- The ongoing battle in Arkansas over new telemedicine guidelines is shining a spotlight on “store and forward” technology.
Long considered the alternative to real-time (or live interactive) telemedicine, store and forward (or asynchronous) telemedicine generally gives a clinician time to review data before beginning a session. As defined by the Department of Veterans Affairs, it’s “the acquisition and storing of clinical information (e.g. data, image, sound, video) that is then forwarded to (or retrieved by) another site for clinical evaluation.”
According to the Center for Connected Health Policy, store and forward “can include X-rays, MRIs, photos, patient data and even video-exam clips (and) primarily take place among medical professionals to aid in diagnoses and medical consultations when live video or face-to-face contact is not necessary.”
“Because these consultations do not require the specialist, the primary care provider and the patient to be available simultaneously, the need for coordinating schedules is removed, and the efficiency of the healthcare services is increased,” CCHP states.
While real-time video visits are generally considered to be the sexier version of telehealth, several commercial providers rely on asynchronous platforms, with clinicians reviewing data sent to them or stored in the cloud and then connecting with the patient via phone, text or e-mail.
“This gives the clinician the time to make a judgment in an informed way,” says Kevin Smith, chief clinical officer for Zipnosis. He sees asynchronous telemedicine is being more clinically focused than video visits because the interaction between clinician and patient is guided by best practices on decision support. .
“This model guides patients through structured, adaptive interviews developed from national best practice guidelines,” Smith wrote in a recent letter to the Journal of the American Medical Association (JAMA) Internal Medicine. “A systematic method also leads providers through curated pathways based on patients’ medical histories. Treatment options are limited to the most appropriate choices supported by evidence-based protocols, thereby reducing variability.”
In Arkansas – reportedly one of the last states to consider expanding telemedicine – questions about what that model should include is holding up passage of new guidelines.
A legislative panel in the state has refused to sign off on proposed telemedicine legislation after opponents cried foul on a last-minute change to the definition of store and forward technology. The change, inserted after the proposed rules had completed a period of public comment, clarifies that a patient completing an online questionnaire and sending it to a doctor does not meet that definition.
Such a ruling, if passed into law, would prohibit telehealth providers who base first-time visits with a patient on a questionnaire from operating in the state.
The proposed legislation, Act 887, defines "store and forward technology" as the transmission of a patient's medical information from the office of a health-care professional to a provider at a different site without the patient being present; as such, the rule states, it is not telemedicine and is not restricted by the law.
Also in the proposed legislation is language restricting the “originating site” of a telehealth encounter to a doctor’s office, clinic or similar healthcare site. This effectively eliminates the home, or any other non-clinical location where a consumer might want to have a conversation with a doctor about a health-related issue.
Those restrictions would not only curb telehealth providers like Zipnosis and Teladoc (which does a vast majority of its business via telephone), but they hamper large businesses who offer the platform to their employees as a health benefit.
That argument points to yet another ongoing conflict between telehealth advocates and healthcare providers who aren’t sold on the technology – the contention that a doctor and new patient must first meet in person to establish a relationship. It’s why only a handful of states, according to the American Telemedicine Association, reimburse for store and forward services in their Medicaid programs, and why many limit the practice to specialties like dermatology, pathology, radiology and ophthalmology.
Jon Pearce, Zipnosis’ co-founder and CEO, feels the healthcare industry has to do a better job selling virtual care – be it asynchronous or real-time telemedicine – to the skeptics. With store and forward, he argues that the platform, used properly, gives the clinician all the tools he needs ahead of time to treat a patient.
“The focus in this case really is on the provider,” he says. “With (store and forward technology), he or she really is providing evidence-based care.”