I had the opportunity to speak with Roy Schoenberg about the model policy recently adopted by the Federation of State Medical Boards (FSMB): Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine. The model policy is offered as a means for state medical boards to get up to speed quickly and to access standards of care that are both protective of patients’ interests and, frankly, are baselines against which physician behavior may be judged by an individual board. Roy distinguishes between telemedicine (doc-to-doc communication) and telehealth (patient-to-doc communication). The latter, particularly using a secure live video platform is a disruptive innovation in a way that the former is not: it allows patients to access medical advice at their convenience, without the need for an office visit or a trip to a specialist.
(Disclosure: American Well is a client of my firm, The Harlow Group LLC.)
Not every state will adopt the model policy as written. Consider, if you will, the case of Idaho, whose medical board recently disciplined a physician for prescribing medication based on a telehealth encounter, even though some members of the state legislature favor the use of telehealth as an important tool to bring scarce medical resources to the state’s far-flung population.
Schoenberg points out that while the model policy recognizes real-time video communication as a means to establish a physician-patient relationship, it does not preclude the use of telephone or email communications between a physician and an established patient (just as these modes of communication are already in widespread use for established patients).
Listen to my conversation with Roy Schoenberg (it’s 20 minutes long) or read the transcript (at the end of this post):
Roy Schoenberg Interview with David Harlow on HealthBlawg
The next step that the FSMB and the individual states will have to take is the development of an interstate medical licensure compact for expedited licensure. We need to have each state’s medical board (and medical society) take a step back from the guild mentality and allow for interstate practice using an expedited licensure process. Only a handful of states have taken that step to date.
While the technological imperative is a key factor in moving telehealth into the mainstream, Schoenberg emphasizes that American Well (and any other company providing a telehealth platform) is a technology company, not a health care provider, and that physicians ultimately hold the power and responsibility to back away from use of technology where it may not fairly be relied upon. As Schoenberg noted, a physician may say to a patient in a telehealth encounter: You really need to go see your PCP so she can look at that in person and recommend a course of treatment. In addition, a physician may refuse to prescribe a certian medication online — just as he or she may refuse to do so in person. As long as the physician’s discretion is preserved, Schoenberg says the Federation model guidelines provide for “a very, very safe embrace of what this technology promises to the American people.”
David Harlow
The Harlow Group LLC
Health Care Law and Consulting
HealthBlawg :: David Harlow’s Health Care Law Blog
Interview with Roy Schoenberg, MD, CEO of American Well, Inc.
June 3, 2014
David Harlow: Hello and welcome to HealthBlawg, this is David Harlow. And I’m speaking today with Dr. Roy Schoenberg who is the CEO of American Well. Good morning, Roy.
Roy Schoenberg: Good morning, David.
David Harlow: I would ask if you could to give sort of a thumbnail sketch introduction to American Well for those listeners who haven’t heard of the company or its operations.
Roy Schoenberg: Sure. I’ll try to be brief – American Well is essentially a software company that’s based in Boston. We’ve been in operation about eight years. And our business is specifically telehealth which is a variation on what people know as telemedicine that is used to connect physicians. Telehealth is really the ability of consumers or patients to use technology to communicate with physicians and other healthcare professionals.
It comes in various shapes or forms like anything that you have in technology. It speans a variety of different devices, browsers, iPhones, iPads, specially-designed kiosks, and it ties into devices that can collect information about the patient and so on. But fundamentally, it does one simple function, it kind of reverses the paradigm that existed for so many years where if you were sick you have to go to where healthcare was. With the use of telehealth, we can actually reverse it and that should bring healthcare to you. And I think that’s one of the reasons why this is such an explosive market.
From a business standpoint, American Well works with pretty much the entire spectrum of the healthcare constituents out there. We work with the largest health insurance companies in the country, the national payers, the regional Blue Cross Blue Shield payers. We work with a variety of healthcare delivery systems, hospital systems, very well-known ones. We also work directly with large employers that provide health insurance to their employees – Oracle, Pitney-Bowes and others. There’s quite a few of these.
And then lastly, we have a variety of other deployments that have to do with direct services to consumers under the name brand of American Well. This is what we do. And we are very, very fortunate, you know, sometimes luck has a lot to do with it. We are very fortunate to be where we are at this day and age.
David Harlow: Well, it seems like there’s more than luck associated with this. And both you and the company had been recognized recently as leaders in the field. And I want to offer my congratulations there.
Roy Schoenberg: Thank you.
Thank you. I appreciate that.
David Harlow: In the past six weeks or so, the Federation of State Medical Boards has adopted a model policy regarding telemedicine. This is not the first policy that the Federation has adopted in this area. I wonder if you could speak a little to what the current policy says and does and how it may differ from prior pronouncements on the subject.
Roy Schoenberg: Sure. So for everybody that’s familiar a little bit about how the regulation of medical practice happens, the regulatory authority in every state is really the State Medical Boards which is a government entity that’s providing physicians with licenses and could potentially sanction physician or even take their licenses in case they do something that is considered poor medical practice.
The Federation of State Medical Boards is an organization that lives in Washington who has all of the different states medical boards as its members. It doesn’t have a regulatory authority in that sense but it is the organization that supports every one of the states’ medical boards in their decisionmaking about what’s right and wrong and how to update and modernize the rules around medical practice. And in that sense, because it is really an organization that is consisting of the chairmen and the delegates of the medical boards, it’s actually is a very, very significant – it has a very significant authority in defining what’s right and wrong.
Now, the FSMB — and I want to be very, very clear, you know, I’m not affiliated with the FSMB in any shape or form but…
David Harlow: Sure.
Roy Schoenberg: …the FSMB has spoken frequently about the practice of telemedicine. As I mentioned at the very beginning of our conversation is a very different kind of animal than telehealth because telemedicine, you know, was in a way a communication channel that allowed physicians to really help each other in terms of sharing skills and knowledge about how they care for patients. And it used the variety of different technologies but it really was a communication channel between physicians.
Where telehealth comes in, the ability of a patient to interact with the physicians through technology raises some very significant questions about how can you establish a patient-physician relationship, how can you examine a patient, how can you provide guidance and care and medications to a patient if you really haven’t laid your hands on them as a physician? Which is really kind of one of the basic principles – when I went to medical school, this is kind of the first thing you do with a patient. You interact with them physically, you examine them and everything else.
So, while the Federation has spoken about telemedicine many times before, this is in fact the first time that the medical authorities in this country are actually engaging and voicing an opinion about the appropriateness of using technology for that kind of care. Now this is remarkably important because if you think about it where telemedicine provides, you know, internal efficiencies between physicians, if you embrace telehealth, you are completely rewriting access to healthcare in this country and potentially beyond this country. You’re essentially saying that wherever technology can reach, we can now project healthcare services.
And this doesn’t only deal with very, very remote geographical areas. This deals with our daily lives, with parents with young kids at night. It deals with chronic patients who are bedridden and need to be frequently followed up and seen by physicians. And now we can using technology bring healthcare to them to follow up with them. There’s a variety of different implications, it is a very, very big deal. Probably most people would agree a much bigger deal than the impact of telemedicine actually to begin with.
David Harlow: So let me interrupt you briefly. So telemedicine, you’re defining as communication from physician to physician, and telehealth, physician to patient directly, so where would you put the situation where you might have a patient coming in to a rural health clinic and then together with the clinician in that clinic being connected to a specialist in the big city, for example?
Roy Schoenberg: That’s an excellent question. I think one of the key reasons why there is so much media coverage, so many, you know, heated discussions around those new regulations is because when you start peeling the onion there are so many different variations that live in between these two domains of telehealth and telemedicine. There are the cases where, for example, patients are interacting with physicians through a telephone. There are ones where they interact through email and text messages. There are different apps that you can put on your phone that can collect information that you can forward to a physician.
One of the key issues and one of the reasons why a lot of people are discussing the new regulations is because they’re actually making a first step in this direction and obviously as a first step, they don’t explicitly address every one of those different variations.
Now one of the things — and I want to stress that out, which is I think the most important thing about it — the Federation has stepped forward — in my interpretation of the new guidelines — they stepped forward and said for the very first time that it is under very, very well-defined and strict and very well-controlled safety measures. Under those safety measures, it is legitimate, it is appropriate for a physician and a patient to establish a patient-physician relationship through technology without being in front of each other in person. And even though, you know, this sounds surprising this is really the first time that the medical leadership in this country said so.
And different states’ medical boards that were, you know, kind of feeling growingly appreciative of the promise of telehealth, of this form of technology-based interaction, have had a hard time defining — they understood that it had tremendous potential — but they had a hard time defining all of the different ingredients that need to be in place in order to make it safe. Because as you can imagine, if you’re using technology to, you know, just do Skype with someone that say that they are a physician or even worse, you’re shooting an email to someone that whose email has doctor something on it and as a result you get a prescription and they’ve never interacted with you, you’re opening the door to a lot of very, very bad medicine.
So, the challenge that was in front of the FSMB was how do we help the states’ medical boards that have the jurisdiction on how to use those technologies in medical practice, how do we help them define the criteria that will make the distinction between good and bad use of this technology. And medical boards, I can tell you, usually don’t have the resources to do that kind of exhaustive understanding of how the technology can be used and what the components are.
The FSMB stepped in and said, We’re going to pick it up. They worked last year extensively in understanding all of the facets and came out with saying one, There is a way to do it safely and it is appropriate to use telehealth in medical practice. Technology can be the channel of interaction between a patient and a provider. They can establish patient-physician relationship for as long as they adhere to the following principles. They haven’t gone into talking about the use of text messages or email or a variety of other communication channels. They really literally address the opening of the door of the use of technology for allowing patients to reach physicians. That’s it.
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vid Harlow: Right. So it’s really offering the state boards a standard of care, if you will, against which they can, as you said, if they’re resource limited state boards, they can now adopt these standards as a way to figure out whether folks are acting within appropriate balance given current uses of this technology. One thing that caught my eye in looking through these guidelines is talking about prescription – offering prescriptions through this mode. And the language basically says this should be done where it’s appropriate. And I see different state medical boards drawing different lines.
Roy Schoenberg: Yes.
David Harlow: Is that the expectation, do you think, from the Federation, that different boards will elaborate on these guidelines in different ways?
Roy Schoenberg: I think it’s inevitable that they will. I think different boards have different ideas about the value of – it’s essentially it’s a risk benefit equation, right? I mean, if you are – if you’re allowing technology to be used to connect patients and physicians, there is inherent risk – I mean, you are without a doubt lowering the level of interaction in comparison to being in the room with a patient. So there is some implied risk in it.
Different state medical boards have to weigh whether that risk is worth it to deliver value to the people in their state and different states have different challenges in terms of access to care. So even just by looking at that equation, you will see variation between one medical board and another.
However – and I think that’s the most important thing — the key principle that was communicated by the Federation which I think all – I think it’s likely that all state medical boards will actually agree with — is that for as long as the use of the technology will preserve two key things in medical practice, one is the physician’s discretion as to what they can and cannot do with the patient in front of them. So the physician has to be able to say under any circumstance, you know, to the patient, This is something what we are now interacting about is something that will require an in-person encounter. This will require a blood test. This will require this before I can render diagnosis or give you treatment. And there should be preservation of that – actually undeterred physician professional discretion on what they deliver through telehealth, that’s one.
The second thing is they said, the physician has to be completely accountable to the care that they render just as they are in real medical practice and in person medical practice. A lot of bad things can happen when you walk into a physician office and ask for a very, very dangerous prescription, and the physician just gives it you. That’s bad medical practice. It has nothing to do whether it’s technology or not. The medical board said if we equate physician discretion, the professional ability to do good medical practice and their accountability to the decisions and the care that they render, then technology is just one of the means of care delivery. And we feel comfortable that in that sense, it is the same standard as in-person care. That opens up the door for – it is very – you may call it conservative – but it’s a very, very safe embrace of what this technology promises to the American people.
David Harlow: Yes. So, one thing that interested me in these proposed – in these model guidelines is that there are still the requirement of state by state licensure and licensure to be determined by the location of the patient. The next step that I understand the Federation would be undertaking in this regard is looking at developing an interstate medical licensure compact that would make it easier or create an expedited licensure process for telehealth. Is it your sense that that’s happening and that state boards are open to that? I know that already exists in some states but not many.
Roy Schoenberg: So I think many people missed – because of all the heated discussions, I think many people misread what the new guideline talks about in terms of state licensure. The guidelines that talk about the use of telehealth – about the appropriate use of telehealth essentially, I think, for good reason said there is a complete distinction between the use of telehealth and medical licensure. These are not the same. There are two different topics. And the wording in the guideline that came out said that the interaction or the relationship that gets established between a patient and a physician through telehealth has to abide by the currently prevailing rules of licensure.
Which essentially says that if different – other initiatives are going to modify the rules and allow license portability, for example, or license recognition which is the pact initiative, any one of these different initiatives that will reform or change the way in which a physician license allows them to practice, that should be applied, that should also be respected and upheld in the use of telehealth. And in that, I think, they made a very, very elegant distinction and release, so to speak, of all of the initiatives that deal with medical licensure to really to go unabated without contradicting in any way the new guidelines about the use of telehealth. I think it was actually pretty brilliantly done, frankly.
David Harlow: So it’s sort of a separate issue. And that continues to be a separate issue. I guess, both some medical boards who we’ve heard from recently taking action against individual physician licenses and organized medicine have a – I would say from my perspectives — seem to have a pretty dim view of prescription of medications by a remote physician. Do you have a reaction to that?
Roy Schoenberg: Yes. I think we’ve had recently, even in the last couple of months, there’s been a couple of cases where medical boards essentially disciplined physicians for prescribing to patients that they’ve either interacted with through email or through the telephone alone without seeing them. If you think about it, that has really a devastating effect on the industry because a few bad apples are going to create a lot of uncertainty by physicians who really want to do the right thing on whether this was right or wrong. And I think the Federation guidelines actually address that, you know, very, very clearly and said that they consider telehealth to be safe when it uses technologies that allows at minimum the patient and the physician to see each other.
So they talk about that under normal circumstances, the use of audio and video to establish a relationship is really what they consider the permissive standard, in which case a physician will not be sanctioned. However, you know, a lot of people are saying or getting very anxious about – so what about emails? A lot of people talk to their physicians by email. If you read the small print of the guidelines, the Federation said there is a different standard for establishing a new physician-patient relationship from the means in which a known relationship can use different communication channels to followup and so on.
Just saying, you can use email, you can use text. It doesn’t really prohibit that in any sort of way if you are already that physician’s patient. But if you are essentially — if this is a new relationship, if you are seeking care with the physician that doesn’t know you, the standard should be that you at least have the opportunity to see each other in order to establish this relationship. That actually provides tremendous clarity, I think, to physicians out there that if you do it this way, it is going to be perceived as good medical practice.
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br />However, if you’re just taking a patient over the phone who you know nothing about, you don’t know who they are, you don’t know if they’re pill poppers, they don’t know who you are and your credentialed and licensed or anything, you just get on the phone together and talk for two minutes and you send a prescription for controlled substances, you’re going to be in trouble. And frankly, you know, as a physician, I can tell you I completely understand that. That is not good medical practice.
David Harlow: Yes. Well, thank you, Roy. We’ve been talking with Roy Schoenberg, CEO of American Well, about the challenges of telehealth in a multistate licensure environment, the new guidelines from the Federation of State Medical Boards. And we’re looking forward, I think, to a new era in telehealth as these guidelines become promulgated in the various states around the country.
Thank you very much for taking the time.
Roy Schoenberg: A pleasure, David, anytime. Thank you so much.
