Times of the Islands - - Contents - BY SANDY TEGER

Com­mu­ni­ca­tion among health providers, their pa­tients and other med­i­cal pro­fes­sion­als is de­pen­dent more and more on tech­nol­ogy that is be­ing used in ways we haven’t ex­pe­ri­enced be­fore. Writer Sandy Teger delves into how this could af­fect you and your fu­ture health care.

By 2020, for the first time in his­tory, the United States will have more peo­ple over age 65 than un­der 5. That trend is pro­jected to con­tinue, such that by 2050 twice as many peo­ple will be over 65 as un­der 5. Florida is at the heart of the ag­ing trend. The per­cent­age of Florida’s pop­u­la­tion age 65 and older in 2015 was 19.4 per­cent, fol­lowed by Maine (18.8 per­cent). Alaska had the low­est per­cent­age (9.9 per­cent). With to­day’s in­creased life ex­pectan­cies, peo­ple who live to 65 can ex­pect to live about 20 more years. The fastest grow­ing sub­set in this group is past 85. The rea­sons are clear: Peo­ple are living longer be­cause in­fec­tious dis­ease has been gen­er­ally con­tained, while new fam­i­lies are hav­ing fewer chil­dren. Mor­tal­ity in older pop­u­la­tions has been sharply re­duced thanks to the progress in the treat­ment of car­dio­vas­cu­lar dis­ease, cancer and di­a­betes.

At the begin­ning of the 20th cen­tury the prin­ci­pal health threats were in­fec­tious dis­eases. To­day the main threats are chronic dis­eases, in­clud­ing heart, stroke, cancer, di­a­betes, hy­per­ten­sion and de­men­tia. Un­like in­fec­tions, these con­di­tions are not cured; they are man­aged.

The im­pli­ca­tions for health care are enor­mous. To treat chronic dis­ease rather than acute ill­ness, the style of medicine will need to change. One-time in­ter­ven­tions that cor­rect a sin­gle prob­lem will tran­si­tion into the on­go­ing man­age­ment of mul­ti­ple dis­eases and dis­abil­i­ties. Doc­tors and pa­tients will need an on­go­ing re­la­tion­ship that helps pa­tients man­age and cope with ill­nesses rather than cure them.

To­day’s meth­ods of pro­vid­ing health care are in­creas­ingly strained. There are fewer gen­eral prac­ti­tion­ers and the wait for ap­point­ments both with them and with spe­cial­ists re­flects our over­bur­dened sys­tems. Any­one who lives in South­west Florida can at­test to the gen­er­ally long waits for ap­point­ments dur­ing the win­ter sea­son, when the num­ber of vis­i­tors in­creases.

An ag­ing pop­u­la­tion has far-reach­ing im­pacts on the pro­vi­sion of health care. It is a sim­ple num­bers game. There are go­ing to be many more 65-plus in­di­vid­u­als in our health care sys­tem than any other age group, and they will in­creas­ingly suf­fer from chronic dis­eases. Their needs must shape how we pro­vide health care. En­ter telemedicine.


Telemedicine is the re­mote de­liv­ery of health care ser­vices, such as health as­sess­ments or con­sul­ta­tions, over the telecom­mu­ni­ca­tions in­fra­struc­ture. It al­lows health care providers to eval­u­ate, di­ag­nose and treat pa­tients prior to or with­out the need for an in-per­son visit. Also called “vir­tual care,” telemedicine is a rapidly evolv­ing area in which meth­ods of care, avail­abil­ity of in­sur­ance cov­er­age and a mul­ti­tude of other de­tails are start­ing to take shape.

Telecom­mu­ni­ca­tions may be be­tween a doc­tor and a pa­tient or be­tween two doc­tors, such as one in an emer­gency room and the other a spe­cial­ist lo­cated re­motely. Med­i­cal spe­cial­ties that de­pend largely on images or ver­bal com­mu­ni­ca­tions as op­posed to phys­i­cal ex­am­i­na­tion are most amenable to telemedicine.

Here are a few ex­am­ples of how telemedicine is be­ing used. Ra­di­ol­ogy was one of the first med­i­cal spe­cial­ties to use telemedicine. Since ra­di­ol­o­gists can eas­ily re­ceive images, an­a­lyze them and pro­vide feed­back to the pa­tient’s physi­cian, some prac­tices and hos­pi­tals use re­mote ra­di­ol­o­gists. Images can even be sent to ra­di­ol­o­gists in lower-cost ar­eas so as to min­i­mize ex­pense or to pro­vide an im­me­di­ate in­ter­pre­ta­tion of the test when no ra­di­ol­o­gist is on duty.

Af­ter a pa­tient has a stroke and is brought to a lo­cal hospi­tal, there is a very short win­dow dur­ing which ap­pro­pri­ate treat­ment should

[ telemedicine] al­lows health care providers to eval­u­ate, di­ag­nose and treat pa­tients prior to or with­out the need for an in- per­son visit.

be given. A neu­rol­o­gist may not be present to de­cide on the course of treat­ment. Emer­gency medicine doc­tors at prop­erly equipped hos­pi­tals can com­mu­ni­cate with neu­rol­o­gists at a cen­tral site us­ing dig­i­tal video cam­eras, In­ter­net telecom­mu­ni­ca­tions, ro­botic telep­res­ence, smart­phones, tablets and other tech­nol­ogy to de­cide whether to ad­min­is­ter cut­ting-edge treat­ments that help pre­serve brain tis­sue.

Re­search shows that these “tele­stroke” ser­vices can be cost ef­fec­tive. The Con­gres­sional Bud­get Of­fice es­ti­mated that although tele­stroke ex­pan­sion would re­sult in ad­di­tional spend­ing in the first year be­cause of ad­di­tional equip­ment and treat­ment, spend­ing would be sig­nif­i­cantly lower

in sub­se­quent years due to a de­cline in the num­ber of pa­tients who suf­fer mod­er­ate or se­vere dis­abil­ity or need long-term care.

Telepsy­chi­a­try is helping bring time­lier psy­chi­atric care to emer­gency rooms. An es­ti­mated one in eight emer­gency room visits in­volves a men­tal health and/or sub­stance-use con­di­tion, ac­cord­ing to the Agency for Health­care Re­search and Qual­ity. Many emer­gency rooms are not equipped to han­dle peo­ple with se­ri­ous men­tal health is­sues and do not have psy­chi­a­trists or other men­tal health clin­i­cians on staff to as­sess and treat men­tal health prob­lems. A 2016 poll of emer­gency room physi­cians found only 17 per­cent re­ported hav­ing a psy­chi­a­trist on call to re­spond to psy­chi­atric emer­gen­cies.

Telepsy­chi­a­try is also be­ing used in nurs­ing homes to pro­vide both on­go­ing psy­chi­atric eval­u­a­tion and care, and emer­gency cri­sis in­ter­ven­tion when it may be dif­fi­cult to find a lo­cal psy­chi­a­trist to as­sist.

If a pa­tient with a se­ri­ous health con­di­tion wants to get a sec­ond opin­ion, it may be dif­fi­cult t o find the time and mone y to fly to a dis­tant cen­ter of ex­cel­lence that spe­cial­izes in that field. In­creas­ingly, cen­ters of ex­cel­lence, in­clud­ing Mayo and Cleve­land clin­ics and Part­ners Health­care (par­ent of Brigham and Women’s Hospi­tal and Dana-Far­ber Cancer In­sti­tute), of­fer re­mote sec­ond opin­ions by their world-class spe­cial­ists.


As we tran­si­tion from of­fice and hospi­tal visits to the in­creas­ing use of vir­tual care, both doc­tors and pa­tients will need to over­come ha­bit­u­ated be­hav­iors. Once this bar­rier is crossed, many pa­tients are de­lighted to do away with a va­ri­ety of in­con­ve­niences that are part of to­day’s sys­tem. These can in­clude find­ing trans­porta­tion to and from the doc­tor’s of­fice; ne­go­ti­at­ing traf­fic on both legs of the jour­ney; and time spent in a wait­ing room, which may be filled with other sick peo­ple. For snow­birds vir­tual care could make it eas­ier to pro­vide more ef­fec­tive and ef­fi­cient care by con­tin­u­ing to have their usual pri­mary doc­tor in­volved.

How­ever, there are four ma­jor im­ped­i­ments to the greater use of telemedicine: the lack of cov­er­age by health in­sur­ance, un­fa­mil­iar­ity to the pa­tient, lack of adop­tion by some providers, and stan­dard U.S. li­cens­ing/cre­den­tial­ing re­quire­ments that to­day are gov­erned by state law and vary from state to state (cre­den­tial­ing).

On Fe­bru­ary 9, 2018, Congress passed and Pres­i­dent Trump signed into law the Bi­par­ti­san Bud­get Act of 2018, which in­cludes sev­eral key pro­vi­sions that ex­pand Medi­care pay­ment for telemedicine ser­vices. Medi­care cov­ers al­most 60 mil­lion Amer­i­cans age 65 and over, as well as those un­der 65 who have dis­abil­i­ties. This is tremen­dously im­por­tant be­cause com­mer­cial health in­sur­ers of­ten fol­low Medi­care’s lead.

The bud­get bill broad­ens Medi­care’s telemedicine cov­er­age by re­im­burs­ing re­mote tele­stroke ser­vices na­tion­wide. Pre­vi­ously, Medi­care tele­stroke pay­ments were lim­ited to re­mote and lightly pop­u­lated ar­eas. It also al­lows re­im­burs­ing for monthly clin­i­cal as­sess­ments via telemedicine for pa­tients re­ceiv­ing home dial­y­sis na­tion­wide; and ad­di­tional telemedicine ben­e­fits for Medi­care Ad­van­tage en­rollees, as well as telepsy­chi­a­try ser­vices.

Also called “vir­tual care," telemedicine is a rapidly evolv­ing area in which meth­ods of care, avail­abil­ity of in­sur­ance cov­er­age and a mul­ti­tude of other de­tails are start­ing to take shape.


In March 2016, the Florida Leg­is­la­ture passed a new bill de­signed to set the stage for tele­health com­mer­cial in­sur­ance cov­er­age in the Sun­shine State. It cre­ated a for­mal Tele­health Ad­vi­sory Coun­cil within Florida’s Agency for Health Care Ad­min­is­tra­tion (AHCA). It re­quires AHCA, Florida’s De­part­ment of Health, and Of­fice of In­sur­ance Reg­u­la­tion to sur­vey providers, pro­fes­sion­als, fa­cil­i­ties, and health plans to de­ter­mine the ex­tent that com­mer­cial health plans are ac­tu­ally cov­er­ing tele­health ser­vices in Florida, as well as the re­im­burse­ment rates the plans are ac­tu­ally pay­ing to providers. In­sur­ers and providers that refuse to re­port the information can face fines and penal­ties. The sur­veys and re­search data must be com­pleted and com­plied by June 30, 2018.

The Tele­health Ad­vi­sory Coun­cil is charged with tak­ing the data and re­search find­ings and de­liv­er­ing a re­port to the gover­nor and the leg­is­la­ture con­tain­ing pol­icy rec­om­men­da­tions to in­crease the use and ac­ces­si­bil­ity of tele­health ser­vices, as well as any bar­ri­ers that should be re­moved. The re­port is due by De­cem­ber 1, 2018.


TOTI Me­dia has fea­tured a series of ar­ti­cles on how tech­nol­ogy is chang­ing our lives. Some of the pre­vi­ous ar­ti­cles tie into this dis­cus­sion of health care. What hap­pens when a per­son needs med­i­cal care and can’t drive, or when the doc­tor needs to see the pa­tient in per­son? As the Jan.-Feb. 2018 ar­ti­cle de­scribed, not long from now they will be able to sum­mon a driver­less car to take them to the doc­tor’s of­fice and back. If they don’t know how to use a mo­bile app to or­der the car, they will be able to use a voice as­sis­tant like Alexa or Google Home—they can say “Alexa, call Uber to take me to Dr. Smith” and it’s done! Rather than be­ing sep­a­rate and dis­tinct, the tech­nolo­gies of driver­less cars, med­i­cal treat­ment and new voice-en­abled in­tel­li­gent as­sis­tants can com­bine to solve real world prob­lems in in­ter­est­ing and some­times un­ex­pected ways.

Sandy Teger lives on Sanibel Is­land and is a part-time tech­nol­ogy con­sul­tant at Sys­tem Dy­nam­ics Inc. She’s also a grand­mother of four, or­ga­nizes the an­nual Sanibel/Cap­tiva Heart Walk and is a gar­den and wine en­thu­si­ast.

Em­brac­ing the con­cept of telemedicine, the Santa Mon - ica Med­i­cal Of­fices is one ex­am­ple of how com­put­ers have be­come ubiq­ui­tous in a doc­tor’s of­fice.

Clock­wise from top left: A doc­tor ser ving a ru­ral com­mu­nity com­mu­ni­cates re­motely with a psy­chi­a­trist about a pa­tient’s treat­ment; Dr . Pe­dro Lucero ex­plains the ca­pa­bil­i­ties of the telemedicine sys­tem in­stalled at a mil­i­tar y med­i­cal cen­ter; Dis­tance Learning and Telemedicine grants through the De­part­ment of Agri­cul­ture’s Ru­ral De­vel­op­ment Pro­gram en­able hos­pi­tals to cre­ate tele­health in­fra­struc­tures.

A spe­cial­ist in re­ceipt of a pa­tient’s scan uses telemedicine to con­fer with the hospi­tal’s at­tend­ing physi­cian.

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