emerging medical technologies such as telemedicine are transforming the way we approach health care and making it possible for a doctor to diagnose a patient from a distance or through video conferencing and digital ok for them to be reviewed by a doctor remotely as opposed to them having to be transported to an emergency room and if that situation where it can be managed sure generally it's a lot better to do that we felt very much this was a win supported they're just a phone call away and you can see them on the screen they can see the patient i can pin into certain areas that they can look at like the feet the are a rash anything it's wonderful especially if i'm not quite sure of what's going on the doctor feels so comfortable the have a professional right there to help you with this it and then i found out they're going to have to sell a medicine where they're going to have twenty four seven care and where the doctors because do face to face encounter see the patients and actually diagnose and treat while they're here i think it's a great value to my parents the doctors came walk to the on the t v screen it's much better the and going in the ambulance advocates of telemedicine believe it will not only improve the patient experience but drastically reduce health care costs in this edition of pro se nation understand the law for oneself we're going to explore the current and upcoming laws surrounding this new technology and the legal issues that relate to the rights of the individual patient joining me today are telemedicine trailblazers from a t v tele health the based in raritan new jersey dr bobby malik is the chief medical officer and mel castro the executive director of  theni that offers telemedicine services to nursing facilities throughout new jersey we are also joined by attorney thomas kemp a solace and this associate with the law firm brock  with offices in new jersey new york and florida this is exciting this is cutting edge some might say bleeding edge for those of us who remember when  doctor coming making house calls was actually customary right not that unusual some have compared this to kind of a an electronic version of the doctor visiting with his black bag right it's amazing exactly the so but obviously with any no technology and often we find that the laws do not keep pace with the technology so that's one of the reasons where we're here today so i want to start off with basically bobbie i want to ask you tell us a little bit about i think the tele health and how it's transforming health care today we really strive to provide excellent clinical care nursing homes so for now we are in nursing homes and providing clinical care when patients to compensate in the middle of the nursing home and then the mill the night or on the weekends if they're not doing well instead of the doctor sometimes they go home at five o'clock and they're after the round in the nursing home so there's multiple hours in the day and on the weekends and holidays where there's no doctor around or there's a snowstorm so we provide a service where we put a very high advanced tele medicine court in the facility and then the nurse activates a number and our doctors pop up on the screen within seconds to see the patient who might be short of breath has a fever w technically de compensated and the nurse needs backup and so we then have a digital stethoscope which the the chronology even i'm impressed with day by day the stethoscope you could hear somebodies heart read a thousand miles away you could hear if there irregular heartbeat murmurs crackles in the long and basically we then after we've face to face seen the patient we give the nurse orders in the building to try to keep the patient in the facility and save the patient from going back to the hospital and the real push nowadays has been not going back to the hospital one of the advantages for patients is that you know it's well known now and studies elderly demented people do worse in hospitals so if we can treat their pneumonia treat their congestive heart failure treat their c e o pretty exacerbation right in the comfort of their own home which is the new home then that improves their quality of life they don't get to the areas which carries a high mortality  hospitals as is deadly so they they we provide you know that we train the nurses and they start i v s right in the nursing home so nursing homes are really becoming many hospitals right and with our help in our doctors on call to support the nursing staff in the middle of the night or on weekends we we support them and we tell them what to do in terms of the medications we give them orders about quality of care and what we need to do and then we talk to families  and families really love this when when the doctor pops up on the screen and a family member is at bedside with their loved one who's not doing well it's a tremendous comfort to the families to see that a doctor they're shocked like you just listen to my mom's heart and lungs i'm like yeah for them with great clarity and they're very impressed by the technology and the fact that we're going to try to save the now you've talked about the savings to  potential savings to the health care industry tell us a little bit about that with rising costs and health care i think multiple billions are spent on readmissions to hospitals per year and so we we have data in our facilities that we have contracted with we basically cut their e r evaluations by seventy percent so there are those patients that routinely might go to them or into room they're not going to the  there they're being seen by us forward suspected fracture of fevers all these diagnosis that traditionally might go to the emergency room now they have the doctor with the nurse there guiding them and taking care of the patient right in house so it really saves literally millions probably a year at least in the long run by not going back to the hospital and then let's face it hospital stays are very costly and besides the costs we talked about the quality of care to owners shared the same issue which is rehospitalization you know and as the hospitals are now being pushed by the government at a higher level of standard now that then trickles down to nursing home facilities that have to perform at a certain level as well you know to become part of as a performance improvement for them as well so with that ultimately in the end it affects the patients patients outcome do right through video conferencing with the patients ok so so they truly love this you know and countless hours of waiting in the e r is no good for them like dr malloch said patients families love this and they get very comfortable with this new type of technology how does it change things for the hospital or the nursing home staff for instance when there's a change everybody a lot of people are always opposed to it possibly resist yeah probably but yeah definitely resistant but in the end the more they use it the more comfortable they get the more confident they get with their assessment skills they learn new new skills new tactics they they see how the physician interacts with it with the patient and they take that skill set with them you know and the more they use it the more comfortable they get and really a lot of nurses reported to me that dave they felt job fulfillment job satisfaction because they've actually felt like they've saved a patient from leaving the facility and ending up at the e r for no apparent reason when they know they have the skills to take care of them right there and then in their facility right how is it that so if you didn't have this technology and the nurses really can't assess i mean they can assess to a certain point but then in terms of getting or getting a prescription or something like that that can't really happen without the doctor intervening part of the process absolutely what traditionally it's been based on a phone call so you know they would call the doctor on call for the patient and they would tell the story of mrs x as a fever and shortness of breath and the doctor would really at the mercy of the nurses presentation and if the nurse is feeling a little nervous i've done this many times myself in my practice i'm setting the patient on i can't see that patient i don't know what's going on with the patient i'm at the mercy of somebody else describing it with this the beauty of technology when you see when a physician sees the patient they know right then they have an idea right there that this patient going to head south or we could save this patient and you know one of the common compl a little bit of a fever a little bit of a chest pain that sounds a typical a little bit of shortness of breath that stable so these things are you know that yours is really going to appreciate this with them seeing now real patients that are acutely emergent stings that we can handle in a nursing home or a subacute facility and they're seeing slot more sicker people in these nursing homes now can do most nursing homes or are they equipped to do an g or x rays that kind of thing experience is about fifty fifty but when we when they consult with us we almost insist on it because now we're seeing sick people we want to be able to do a stat e k g most of them do x rays that come back within a couple hours most of them do blood work but e k g s is a hit or miss but when we when they contract with us we almost insist on it because we're taking that facility the next level right that e k g is a critical thing because frankly certain now back to that we have this is a story that's been going for decades and we're talking what i what is the average hospital stay a day i mean anywhere it's probably three to five days for certain diagnosis it depends on the diagnosis ok but so you know for a chest pain they might stay for a day but then you know something else popped up because i'm more confuse another have a fever now from hospital and acquired infections and what is the average cost associated per day i heard somewhere between two to four thousand a day at the minimum if it's and if it's a telemetry floor that could be a pis five thousand just to monitor the patients whose really wasn't cardiac to begin with friday when we this is the beauty of the tele medicine we've had they feel better about that and they prove life proof right there and sort of sitting and billons and finding out later well so clearly we there are there are plenty of benefits to this right so it can perhaps become basically does the real it does the goal if you will responsibility between the doctor and the patient change once you have this new paradigm of telemedicine  or tele health i think well the short answer is no but i think what's should be comforting to the patient is that the answer's no and so at the end of the day the petion relationship with the physician is stable and it stays the same and i think if anything what i think is going to strive to do is ensure that it's doctors understand that regardless of whether you're seeing a patient through a screen or seeing a live or consulting with a nurse on the phone that the relationship is the same that the patient should receive the same level of care and the same type of care that they would otherwise receive and i think that at first blush that might be difficult for some  to comprehend because you are seeing the person you know through a monitor as opposed to being returned from home but i think the beauty of the service is that the patient will receive the same level of care and the same  experience with their physician that they would otherwise see live and i guess it does and it probably doesn't vary greatly from a face to face interactive real time a situation because  god forbid something go wrong if it were in a if a doctor were present there would still be the same questions about you know was it was it the tools was it the those issues remain stable and don't and shouldn't be different and as technology improves we would think that that would become even greater nine not worse right when it comes to hipaa laws and patient privacy you now have you know it well we're all concerned about how stable our connections are these days right and who could hack into them or  not how does it does that change when doctors is now diagnosing a patient out of distance over the the internet i can tell you that from a legal perspective presently you know hipaa the whole concept of hipaa goes to the idea of protected health information which is what which is defined by hipaa and it's implementing regulations those laws do not change in kind of that we need to see the zoom is better the naked eye the step the scope has a very powerful audio and so the visit itself is just as good as a regular visit and i think he when the american telly medicine association is confirmed their view is that this is a this is like a regular visit getting back to the security port you know the software that we use is all hipaa compliant the video is hipaa compliant when patients enter the facility they sign a statement that if your loved one is d compensating or if you do you compensate you are allowed to use a physician in seven years of doing this i actually have had maybe one person say i don't want to tell the medicine visit in seven years most of them embrace it because they're not feeling good they get there if they get to see a doctor that time they're very happy to see you and so basically the software they use it was their uses hipaa compliant and we we also have access nowadays most facilities or have you know more electronic medical records so we have actually have access and passwords that are hipaa complain to those so after our interaction with the patient we actually write the note into that you know more so than the patient's own doctor after already seen a very sick patient and we save them for sa failure and we started i v lasix their own doctor in that own you know more in house e m r which is fully secure our nodes are in there so we're kind of embedded with the facilities that we contract with and that we're with to kind of keep major compliance with if a patient is considering a certain nursing home but maybe they're not sold on the telemedicine thing they do they have a right to opt out if they're going to be at that facility well i think there is a couple of interesting questions but i think the straight answer is that when you're looking to go into a nursing facility  patient can learn from the nursing facility staff what how their call coverage is it is utilized not by and large currently the telemedicine at least that provides our during what i would call the overnight shift or holidays and weekends so the rest of the time there is a lot of doctor to see the patients so it's actually a trucks patients that they could say that in a snowstorm on the weekends when i am my doctor is not around i will get a board certified doctor see my loved one to take care of them in the middle of the night tell me are there any other legal issues that you see  on this landscape right now is that i know again it's emerging so i'm sure that they'll be i think that what it's what we don't know presently that is what's most interesting i mean several states are attempting to pass laws related to a medicine but i think the i think what you said at the open maryland was was poignant which was that  you know the law doesn't often keep pace with technology and i think that's where we are with telemedicine as a whole you know for example a different states have different laws and it's sort of in a state of flux at this point as to whether again just for example say a doctor in the state of tennessee can see a patient in this new jersey and vice versa and under what circumstances that can happen states have varying requirements for whether or not physicians who are part of a practice all need to be registered in every state in which they practice and whether or not the practice can cross state lines with different rules about the corporate practice of medicine  about when they're starting to grow this business and expand no you have do you have a lot of interaction with the patients and what are some of the comments that you've gotten are are you know are they overall sort of embracing or are they resisting what it beginning they were somehow they look center earned not so much concerned just not used to the new technology what i said earlier there are more traditional kind of medicine that they want to see a physician coming in with a white coat was that the scope on their neck but now you know as they see it more and more they become more comfortable with it and they're confident that they're going to be taking care of the wee hours of night weekends and twenty four hours on holidays as well right and they're always going to have a physician right by their side one push of a button and they're right there without waiting bobby actually i have asked you in the preinterview about legislative laws  some of the the laws that are starting to address telemedicine you know when there's a lot of bills as we speak in front of congress right now and you know there you know one of them is called the medicare tell health parity act and they're trying to say this started out ten plus years ago in rural areas you know at least you know a decade plus ago and so they're trying to say you know that metro metropolis metro metropolitan areas cities they all need this and so one of the bills that they're proposing is we can't just start only doing this in rural areas and so you know there's and speaking of the licenses in different states there's you know a you know medical license in a you know interstate  compact that they're talking about where so for eighteen states have joined the closest one to us is pennsylvania but they're going to share so if i have one license in pennsylvania i can essentially have eighteen licenses there's a lot of legislation out there i believe and i was comparing this to the wilder west here a couple of weeks ago this is going to explode so it's inevitable that this is going to really catch you know already is obviously getting very big but it's going to get just pervasive in you most like to convey to the average person out there about telemedicine right now this increases quality of life i think there's no denying that and that's why the legislation will catch up because it's going to actually  one of the perfect storms it's going to save money literally billions and it's going to actually very much improve quality of life in disabled and elderly people whether they're at home or whether they're in a nursing home the visit is as a physician for fifteen years in practicing geriatric it's as good as a real life is now all right so so for for the families i just want to make sure that they know everybody knows that telemedicine is not here to be replacements to attending physicians right we actually collaborate with them to to have continued he of care and which is what all patients residents need and facility is without without that if you can't just stop in the middle of the night because your your life the care continues on throughout the whole day throughout the next day so we need to have that continuous care and i think that's the most important part here for me as a clinician that we continue to collaborate with attending physicians and that's part of our services as well as make sure we communicate make sure everybody's on the same page everybody's on the same team and everybody knows exactly what's going on right  learn about the service i encourage encourage patients who may have it themselves or loved ones who might be going to a nursing facility at some point soon i encourage them to read and learn and use the google machine to have explain what what the service is and how it can be of value to them and why they shouldn't be afraid of it because i think people are just reluctant to change oftentimes i think when it comes to practitioners  who are looking to get into the space understand what you don't understand and i think you know take the time to research and know what it would depending on what state you  in you know what regulations if any govern the practice of medicine as a whole and what specific regulations govern told medicine so that when you decide to get into the space that you're doing it correctly so i think it's just an overall message