What is Telemedicine? Complete Telemedicine Guide

Telemedicine is a relatively new field that allows medical professionals to evaluate, diagnose, and even treat patients through phone and video.

This remote delivery of healthcare is quickly revolutionizing medicine by allowing physicians to treat patients at a distance, including patients who may not be mobile.

 

Telemedicine History

 

A 2010 report by the World Health Organization (WHO) found that telemedicine can be traced to the 1800s when telecommunications technology to send information over a long distance with electromagnetic signals was created.

The earliest forms of telecommunication included the radio, telegraph, and telephone.

In 1879, the Lancet envisioned telemedicine of the future by discussing the use of the telephone to reduce unnecessary doctor visits.

The first mention of telemedicine in a published account was in 1925 when a cover illustration of Science and Invention featured a new invention by Dr. Gernsback called a teledactyl.

This imagined device would use robot fingers and radio to examine a patient remotely and display a video feed for a physician.

While this device never made it past a concept, it did predict the most common form of telemedicine today — a video conference between a doctor and physician.

Another early glimpse of telemedicine came in a 1924 Radio News cover that showed a home radio with a video screen showing a “radio doctor” speaking with the family.

In the 1920s, radio was only just reaching homes in the United States and the first experimental TV transmission didn’t take place until 1927, three years after the magazine was published.

By the 1950s, there were already hospitals and university medical centers experimenting with telemedicine.

Two health care centers in Pennsylvania located about 25 miles apart made history by transmitting radiologic images over the phone.

A Canadian doctor then improved this technology with the Teleradiology system in Montreal.

By 1959, physicians at the University of Nebraska managed to send neurological exams to med students across campus with a two-way television.

This was the first medical use of video communication in the United States.

A telemedicine link was created 5 years later to provide services to a hospital over 100 miles away.

During this experiment, the team explored the technology for use in group therapy consultations to offer a diagnosis for difficult psychiatric cases, research seminars, speech therapy, and education.

In the late 1960s and early 70s, the technology that became telemedicine was used in space and military industries.

In the beginning, telemedicine technology was used to deliver healthcare to fit the needs of NASA which wanted to better medical care during long-term space missions.

It was during this time that electro-cardiac rhythms could be sent in emergencies by fire rescue teams over voice radio channels.

Today, it’s common for paramedics to transmit heart rhythms and ECGs to hospital ERs.

Other advances in the 1960s include the use of ship-to-shore ECGs and x-rays, transoceanic transmission of ECGs, and radio telemetry for monitoring patients.

In the 1970s, a pilot remote monitoring system was created by Kaiser Foundation International and Lockheed Missiles and Space Company with a goal of delivering medical care.

The program, called Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) began in a rural community with few health care services to provide healthcare to rural Native Americans and astronauts in space.

At the time, doctor assistants were able to transmit patient data using these remote monitoring solutions to a medical facility or hospital.

The site for this remote monitoring system was in southwest Arizona on the Papago Indian Reservation. The project ended in 1977.

One of the first formal telemedicine programs prior to 1986, which continued through the mid-1990s, was established at the Memorial University of Newfoundland.

The program started in 1977 as a 3-month demonstration involving two-way audio and one-way television.

This test was considered successful at showing the benefits of television, but the team found that much of the educational data and information could be provided easier and with a lower cost through videotapes, telephone, print, and audio teleconferences.

Over the last 5 decades, several barriers have stood in the way of widespread adoption of telemedicine, including a lack of broadband infrastructure to deliver store-and-forward service and on-demand video conferencing.

The replacement of analog forms of communication with digital has played a major role in the interest and application of telemedicine.

In addition, the rapid decrease in the price of information communication technology (ICT) has made the development and implementation of telemedicine more possible.

It was the introduction and expansion of the internet that allowed the scope of telemedicine to expand to Internet-based applications like video conferencing and digital imagery.

Healthcare reform and new federal legislation have also played a role in the expansion of telemedicine by pushing for technological advances like mobile health devices and electronic prescribing.

Two of the most important pieces of legislation in telemedicine history are the American Recovery and Reinvestment Act and the HITECH Act which helped foster medical technology improvements and reform.

The Affordable Care Act (or Obamacare), signed into law by President Obama in 2010, created Accountable Care Organizations (ACOs) with a goal of improving care coordination in medical facilities and foster teamwork among several providers who provide care to the same people.

The American Telemedicine Association (ATA) believes the ACO setup has been especially beneficial to telemedicine by fostering the notion of shared specialties, coordinated patient care, and better access to care to reduce health care costs.

 

Telemedicine Today

 

Many of the early devices used in telemedicine are still used in the field today, although with technological advances that make them smarter, faster, and stronger.

The telemedicine field is evolving faster than ever with new technological advances occurring at exponential levels.

This has led to greater affordability and accessibility of basic tools for telemedicine.

As an example, most people in the United States have access to an Internet-connected smartphone or computer with experience using video chat apps like Skype, which is similar to the type of video conferencing used in telemedicine.

In the beginning, telemedicine was envisioned as a means of giving quality healthcare to patients in remote, rural areas without access to medical professionals.

Telemedicine today is still used to achieve this goal, but it has increasingly been adopted for the convenience and low cost.

Patients today appreciate the ability to see a doctor right away from their own home rather than the average 20-day wait for an in-person visit that comes with a commute and time in a waiting room.

Increased bandwidth, cloud technology, better digital security, the rise of mobile technology, and a large push for improvements in patient care have created what can be called a perfect storm for the adoption of telemedicine today.

The use of telemedicine in the home and nonclinical sites is greatly accepted by patients, doctors, and insurance companies to avoid unnecessary office visits, reduce costs, and improve convenience.

Telemedicine has also been applied to prison populations with objectives of avoiding the high costs of bringing specialists into prisons or transporting patients to a care center and reducing public concern.

Telemedicine today is used not only in homes and prisons but also nursing homes, hospitals, rural communities, third-world nations, and even in space.

Telemedicine has now evolved to the point where no complete inventory can be made of its applications.

Most people today think of telemedicine as a video conference between a patient and physician, but it is also used by medical professionals for training, diagnosis, sharing information, and consultations; post-surgical monitoring of patients, wound care, prenatal care, management of chronic conditions, medication management, triage, and more.

The rise of wearables has even contributed to interest in telemedicine services with many companies offering everything from wearable heart rate monitors and mobile glucose monitors to computer chips in shoes and smartphone app devices that track vitals.

With widespread shortages of medical professionals and a demand for more convenient, affordable care, a number of telemedicine companies have risen to the challenge.

Many of the telemedicine companies today offer patients 24/7 access to doctors with on-call physicians contracted by the company.

Other telemedicine companies offer hospitals and healthcare centers access to specialists and even additional clinical staff to outsource special cases.

Some companies offer telemedicine platforms for doctors to use for virtual visits with patients.

Telemedicine is increasingly being viewed by medical practices as a way to get an edge in a competitive landscape where it can be hard to remain an independent practice and still make a living.

Telemedicine is quickly expanding to serve millions of patients with new innovations and services offered.

Regulations are also changing in the federal, state, and private payer landscapes to increase the availability and affordability of telemedicine to patients while increasing reimbursements for providers.

Private research companies, physicians, and government agencies continue to find new uses for telemedicine to improve health care access and quality for patients across the country.

About 66% of physicians ranked telemedicine as a major priority in 2017 with primary objectives of improving patient outcome, providing rural and remote access, and increasing convenience for patients.

 

Telemedicine and Telehealth Difference

 

The terms telemedicine and telehealth are related, but not interchangeable.

Telehealth is generally used as a broad term that encompasses all forms of remote health care but not necessarily clinical services.

According to the Department of Health and Human Services (HRSA), telehealth covers any remote healthcare services that are clinical and non-clinical.

Telehealth can be used to refer to all types of nonclinical remote services, including provider training, continuing professional education, and administrative meetings.

The term telemedicine is usually used to refer to remote clinical services in particular.

Telemedicine focuses on healthcare services and education over a distance, usually through the use of voice and video.

Telemedicine allows physicians to provide clinical services to patients with electronic communications without the need for an in-person visit.

In this way, telemedicine can be used for follow-up visits, managing chronic conditions, specialist consultations, medication management, and more.

More simply, telemedicine can be defined as services that are delivered by physicians, while telehealth can refer to any type of services provided by health professionals such as pharmacists and nurses.

In general, all telemedicine is a type of telehealth, but not all telehealth services can be referred to as telemedicine.

Still, these definitions are not strict and even organizations like the World Health Organization (WHO) and the American Telemedicine Association (ATA) use the terms interchangeably.

Sometimes the definition changes depending on the organization as well.

 

Pros and Cons of Telemedicine

 

Telemedicine is generally viewed positively by patients as well as medical providers, especially in underserved and rural regions in need of quality health care.

Telemedicine can reduce health care spending while engaging patients who may otherwise go without care, particularly the elderly who may have mobility and transportation issues.

Despite its many benefits, telemedicine has a few drawbacks, especially in terms of technology and social barriers.

The growing acceptance of telemedicine will likely help resolve many of the drawbacks of this form of medicine, however.

 

Pros

 

• Greater Accessibility and Convenience for Patients

One of the greatest benefits of telemedicine is it makes health care more accessible and convenient for patients.

Telemedicine was originally designed to bring healthcare to underserved and rural areas, but it has now expanded into many specialties and forms.

It can be used to allow elderly patients to see their doctor from home, bring healthcare to third-world countries, and allow for follow-up care, rehab sessions, and post-op check-ups remotely.

• Reduces Health Care Spending

Every year, healthcare spending in the United States $646 billion.

This is a total of $10,000 in health care costs for every person in the country.

Many of these healthcare expenses are unnecessary, and healthcare costs are notoriously uneven across the country.

Telemedicine can reduce health care spending by reducing issues like non-adherence to medication, avoidable ER visits, and the expense of in-person doctor visits and overhead.

• Improves Quality of Patient Care

Through telemedicine, physicians can better follow-up with patients.

This may be done with a video chat to answer questions after a discharge or check on a patient’s recovery or even through a remote monitoring system that gives the provider real-time feedback on the patient’s heart health or other biometrics.

• Extended Access to Specialists

For every 100,000 rural patients in the United States, there are just 43 specialist providers.

This means hundreds of thousands of patients must suffer from longer commutes to see specialists or difficulty accessing care for specific diseases and treatments.

Telemedicine allows patients to access specialist care from any location.

• Eliminates the Transmission of Infectious Disease

Doctors offices, hospitals, and ERs are a common source of infection for patients and family members.

Health care-associated infections affect up to 10% of hospitalized patients every year with more than 1.7 million infections in hospitals every year that cause 99,000 annual deaths.

Telemedicine eliminates the risk of infectious diseases like MRSA and the common cold.

This is especially beneficial to at-risk patients such as the elderly and those with immune disorders and heart failure.

 

Cons

 

• Specialized Training and Equipment are Necessary

One factor that holds back telemedicine in many practices is the need for new equipment and the technical training that comes with it.

Implementing a telemedicine program can cost time and money.

• Telemedicine can Reduce Care Continuity

Many patients today use on-demand telemedicine, which means they are connected with a random physician.

This reduces care continuity as the provider may not have access to the patient’s full medical records and history.

• Difficulties with Health Care Laws and Reimbursement

While healthcare laws and insurance reimbursement policies are adapting to the rise of telemedicine, there is still a struggle in the medical community to keep up with regulations and the reimbursement landscape.

The good news is Medicare and Medicaid now pay for many telemedicine services in recognition of the quality care and reduced cost.

Several states also have parity laws in place that require private insurance companies to reimburse for telemedicine appointments as if they were in-person visits.

• Reduced In-Person Interactions

One drawback to telemedicine that is unlikely to change is the reduction of in-person interactions with physicians.

There is value to in-person medical appointments, and sometimes they are necessary.

Despite this, minor conditions and follow-up care typically do not require an in-person appointment with an established patient.

 

Telemedicine Medical Specialities

 

Telemedicine is currently used in several medical fields to consult with patients as well as other providers remotely.

Telemedicine has also proven useful for healthcare providers who wish to expand access to care.

While some specialties were quick to adopt telemedicine, others have come into the field more recently.

The following are the main telemedicine specialties currently available to patients.

• Teleradiology

In this specialty, telemedicine usually involves imaging test results in the radiology field being digitized and sent for diagnosis to a radiologist at a different location.

• Telepsychiatry

Telepsychiatry is one of the most popular specialties of telemedicine due to an ongoing shortage of qualified psychiatrists.

Through telemedicine, psychiatrists can provide remote treatment to patients, including counseling sessions by video or phone.

Patients often feel more at ease during psychiatry visits in their own home rather than a sterile institutional setting.

• Teledermatology

A variety of skin problems can be diagnosed remotely by dermatologists, who may prescribe or recommend treatment solutions after a consultation.

Teledermatology can also involve a general doctor sending images of a patient’s skin anomalies for remote diagnosis by a dermatologist.

• Teleophthalmology

Telemedicine allows ophthalmologists to examine a patient’s eyes remotely or consult about treatments.

This type of technology is also used in another fashion with the use of retinal imaging equipment, which captures detailed scans of a patient’s eyes and forwards them to a remote specialist.

• Telenephrology

A nephrologist specializing in kidney care may employ telemedicine inter-professionally to consult with general physicians about a patient with a kidney disorder.

• Teleobstetrics

Telemedicine can be used to provide prenatal care remotely.

In most cases, it is used between physicians to forward information about a patient.

This technology can also be used in the OB/GYN field to manage medications, discuss lab results, observe treatment plans for conditions like gestational diabetes, and offer post-op care.

• Teleoncology

Teleoncology is becoming more common and popular as it allows oncologists to provide care to cancer patients from their own home.

Teleoncology may involve video consultations with patients or interprofessional tools to share images and information for treatment and diagnosis.

• Telepathology

Through unique telepathology solutions, pathologists can share information remotely for education, research, and diagnosis purposes.

• Telerehabilitation

Telemedicine can be an effective way to rehabilitation specialists to provide at-home rehab services for patients who may have trouble with mobility or traveling for frequent rehabilitation sessions.

• Telesurgery

Telesurgery can refer to two forms of telemedicine: remote consultations between doctors about the need for surgery for a patient or evaluating a patient who is recovering from surgery, or even surgery that is performed through robotics while the surgeon is in a different location.

• Teletrauma

Also known as tele-ER care, this specialty allows trauma specialists to interact with each other remotely to determine the severity of a patient’s injuries.

It can also be used to identify candidates who should be admitted to local facilities to reduce unneeded transfers.

 

Telemedicine Services

 

Telemedicine is most frequently used to provide health services between a primary care physician and a patient.

A wide variety of ailments can be diagnosed and treated through telemedicine such as:

• Allergies
• Arthritis
• Asthma
• Back problems
• Bronchitis
• Cold or flu
• Diarrhea
• Ear infections
• Eye problems
• Infection
• Pharyngitis
• Conjunctivitis
• Rash
• Respiratory infection
• Sinusitis
• Skin inflammation
• Cellulitis
• Sore throat
• Strain or sprain
• Bladder infection
• Urinary tract infection
• Sports-related injury

In addition to treating common health conditions, telemedicine can be used in a wide variety of ways in different specialties of medicine.

 

Postoperative Care

 

Telemedicine is becoming a mainstay in postoperative care as most patients prefer virtual visits with their surgeon after a surgical discharge rather than traveling to an appointment.

Most post-op check-ups are also routine and can be adapted well to telemedicine.

With a video visit, a physician can check the patient’s bandages and drains visually, confirm wound healing, and ask follow-up questions.

One study published in JAMA Surgery also found that telemedicine can help identify post-surgery veterans who require an in-person visit for further care or assessments.

 

Medication Management

 

Medication management is an easy and effective adaptation for telemedicine as it allows physicians to discuss medication side effects, prescription refills, and monitor medication adherence.

This solution can also be combined with remote patient monitoring to allow a physician to monitor a patient’s vitals and other data from afar and make prompt adjustments to medication or the treatment plan.

According to research presented at the American College of Cardiology Annual Scientific Session in 2012, telemedicine was found to better control high blood pressure, reduce cardiovascular risk, and increase the effectiveness of pharmacotherapy compared to standard periodic office visits.

 

Managing Chronic Conditions

 

Telemedicine offers advantages for patients and physicians in the long-term management of chronic conditions like depression, type 2 diabetes, arthritis, heart disease, and cancer.

Video visits with a physician can improve the management of chronic conditions in several ways, including treatment plan management, remote lifestyle counseling, triage to determine if a new symptom requires attention, and medication management.

Telemedicine can even be used to actively manage chronic conditions with the use of high-tech sensors and health and activity monitors.

Physicians can remotely monitor a patient’s glucose levels, blood sugar, heart patterns, vitals, and more.

In these cases, patients can use weight scales, blood pressure cuffs, glucometers, and more in their home with alerts automatically sent to their doctor if readings fall outside of normal.

 

Geriatrics

 

Telemedicine has the power to be immensely helpful in the treatment of geriatric patients for whom visiting a physician can be a great burden.

Telemedicine can allow geriatric departments to detect at-risk patients after discharge and provide intervention when necessary to avoid readmission.

It can also be used to provide remote healthcare visits in nursing homes.

 

Other Applications

 

While the above are the most services provided by telemedicine, services can be adapted further to each specialty.

For example, gynecologists can use live video chats to offer birth control counseling while an endocrinologist may chat with a patient remotely to discuss lab results and answer any questions.

 

Telemedicine Uses

 

Telemedicine is used in many specialties to deliver a variety of services, but there are also different telemedicine systems that can be implemented.

There are a few types of technology that allow digital video and voice connections between providers and patients.

The following are the most common types of connections used in telemedicine.

• Monitoring Center Links

A monitoring center link is used for remote patient monitoring.

With this type of program, a connection is made between the patient’s home and a remote monitoring facility, allowing the patient’s medical information to be measured and collected at home and transmitted to a remote monitoring facility.

Monitoring center links can involve SMS (text message), the Internet, or phone connections.

• Networked Programs

A networked connection, such as a high-speed internet line, connects a remote health care center to a larger facility.

There are nearly 200 networked telemedicine programs currently in operation that give telemedicine services to over 3,000 rural areas.

• Point-to-Point Connections

A point-to-point connection works to connect a small, remote health care center to a larger central facility over the internet.

These connections allow small and understaffed clinics in rural areas to outsource specialists in other locations.

This type of connection is most common in urgent care centers, teleradiology, and telepsychiatry.

 

Telemedicine Types

 

Most people envision telemedicine as a doctor visiting with a patient through a video chat.

While this is one of the most popular uses of telemedicine, the field can include a broader range of services.

This is because telemedicine can refer to any type of clinical service offered through telecommunications technology.

 

Remote Patient Monitoring

 

Remote patient monitoring is a solution that allows a provider to track a patient’s vital signs and data remotely.

This type of technology allows a physician to watch for warning signs, get immediate alerts if a patient’s vitals fall outside of normal, and take quick action to intervene.

Also called telemonitoring, this technology is growing in popularity as it can save lives.

One of the most common ways remote patient monitoring is used is in the management of chronic illnesses.

A patient with diabetes, for example, can measure their glucose levels at home and have the data transmitted to their doctor.

The results can be recorded if normal or flagged if the results are off, in which case the doctor can call the patient right away for a consultation.

This area of telemedicine is rapidly evolving with a broader range of mobile medical devices and wearables, including devices that connect to a smartphone app.

 

Real-Time Telehealth

 

This solution, also known as synchronous telemedicine, is what most people think of as “telemedicine.”

It involves a live interaction between the patient and physician through audio and/or video.

The goal of real-time telemedicine is allowing the doctor and patient to communicate normally from afar.

The physician can visually check on the patient, check healing or post-op progress, consult about an injury or symptom, and more as an alternative to an in-person exam.

There are now several major companies that offer real-time telemedicine, most notably Doctor On Demand, Consult A Doctor, and Teladoc, all of which make it easier and more affordable for patients to be seen by a doctor from anywhere.

 

Store-and-Forward Telemedicine

 

This type of solution, also known as asynchronous telemedicine, allows medical providers to forward and share a patient’s medical information, including images, records, and lab results, to another provider remotely.

Store-and-forward platforms typically offer a secure and private email platform to keep data encrypted.

Store-and-forward solutions are best used for interprofessional services, such as outsourcing a diagnosis or treatment recommendations from a specialist.

This type of technology is especially common in teleradiology as it allows doctors and technicians in smaller clinics to send a patient’s x-rays to a specialist in a remote location for diagnosis.

Store-and-forward telemedicine can also improve efficiency because the patient, physician, and specialist do not need to be in the same place or even communicate at the same time.

This type of technology can speed diagnosis as well, especially in underserved communities.

 

Telemedicine Clinical Guidelines

 

There is not yet an industry-wide set of established guidelines, but the American Telemedicine Association (ATA) has created guidelines for common telemedicine specialties based on more than 600 studies.

The following are the clinical, administrative, and technical protocols the ATA recommends for urgent care or primary care telemedicine.

 

When Telemedicine Should be Used

 

There are a number of conditions that a good fit for treatment through telemedicine.

This includes, but is not limited to, UTIs, back pain, bronchitis, upper respiratory infections, behavioral health, hypertension, diabetes, preventative and wellness visits, and asthma and allergies.

Telemedicine is not recommended for a condition that requires an in-person appointment due to protocol-driven procedures, aggressive intervention, or serious symptoms.

Professional judgment should be used to determine when telemedicine services are appropriate.

 

Prescriptions

 

Prescribing medication is considered reasonable for live video telemedicine visits that can substitute for in-person exams.

If the physician has an existing relationship with the patient, telephone consultations are also sufficient for prescribing.

 

Informed Consent

 

A few states have regulations on the books that require providers to get a patient’s informed consent before telemedicine can be used.Still, this practice is always a good idea, even when it is not required.

Still, this practice is always a good idea, even when it is not required.

Medical providers should explain how telemedicine services work, including any scheduling and privacy concerns, confidentiality limits, the possibility for technical problems, protocols in place for virtual visits, prescribing policies and coordinating care in clear language before the first virtual appointment.

The ATA recommends that providers set reasonable expectations for a telemedicine visit, including prescribing policies, the scope of service, and follow-up.

 

Plan for Referrals and Emergencies

 

Providers should have a plan in place for medical emergencies that can be communicated to patients ahead of visits.

Information should also be available for request and referral requests.

When indicated, a provider should refer a patient to the appropriate level of care, such as a specialist, urgent care, or emergency room.

The ATA recommends incorporating triage protocols into telemedicine systems.

 

Dedicated Space for Visits

 

The ATA recommends setting up a dedicated space for virtual appointments to ensure correct lighting and audio, privacy, and prevent interruptions.

The camera should be installed on a level stand at eye level.

 

Patient Evaluation and Management Guidelines

 

Physicians must use professional judgment to determine when telemedicine is appropriate for the patient in question.

Patient evaluations should always be based on access to medical records and the patient’s medical history, when available.

The ATA recommends providers create clinical protocols to make these decisions.

These protocols should include the condition being treated, scope of the condition that can be addressed through telemedicine services, guidelines required to diagnose a condition such as live video or phone consultations, documentation required to assess the condition, parameters for when a condition can and cannot be treated, protocols for when prescribing may be done, and basic telemedicine guidelines.

Detailed protocols should be set up for every condition the physician plans to treat.

To diagnose a condition, the following information must be gathered:

• Review of symptoms
• Identifying information
• Source of patient history
• Primary complaint
• History of illness
• Signs and symptoms
• Family history
• Personal medical history
• Medication review
• Known allergies
• Provider-directed self-examination that may use mobile medical devices.

 

Quality Assurance

 

Routine quality checks on telemedicine services should be conducted to detect risks and problems like connectivity, equipment issues, and patient complaints.

The quality review should also include an assessment of clinical quality and patient and provider satisfaction.

 

Telemedicine Billing

 

The cost of telemedicine services should be known to patients before a virtual visit.

 

Eye Contact

 

Eye contact is an important aspect of provider-patient interactions by establishing trust, rapport, and even facilitating memory.

The ATA recommends a basic understanding of eye contact etiquette based on culture.

In telemedicine, the camera should be located above the face for an accurate estimate of gaze with a viewing distance that includes the head and top of shoulders.

Placing the camera too close can make a patient feel that their personal space is invaded.

It’s important to avoid the inclination to look at the face on the screen instead of into the camera lens, which replicates real eye contact patterns.

 

Ethical Guidelines

 

The following ethical guidelines are recommended:

• The provider should uphold the code of ethics for their profession and follow all federal, state, and jurisdictional regulations.

• Telemedicine services should not be used to preferentially avoid in-person visits based on gender, gender preferences, sexual orientation, disability or disease, socioeconomic status, behavioral factors, religion, ethnicity, and other factors. The exception to this is to avoid the spread of infectious disease during pandemics and epidemics.

• Payment from a patient should never be conditional on receiving a particular treatment or diagnosis.
• A conflict of interest policy should prevent a provider from using telemedicine for the primary purpose of improving income.

• Patients should be informed of their rights, including the right to refuse or suspend treatment.

• There should be a policy regarding the disclosure to patients of equipment or technical failure during a service session, a contingency plan in case of technical problems, and how to document occurrences in a patient’s health record.

 

Follow-Up Protocols

 

Follow-up is an important aspect of quality patient care that should include:

• Making available relevant clinical reports to referral sources
• Knowledge of the patient’s healthcare network for referrals and specialty consultations
• Facilitating the transfer of home monitoring and electronic data
• A process for patients to request copies of telemedicine encounters and requests for records to facilitate specialty care

Additional practice guidelines are available through the ATA for specialties such as telestroke, telerehabilitation, pediatric telehealth, teledermatology, teleburn, telepathology, video-based metal health, and more.

 

Telemedicine and Medicare

 

In the beginning, the federal Medicare program only reimbursed medical providers for a few specific telemedicine services with strict requirements in place.

As telemedicine has grown quickly over the last several years, Medicare has recently expanded its list of telemedicine services that can be reimbursed, although there are still many restrictions in place.

 

Medicare Chronic Care Management (CCM) Program

 

In 2015, Medicare began the CCM program to pay separately under the fee schedule for CCM services furnished to Medicare recipients with several chronic conditions.

This national policy has no restrictions on the practice of telemedicine as it was enacted to help doctors provide better monthly medical care to patients who have at least two chronic conditions with the help of telemedicine.

Patients with chronic conditions can be located anywhere, even metropolitan areas, and receive services from any facility, even their home.

The new CCM program compensates providers a monthly amount to coordinate care of Medicare patients with at least 2 chronic conditions and many specialists can qualify, including neurologists, allergists, endocrinologists, immunologists, podiatrists, rheumatologists, urologists, and ophthalmologists.

The program requires at least 20 minutes of clinical staff time directed by a physician or qualified healthcare provider per month for reimbursement.

 

Originating and Distant Sites

 

For Medicare to reimburse for a telemedicine service, the originating site (where the physician is located) must be within an HPSA (Health Professional Shortage Area).

Medicare defines originating sites as hospitals, practitioner or doctor offices, Critical Access Hospitals (CAH), rural health clinics, hospital-based and CAH-based dialysis centers (not independent rental dialysis centers), skilled nursing facilities, federally qualified health centers, and community mental health centers.

 

Approved Telemedicine Services

 

Only some types of telemedicine are reimbursed by Medicare.

In general, Medicare will only reimburse for live video telemedicine with a patient as an alternative to an in-person appointment.

Medicare guidelines are very clear that to qualify, telemedicine must be provided with a video and audio telecommunications system that allows real-time communication between the doctor and patient.

In Alaska and Hawaii, however, Medicare reimburses for store-and-forward telemedicine, too.

Only specific HCPCS and CPT codes are eligible for reimbursement.

When physicians bill Medicare for telemedicine, the GT modifier must be included with the correct CPT code to indicate a virtual service.

 

Eligible Providers

 

Medicare allows only eligible medical providers to use telemedicine.

This includes physicians, physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, clinical psychologists, clinical social workers, and registered dietitians.

Clinical psychologists and clinical social workers cannot bill Medicare for psychiatric diagnostic interview exams with medical evaluation or medical services.

 

Facility Fees

 

Medicare also reimburses facility fees to the originating site.

This means if a doctor is having an in-person office visit with a patient and conducts a telemedicine consultation with another physician remotely, the doctor can bill Medicare for two services: a facility fee for using the practice to “host” the patient visit and the qualifying telemedicine service.

 

Telemedicine and Medicaid

 

Medicaid is run by individual states which mean telemedicine policies and reimbursement vary by state.

The good news is telemedicine is being rapidly accepted by Medicaid programs as a cost-effective way to improve health care.

Under federal Medicaid statutes, telemedicine is not recognized as a distinct service, but states have been encouraged to accept telemedicine.

Here’s a brief overview of Medicaid reimbursement policies for telemedicine in the United States:

• 48 states reimburse for some form of live video under Medicaid.
• 22 state Medicaid programs reimburse for remote patient monitoring.
• 13 states reimburse for store-and-forward telemedicine services.
• 7 Medicaid programs reimburse for all three: live video, remote patient monitoring, and store-and-forward.
• 30 state Medicaid programs reimburse a facility fee, transmission, or both.

• Synchronous Video & Medicaid

Rhode Island and Massachusetts are the only states that do not reimburse for live video through Medicaid but states that do allow it can restrict reimbursement based on medical specialty, type of service, the location of patient and location of the provider.

• Remote Patient Monitoring & Medicaid

22 states currently reimburse for RPM in some way through Medicaid, although there are usually restrictions on the qualifications.

Two states — South Dakota and Pennsylvania — offer reimbursement for RPM through their Department of Aging, not Medicaid.

• Store-and-Forward & Medicaid

Many states define telemedicine as happening in real time, such as live video teleconferences.

Just 13 states reimburse providers for store-and-forward services, but these states can also restrict reimbursement based on specialty type and services provided.

Nevada is the latest addition to this list as of 2016.

Medicaid programs that reimburse for store-and-forward include:

• Alaska
• Arizona
• Connecticut
• California
• Hawaii
• Illinois
• Minnesota
• Mississippi
• Missouri
• Nevada
• New Mexico
• Virginia
• Washington

Unlike Medicare, which restricts the location of the patient receiving telemedicine to a rural or underserved region, Medicaid programs usually just limit the type of facility where a patient may receive care.

Many programs exclude telemedicine delivered to a patient’s home while others require a licensed provider be at the same location as the patient.

The National Telehealth Policy Resource Center is an excellent resource for patients and providers to better understand telemedicine policy in their state with an interactive map.

 

Telemedicine Statistics

 

The numbers all indicate that telemedicine is experiencing tremendous growth and the industry is only going to expand into new areas of medicine in the years ahead.

In 2014, the worldwide telemedicine market was nearly $18 billion, but it’s predicted to exceed to $34 billion by 2020.

In 2015 alone, ATA President Dr. Tuckson estimated there were nearly 800,000 virtual consultations in the U.S. alone.

According to IHS Technology, the volume of people turning to telehealth services should increase from 350,000 in 2013 to more than 7 million by 2018.

Already, more than 50% of all U.S. hospitals use telemedicine in some fashion and this number is rising.

A 2014 survey found 90% of healthcare executives have started to develop or implement a telemedicine system into their organizations and a full 84% said they believe telemedicine is important.

Many skeptics cite the loss of in-person human interaction, but research shows 76 percent of people think access to medical care is more important than in-person interaction.

One of the biggest factors influencing this preference is long wait times to see doctors.

The average appointment wait time for a family doctor ranges from 5 days in Dallas to an average of 66 days in Boston.

Across all 15 markets in the study, the average cumulative wait time to see a family doctor was more than 19 days.

Research has also found that patients would prefer a virtual telemedicine visit over an ER visit.

Only 16 percent of people would prefer an ER visit for a minor condition.

Sources have indicated that up to 27% of ER visits are non-emergencies that could have been treated by a clinic or family doctor.

In addition to greater convenience, telemedicine is far more affordable than an ER visit.

A study by the National Institute of Health in 2013 found the average ER visit is more than $2,100 compared to an average telemedicine appointment between $40 and $50.

Telemedicine has the power to not only reduce health care spending but also reduce strain on over-stressed emergency rooms.

Multiple studies have found that telemedicine can reduce hospital readmissions as well.

When the Visiting Nurses Association of Rockford (VNA) began using the Honeywell Genesis line of remote patient monitoring, it found that it reduced readmission rates for high-risk chronic heart failure patients by 14%.

Partners HealthCare in Boston implemented a telemedicine program for patients with heart failure and chronic conditions in 2006 and reported readmission rates for heart failure patients fell by half and non-heart failure readmission rates dropped by 44%.

The Veterans Health Administration reported similar results for patients who had suffered heart attacks with heart failure-related readmissions dropping by 51%.

Over the last few years, there has been a great deal of scrutiny around the reimbursement challenges faced in the telemedicine field.

In 2017, over half of all states cover telemedicine services and it’s predicted that reimbursements will no longer be an issue in the near future.

About 70% of employers plan to offer telemedicine services as an employee benefit to reduce costs and attract employees.

With annual healthcare spending topping $3.3 trillion, cost reduction is a major concern for patients, private payers, and government programs.

Existing research indicates that telemedicine has the power to dramatically reduce healthcare expenditures without reducing the quality of care.

The American Hospital Association recently reported on a telemedicine program that tripled return on investment for investors and cut costs by 11%.

The Veterans Health Administration has pioneered the use of telemedicine in the United States with telehealth programs in use since the 1990s.

The annual cost to provide telemedicine services in 2012 through the VA was just $1,600 per patient per year compared to more than $13,000 for traditional home-based care or more than $77,000 for nursing home care.

The VHA has reported a 25% drop in the number of bed days of care and a 19% decline in hospital readmissions across all patients using telemedicine.

The Congressional Budget Office (CBO) has long held the belief that expanding telemedicine access would drive up spending due to higher utilization, although it has overestimated the cost of implementing telemedicine in previous bills passed into law.

For example, Congress authorized currently limited guidelines on telemedicine coverage for Medicare in 2011 and predicted that providing telemedicine to Medicare recipients would cost the program $150 within just 5 years.

In reality, Medicare has spent just $57 million in 14 years.

Finally, research into quality of care with telemedicine has been positive.

About 50% of patients report that telemedicine has improved participation in medical treatment decisions by engaging them in their care.

In a study published in the Annals of Family Medicine in 2017, patients expressed satisfaction after using telemedicine video visits for primary care visits and most expressed interest in continuing virtual visits as an alternative to traditional in-person doctor visits.

 

Telehealth Resource Centers

 

There are 14 Telehealth Resource Centers in the United States funded by the Department of Health and Human Services (CMS’s) Health Resources and Services Administration (HRSA).

Resource centers work as a local hub for telemedicine research and information with a special focus on improving access to care in underserved areas.

Each resource center offers information to navigate telemedicine services and policies, but some offer their own strengths such as webinars and fact sheets.

California Telehealth Resource Center

877-590-8144

This resource center offers an excellent resource for developing a telemedicine program with sample forms and guidelines.

They also provide a training page with on-site training services and webinars for programs in California.

National Telehealth Policy Resource Center

877-707-7172

The designated NTRCP, or the Center for Connected Health Policy, is an excellent resource for policy information with regular updates on the telemedicine industry through social media.

This organization offers legislative tracking, technical assistance with policy, and policy analysis to 12 regional telehealth resource centers across the country.

The CCHP also serves as an independent resource for telemedicine policy issues while engaging decision makers.

The CCHP produces helpful infographics, fact sheets, reports, and policy briefs for consumers, medical professionals, and decision makers with a goal of advancing telemedicine policy through unbiased, thorough, and practical research.

Heartland Telehealth Resource Center

877-643-4872

The Heartland resource center offers reimbursement and regulation guides for Oklahoma, Missouri, and Kansas.

Mid-Atlantic Telehealth Resource Center

855-628-7248

The Mid-Atlantic center offers regulation and reimbursement guides for New Jersey, Washington D.C., Kentucky, West Virginia, Virginia, Maryland, Delaware, North Carolina, and Pennsylvania.

Northeast Telehealth Resource Center

800-379-2021

The Northeast center offers a Telehealth A to Z section with resources on topics like technology, finances, and clinical.

It also offers toolkits for dermatology and psychiatry.

National Telehealth Technology Assessment Resource Center

877-885-5672

This resource center offers information for healthcare providers in search of devices and technology to incorporate into a telemedicine solution.

The User Reviews section of the website offers feedback on a variety of telemedicine products with the toolkits offer apps, medical devices, and technology for use in a telemedicine system.

 

Future of Telemedicine

 

The future of telemedicine looks bright with advances in technology that will only make telemedicine easier and more accessible in the years to come.

The telemedicine market is predicted to increase in popularity among many patient populations as federal programs expand coverage for telemedicine and the technology becomes more affordable for healthcare practices to implement.

Practice implementation of telemedicine solutions should become more common as the baby boomer generation ages and chronic health conditions begin to affect more adults.

Health care organizations and hospitals are also increasingly seeking ways to reduce hospital stay lengths and hospital readmissions.

New telemedicine solutions like remote patient monitoring will likely play a big role in meeting these goals.

The greatest hurdle for telemedicine to overcome is administrative barriers like restrictions on telemedicine practice through state legislation, state licensing requirements through medical boards, and reimbursement policies that affect whether physicians will be reimbursed by payers or patients and whether it’s feasible for their practice to adopt telemedicine.

The telemedicine market is predicted to grow to $34 billion by the end of 2020 and more than three-quarters of surveyed patients have expressed an interest in telemarketing, which means that demand will likely help overcome the hurdles in the field.

 

Regulations in Telemedicine

 

Telemedicine regulations are constantly changing today as states introduce new legislation on telemedicine and medical associations update their guidelines for telemedicine practices.

Telemedicine reimbursement rules for private payers and Medicaid are also changing rapidly.

The increasing popularity of telemedicine and the widespread adoption by hospitals, private practices, and health systems has led to an explosion of telemedicine legislation.

All of this means that telemedicine regulations can vary a great deal from one state to the next in several key areas.

In a single month of 2015 alone, more than 100 telemedicine-related bills were introduced.

 

State Reimbursement Regulations

 

Reimbursement regulations affect who pays for telemedicine services: payers or patients.

These regulations can also affect whether a physician or practice will implement a telemedicine system as it may not be feasible if they are unlikely to receive a full reimbursement rate.

• Medicaid Reimbursement

Medicaid is usually held to the same standards as the federal Medicare program in terms of telemedicine regulation, but Medicaid is state-run and rules are determined by each state.

Medicaid reimbursement rules vary a great deal and are usually less restrictive than Medicare with reimbursement for telemedicine.

48 Medicaid programs now reimbursement for some live telemedicine services while 19 states reimburse for remote patient monitoring.

12 states reimburse for store-and-forward services, but there are more states that reimburse for only teleradiology.

30 states also reimburse a facility fee, transmission fee, or both.

• Private Payer Reimbursement

There are currently 30 states with a mandated private payer reimbursement law for telemedicine, but several other states have pending legislation.

While telemedicine parity laws require that private payers reimburse for telemedicine, there are specific reimbursement restrictions that vary wildly.

In some states, private payers reimburse the same amount as if it was an in-person service.

It’s believed that private payer reimbursement mandates will be essential to pushing telemedicine forward in the next decade.

 

Medical Board Regulations

 

Several medical boards are adopting telemedicine standards for doctors within their state based on the concept that providing care through telemedicine should be done to the same standards as in-person care.

The Federation of State Medical Boards (FSMB) offers a document that outlines administrative and regulatory requirements for telemedicine by the state.

• Cross-State Physician Licensing

Cross-state licensing refers to authorizing physicians to offer telemedicine to a patient in a state in which the doctor is not licensed.

This type of reciprocity would allow doctors to practice across state lines without getting a full medical license in each state at a high cost.

There are a few models for cross-state licensing in addition to reciprocity, including licensure by endorsement, which allows medical boards to grant licenses to professionals in other states that have similar standards.

Sometimes these medical licenses require additional documentation or qualifications before an endorsement can be granted.

Another option is mutual recognition, which allows a licensing authority to enter into an agreement that legally accepts the policies of the home state of the physician.

• Patient Informed Consent

In some states, informed consent is necessary to provide telemedicine services.

A written informed consent form may be necessary, although several states do not require this.

• Pre-existing Relationship between Doctor and Patient

States have varying laws on what it legally means to establish a doctor-patient relationship.

In some states, an in-person physical exam is necessary before telemedicine services can be provided but other states allow this relationship to be established through a live video conference.

• Online Prescribing

A number of states have adopted online prescribing regulations, especially rules involving medications to treat chronic pain and scheduled drugs.

In some states, an in-person physical exam must be conducted before a patient can be prescribed medication through telemedicine.

 

Other Regulation Considerations

 

There are a few other areas of concern for physicians in the telemedicine field.

• Liability for Malpractice

Malpractice liability in the telemedicine field is becoming a greater concern for physicians as there are no public studies on telemedicine and the frequency of malpractice claims, which means insurance carriers must make this a priority.

• Credentialing and Privileging

A predetermined process is used by healthcare organizations to credential and privilege providers who practice medicine within the organization.

In 2011, the Centers for Medicare and Medicaid Services (CMS) instituted a new rule allowing hospitals and critical access hospitals (CAHs) to implement a new process for credentialing and privileging telemedicine providers.

Most states use AMA guidelines that recommend eliminating dual privileging for distant and originating site locations.

By requiring privileging only from originating site hospitals, medical providers have greater freedom to access patients.

 

Telemedicine Barriers

 

Despite rapid growth over the last few years, there are still remaining barriers to the widespread adoption of telemedicine in the United States.

• Reimbursement

Reimbursement is a commonly cited barrier to telemedicine.

Medicare offers little reimbursement in the fee-for-service arena and the reimbursement it does offer is limited by area, institution, and CPT code.

• Regulations

There are now multi-state telemedicine systems operating with multi-state practices.

As these providers move into a national telemedicine system, licensure can become a barrier.

While telemedicine, in theory, allows for cross-state consultations, physicians who want to practice in another state — even through telemedicine — must often obtain a full medical license in both states.

This can require the physician to pay a high fee to practice across state lines and they may be required to adhere to practice rules that are very different or even conflict with each other.

Practice regulations also represent a hurdle as many state medical boards require an in-person consultation before telemedicine services can be offered.

The Social Security Act even limits the use of telemedicine to specific providers.

• Implementation

While telemedicine solutions are growing in diversity with more affordable options available to providers, telemedicine services still require the purchase, setup, and training involved with new equipment and technology.

This can be out of budget for smaller or independent practices.

Some patients may find telemedicine to be out of reach as well without easy access to the Internet or a smartphone.

 

Who Pays for Telemedicine?

 

Telemedicine services are paid by Medicaid, Medicare, and private insurers, although each has limitations and qualifications that must be met.

The number of insurers and government programs accepting telemedicine is rapidly growing as state legislatures have debated the issue while hospitals press for coverage of telemedicine.

 

Private Insurers

 

Private payers are rapidly accepting and paying for telemedicine because it is cost effective.

Many insurers even offer deductible-free unlimited telemedicine services to policyholders.

Of course, how much and which type of telemedicine private payers will pay for can vary a great deal by state.

In 2016, the Massachusetts Hospital Association raised support for House Bill 267 to mandate that private payers in Massachusetts would reimburse telemedicine services at the same rate as in-person medical services, ensuring all Medicaid and state employee plans would cover telemedicine.

29 states currently have some form of parity law that requires private insurers provide some coverage for telemedicine, but not all mandate equal reimbursement for telemedicine and in-person visits.

There is also the problem of states defining telemedicine services in several ways. 21 states, including Texas and California, now have full parity laws on the books to require full reimbursement for telemedicine.

 

Medicare

 

Medicare pays for some forms of telemedicine when certain conditions are met.

In general, Medicare pays for live telemedicine services that are delivered with interactive video and audio in the form of a video chat.

The other major condition that must be met is telemedicine services can only be paid by Medicare when the patient is in a rural or underserved area, or a Health Professional Shortage Area, and receives care from an eligible provider.

In these cases, the service also has to fall under a covered CPT/HCPCS code.

When all conditions are met, Medicare pays for 80% of the doctor fee and the patient pays for the other 20%.

A facility fee is also paid to the originating site.

 

Medicaid

 

Medicaid is state-run with wildly varying telemedicine policies. 48 states will pay for live video telemedicine through Medicaid and 22 states pay for remote patient monitoring (RPM).

Only 13 state Medicaid programs pay for store-and-forward telemedicine and just 7 states reimburse for all three telemedicine solutions.

In 30 states, Medicaid pays for a facility fee or transmission.

Because most state Medicaid programs reimburse low-income patients for the cost of transportation, lawmakers are increasingly seeing the cost benefit of telemedicine to reduce the expense of the transportation reimbursement in rural areas.

 

Patients

 

Telemedicine visits are often paid directly by patients due to the convenience and affordability.

Many online telemedicine services offer on-call access to a doctor 24/7 with a per-visit fee or a yearly or monthly subscription.

Many doctors who offer telemedicine visits with patients do so through a concierge or direct-pay model.

 

Telemedicine and HIPAA

 

As with any form of health care technology, all telemedicine solutions must consider HIPAA compliance to protect patient privacy.

Consumer-grade services like FaceTime and Skype do not support HIPAA-compliant video conferencing because the data is not encrypted.

This means applications must have high-level security to prevent breaches that can endanger patients’ health information.

Telemedicine solutions can be made compliant by ensuring a secure connection, fully encrypting all transmitted data, and avoiding the storage of any video.

In addition to using products that are compliant with HIPAA, providers, staff, and patients must also take care to stay in compliance with HIPAA laws.

Essentially, using HIPAA-compliant telemedicine software is not enough to protect against HIPAA violations.

This usually means systematic HIPAA training for any staff that will be involved with telemedicine and no messages shared with patients outside a secure HIPAA-compliant portal.

 

Telemedicine Terms

 

This glossary includes a brief definition of common terms used in telemedicine.

• Accountable Care Organization (ACO). An ACO is a healthcare company, typically a hospital or group of doctors, that ties provider reimbursement to quality metrics and a reduction in total cost for a population.

• Application Service Provider (ASP). An ASP is responsible for hosting many applications on a central server. Customers can use these applications with a fee through their private network or secure connection. Customers essentially rent the desired applications from the ASP rather than maintaining the software on their own hardware.

• Assistive technology. In 1998, Congress passed the Assistive Technology Act that defines adaptive or assistive technology as any equipment, product, or service that is used to improve, maintain, or increase the functional capabilities of someone with a disability. This includes speech recognition software, touch screens, and type-to-text software.

• Asynchronous. This term describes store and forward (S&F) transmissions of medical data and images. These transfers generally occur over a time period in separate time frames, not simultaneously.

• Asynchronous Transfer Mode (ATM). This is a telecommunications protocol that supports video, voice, and data communication by encoding data into tiny cells instead of frames or packets.

• Authentication. This refers to verifying someone’s identity through keys, passwords, or automated identifiers before receiving or sending information.

• Bandwidth. This is a measure of how much information an Internet connection can handle within a given time. Bandwidth will determine the maximum data speed a network connection can support.

• Basic Rate Interface. This is an Integrated Services Digital Network (ISDN) that is configured to provide two bearer channels and one data channel. The bearer channels are used for voice data while the D channel is used for data and control.

• Bits Per Second (bps). This refers to the number of data bits that can be processed per second. Larger units than bits are often used to identify higher data speeds, such as a megabit. One megabit per second or Mbps is equal to 1 million bps.

• Bluetooth. This is a specification that applies to short-range wireless interconnection, allowing the connection and exchange of information between devices like cell phones, laptops, computers, and printers.

• Bridge. This is a device used to link several video conferencing sites into one video conference session.

• Broadband. This is a type of communication with the ability to carry many frequencies. A broadband connection allows many messages to be transmitted at the same time.

• Cache. This is a dedicated system of memory that reduces processing bottlenecks and improves the performance of devices.

• Cascading. This is a way to increase the number of video conferencing participants compared to using a single multi point control unit (MCU) or bridge that is connected to another MCU.

• Certification Commission for Health Information Technology (CCHIT). This commission was founded to increase the implementation of telehealth technology and it certifies digital health records.

• Centers for Medicare & Medicaid Services (CMS). This federal agency administers Medicare and works with state governments to provide the State Children’s Health Insurance Program (SCHIP), Medicaid, and HIPAA standards.

• Clinical Information System. This type of system relates to information about patient care rather than administrative data. Clinical Information System is a hospital-based solution designed to collect and organize patient information.

• Clinical Decision Support System (CDSS). This is an interactive tool that helps healthcare professionals with clinical decision making. A CDSS can be used to facilitate diagnoses and treatment plans and it can take into account the patient’s history and the results of exams and labs. A CDSS typically has a dynamic knowledge base that may include drug interaction information, clinical trial results, and more with a set of rules.

• Cloud computing. This is the use of hardware and software resources delivered online as a service to store data off-site. Cloud computing entrusts a remote service with the user’s software and data.

• CODEC. This acronym stands for coder-decoder and it’s a video conferencing tool that converts analog data into digital to conserve bandwidth.

• Compressed video. To send data over a phone network, video images must be compressed to reduce the bandwidth necessary to capture and transmit the information.

• Computer-based Patient Record (CPR). This is a patient’s individual data in an electronic format designed to make access easier.

• Data compression. This is a way to cut down the volume of data by encoding it. With compression, the data has fewer pieces of information for reduced storage and bandwidth requirements.

• Digital Imaging and Communication in Medicine (DICOM). This is an international standard to format, identify, send, and display medical images and other information.

• Digital signature. This is a mathematical means of authenticating or verifying digital messages and documents. With a valid signature, the recipient can see that the message was made by a known entity and is unaltered.

• Digital Subscriber Line (DSL). This is a form of technology that provides internet access by sending digital information over a local phone network. DSL divides an existing telephone frequency so data and voice information is transmitted simultaneously without interference.

• Distant Site. This is the location from which the practitioner delivers the service when a telecommunications system is used. It can also be called the consulting site, referral site, specialty site, hub site, or provider site.

• Electronic Patient Record. This is a patient’s information in the electronic format that gives a provider complete access to the patient’s data with links to medical information, reminders, clinical decision support systems, and other aids.

• E-pharmacy. This is the use of digital information and telecommunications technology to offer pharmacy services remotely.

• Encryption. This is a system to encode data on a website or email so only the computer authorized to view the data can retrieve and decode it.

• Evidence-based medicine. This is the use of expert systems to improve medical practice by integrating research evidence, scientific studies, and best clinical practices in the clinical decision-making process.

• Firewall. This is computer security software and hardware that blocks unapproved data exchange between the computer network and any external networks.

• Frame rate. This is the frequency or rate at which an imaging device can produce consecutive frames. It’s expressed in frames per second (FPS).

• Gatekeeper. This is a device that manages video conference traffic in an IP-based network to eliminate bottlenecks.

• Ghosting. This is a video artifact that is usually seen in a video display over a connection with a high amount of latency. As an image moves across the screen, it may leave a trail of visible “ghost” images.

• Health Information Exchange (HIE). Electronic HIE allows health providers and patients to access and share a patient’s medical information electronically. This can help reduce medication errors and readmissions while improving diagnoses and decreasing duplicate testing.

• Health Level Seven Messaging Standard (HL7). This is a series of communications protocols to send private health information. With HL7 messaging, many medical devices and applications can interact and exchange information securely.

• HIPAA. The Health Information Portability and Accountability Act was passed by Congress in 1996 to reduce healthcare abuse and fraud and institute industry standards for the privacy and protection of identifiable patient health information.

• Integrated Services Digital Network (ISDN). This is a dial-up transmission path that is used for video services. ISDN services can be used on demand when another ISDN device is dialed.

• Internet Protocol (IP). This is the protocol for the transmission of data between 2 or more computers. Every computer a unique IP address that identifies it and allows for tracking. In video conferencing, the IP address is the phone number.

• Kiosk. This is a specially designed system to access programs and search websites. Its unique design prevents tampering and theft and it can hold up to public use without an attendant.

• Latency. This is the detectable delay between when information is sent and received over a connection. A slow connection or high network activity can increase latency.

• Local Area Network (LAN). This is a computer network within an organization that links computers, printers, and other devices while supporting data, audio, and video exchange.

• Lossless. This type of data compression results in no loss of original data when the information is reconstructed.

• Lossy. This type of data compression results in permanent data loss when reconstructed.

• Meaningful use. This set of standards was defined by the CMS to govern the use of digital patient health records. It also gives eligible hospitals and providers incentive payments when they meet certain criteria.

• Medical codes. This is a way to describe medical procedures and diagnoses with universal medical code numbers. Medical codes are used to ID, track, and pay for services.

• Noise cancellation. This is a method to reduce undesired sound during video conferencing.

• Originating site. This is the location of a Medicaid patient when the service is being provided through telecommunications.

• Picture-In-Picture (PIP). This allows both sides in a video conference to be viewed at the same time on the same screen.

• Presenters. Presenters are those who provide telemedicine services and overall exams for patients. Presenters must have experience providing healthcare services to patients and may be registered nurses.

• Protected Health Information (PHI). Under HIPAA, this is individually identifying health information. This includes any information that is not specifically tied to someone but could reasonably allow for individual identification.

• The Quality of Service (QoS). This is a way to prioritize network data traffic to ensure video conferencing data is viewed as a high priority for improved quality without interruptions.

• Regional Health Information Organization (RHIO). The terms RHIO and HIE are used interchangeably. RHIO is a group of organizations with a goal of improving the efficiency, safety, and quality of healthcare services.

• Router. This device provides a connection to at least 2 networks on multiple locations. A router is responsible for telling a video conferencing device where the destination devices are located and it will locate the best way to retrieve information from that location.

• Store and forward (S&F). This is a type of telecommunication solution that uses still images from the patient to determine a diagnosis. Store and forward solutions are often used in wound care, radiology, and dermatology. S&F can also be used to transmit clinical data like ECG measurements from one location to another.

• Streaming. This is the transmission of audio or video data over a network as needed.

• Synchronous. This is an interactive type of connection between two videos in which information is transmitted between locations at the same time.

• TCP/IP (Transmission Control Protocol/Internet Protocol). This is the underlying communications protocols that allow computers to interact and exchange information online.

• Teleconferencing. This is an interactive digital communication between at least 2 users at different sites using data, video, and/or voice transmissions.

• Telemonitoring. This is the use of video, audio, and other telecommunications and digital technologies to monitor a patient’s health.

• Videoconferencing system. This is software and equipment that offers real-time two-way transmission of video between locations.

• Virtual Private Network (VPN). This is a way to carry private communications network traffic over the public internet by “tunneling” or “port forwarding” information in an encapsulated format.

• WiFi. WiFi was developed for use with laptops and other mobile computers in LANs, but it is now used for a variety of other services like VoIP phone service, gaming, and basic connectivity of televisions, cameras, DVD players, phones, and more.