Dr. Reed Tuckson

While attending the American Telemedicine Association (ATA) meeting in Austin, Texas this week, Dr. Andrew Watson, a colorectal surgeon and executive director of telemedicine at the University of Pittsburgh Medical Center, stumbled across a petting zoo. His young daughter wasn't with him, but he wished she was. Luckily, he was in a telemedicine mindset.

"I took my daughter on a tour of the petting zoo via FaceTime on my iPad this morning," he told the crowd at ATA. "Who knows what the point of care is anymore? But it's certainly not in the offices and the ERs and the ORs. It's going to be in the home and in the cloud."

Video visits, remote monitoring, and better data integration are moving us into a world where we don't think of distance as an impediment to care. And many of the stories told at ATA were stories about scaling telemedicine to meet the growing needs of hospitals to cut costs and reduce readmissions. But medical practices implementing telemedicine still face challenges around licensure, reimbursement, and regulation, as well as challenges about how best to implement and scale their programs.

"The average American is looking to you to deliver on the promise of telemedicine," Dr. Reed Tuckson, former executive vice president of UnitedHealth Group said at the event. "We have so much illness that is washing over  us. We are living longer, but what we are living longer with is chronic illness, which comes earlier in our lives. So we're living sicker, earlier."

The state medical license problem is one that some legislators are working to solve, but in the meantime it puts serious limits on telemedicine as a practice, because, depending on state laws, many doctors can only practice telemedicine if both they and their patient are in a state where they're licensed.

"Even though your driver's license is good enough to drive in every state, you need to have an individual license to practice medicine," said Don Kosiak, from Avera eCARE, a community hospital network in rural South Dakota that leans heavily on telemedicine.

In addition, billing codes for Medicare and Medicaid reimbursement often specifically refer to an "initial face-to-face visit," despite the fact that with telemedicine an initial visit can be conducted over videoconferencing. In general, the codes weren't designed with telemedicine in mind and some virtual visits don't fit in well, or can't be reimbursed at all under the current system's language.

"Telemedicine has outpaced billing and coding infrastructure," Tuckson said.

Dr. Ray Johnson, Director of Neurology Telehealth at Johns Hopkins put it more pointedly:

"If [patients] come in to the hospital, we get $200. If they go to a rural clinic we get $100. If I come into their home [virtually], we get zero dollars," he said. "There's no rational reason taxpayers are seeing their dollars go to high cost rather than low cost means of delivering care."

And speaking of costs, the pressure is on providers to lower costs right away, which means, Tuckson said, telemedicine doesn't have time for a cycle where new technology is introduced at the typically higher pricepoint before costs are brought down once scale is reached. The UK Whole System Demonstrator that was recently completed in England demonstrated a lower return on investment than the government had hoped -- but the clinical outcomes were much more positive. The technology was just more expensive.

"Every new thing in healthcare seems to cost more than the old thing. Other industries don't have that problem," said Tuckson. "So somebody has to do a value-based technology assessment: Does it have efficacy and clear advantage over existing alternatives?"

Kosiak spoke about the difficulties in persuading hospitals to participate in telemedicine, even in rural areas. Kosiak said that when he went to pitch Avera in his hometown, his own father said they didn't want big city docs looking over their shoulders.

Wesley Valdes, director of telehealth services at Intermountain Healthcare, stressed the need to make telemedicine easy to use.

"What we're doing is we're working very hard in investing to make a platform that follows the clinical workflow," he said. "I've been to many talks that say 'if you buy my stuff and change your workflow wonderful things will happen.' Well I don't want to change my workflow."

Despite the many challenges, though, telemedicine is continuing to advance. The ATA show floor was ripe with vendors announcing pilots and full-scale deployments, and telehealth directors with success stories to tell.

"That's the story that we want to tell," Jim Pursely, VP of sales and marketing for GE Intel Care Innovations told MobiHealthNews. "This is real. The benefits are real. The time is now. You don't have to keep languishing in 'pilot-itis' mode."