the promise of timely, cost-effective, high quality health care.  To see such distinguished advocates of telehealth is extremely gratifying given my professional path to date.

When I completed my training approximately 10 years ago, telehealth was largely a care solution found only in institutions serving vulnerable populations such as the incarcerated or military personnel.  Serving these people typically required expensive hardware setups and Internet connections that cost thousands of dollars per month for effectively dial up service bandwidth. I was fortunate to have trained in the state of Louisiana where, like Texas, they embrace telehealth as a way to address the unacceptable access challenges facing too many of their citizens.  From the moment I began caring for incarcerated juveniles without the hassle of travel or concern for my safety, I knew I would devote my professional life to becoming good at telehealth so that I could care for those in need. 

When my wife and I moved to Georgia so that she could pursue her fellowship, I was confronted with a question…How do I keep caring for my Louisiana patients?  Six months of effort led to my successfully transferring my practice to Georgia. Soon after, my wife and I secured our first job in the state of Maryland.  That transition took me about six weeks. It was also at this time that Hurricanes Katrina and Rita ravaged the Gulf Coast and I was fortunate to work with a wonderful team seeking to rebuild lost capacity through telehealth across four states. Finally, when my son was born, it became clear that we wanted to raise him in Texas so we got here as quick as we could, including my patient panel who I care for to this day.

This personal highlight reel was how I came to understand what telehealth represents to a provider rather than a health system. I didn’t have the benefit of training or a mentor who could help me figure out how to make this work as my life circumstances changed. Only after persisting through challenge after challenge did I come to realize what telehealth was.  At the risk of re-traumatizing any of you with less than positive memories of high school physics…telehealth exhibits a paradox similar to light being both a particle and a wave. Telehealth is both a skill to be mastered as well as a system to be optimized. Recognizing these distinct properties allows us to more easily unpack some of the challenges facing telehealth today.

I will briefly touch on four challenges that have particular relevance to a legislative body who are in a position to help guide disruptive innovation while maintaining public welfare.

The first is Connectivity. 
The single technologic area that has been cited as fundamentally essential to society is access to broadband Internet.  Countries like Finland, France, and Spain have declared specific rights for their citizens to have access to the internet.  Such rights typically cite the importance of facilitating the freedoms of expression, assembly, and education; but access to health care can easily be counted as another notable value of broadband connectivity.  To be clear, I am not suggesting that the US is anywhere close to making similar declarations, but fiber optic broadband represents an order of magnitude improvement in bandwidth with even greater opportunities for potential applications. Encouraging continued expansion of broadband availability as a system resource particularly to communities continuing to struggle with access to care challenges is vital. 

The second is Licensure. 
As a physician who has practiced in four states to date, I have first hand experience with how licensure requirements vary.  For telehealth providers who seek to practice across state lines, the current recommendation is to secure a license in any state that either the provider or patient lives in.  This is a requirement that I am happy to do in order to continue to care for my military patients out of Fort Hood, my at risk juveniles in Louisiana, and a displaced Katrina survivor in Maryland.  The challenge is fairly clear as I am often asked if I would care for folks in states I am not currently licensed in.  At some point, multiple licenses become prohibitive for a skilled telehealth provider seeking to care for patients in need.  Fortunately, there is active discussion around the merits of a national licensure versus establishing a compact of reciprocity.  To be clear, the TMA supports an interstate compact for licensure. And while personally confident that some better pathway will emerge in time, there remain those who continue to oppose such efforts. To these critics I highlight telehealth as a skill set. In residency, doctors are trained to function in a hospital ward, outpatient clinic, and emergency department.  While we may pursue work in any of these environments, it is unlikely that we would pursue them all.  In this same way, however much I would like to assist all 48,000 Texan physicians to master telehealth care, I suspect a good number of them would choose not to do so.  For those that do pursue telehealth as a career, a supportive licensure pathway is key to realizing the maximum benefit from this specialized provider resource in order to better respond to the growing clinical needs both here in Texas and elsewhere. 

Third is Reimbursement.
I do not believe telehealth care to be an equivalent or proxy for conventional care. It is a unique environment that requires a unique skill set to be mastered.  That being said, both the TMA and I believe in telehealth payment parity.  Historically, telehealth has garnered the most interest in places with the highest need, namely rural America.  As such, reimbursement for telehealth care is restricted to areas that meet two designations – Non Metropolitan Statistical Areas and Health Provider Shortage Areas. The logic behind these requirements made sense at the time they were drafted, but reimbursement requirements should be reconsidered as an access issue given the growing numbers of Texans in need both 600 miles and 6 blocks from where we stand.  

Fourth is the Electronic Prescription of Controlled Substances. 
The electronic prescription of controlled substances is not so much a challenge as it is a milestone of progress for all Texas prescribers.  Following the issuance of DEA guidelines in 2010, the Texas Department of Public Safety adopted these guidelines in 2013 and completed their beta testing in 2014. The result is a safe and effective way to perform a critical provider task with evidence of improved care quality. For telehealth providers, this is much appreciated progress and an improvement over current workarounds though it also remains mostly unrealized as not all prescribing software vendors are currently offering this feature. 

These four areas demonstrate opportunities for our elected officials to support and encourage the continued growth and maturation of telehealth in Texas. Additional challenges do remain and largely revolve around our current inability to know exactly how best to proceed. Technology innovates at a blazing pace creating devices and services with enormous potential every day. As a doctor dedicated to figuring out how best to use technology, even I am sometimes captivated by the latest and greatest.  Ultimately, I tend to support care models that strike the balance between innovative improvements and the maintenance of standards of care.

In closing, I wish to thank Chairwoman Crownover and the Public Health Committee for convening this gathering as I hope this leads to publically demonstrating that the state of Texas remains a leader in the field of telehealth care.

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Last Updated On

March 08, 2017

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