1. 2007 International Conference Washington, D.C. ~ November 7-9, 2007 Paging Dr. Faraway – Telemedicine ’ s Risks and Rewards

2. Paging Dr. Faraway Panel Members MODERATOR: Angela Williams Russell, Managing Partner Wilson Elser Moskowitz Edelman & Dicker, LLP Charles Citrin, M.D., Neuroradiologist Washington Imaging Associates, LLC / HealthSouth Susan Durbin Kinter, Director of Claims & Litigation Maryland Medicine Comprehensive Insurance Program Joshua Stein, Chief Underwriting Officer OneBeacon Professional Partners

3. WHAT IS TELEMEDICINE? Common Uses  Radiology, Pathology, Cardiology, Neurology, ICU, Obstetrics, Medical Education  Most Common application – Teleradiology Purpose  To overcome time and distance barriers that separate patients from care givers  To eliminate barriers that separate some caregivers from new medical technologies Goals  To improve the quality of healthcare, increase efficiency, and expand access

4. HOW IT WORKS RADIOLOGY PERSPECTIVE  Demonstration  Prevalence of Teleradiology 92% use for preliminary on-call reads 20% use for consultation with other radiologists 95% use for interpreting CT scans 84% use for Sonography 47% use for MRI 43% use for Conventional Radiographs* OTHER EXAMPLES * Based on 1999 Survey of 970 radiologists by the American College of Radiology

5. DEVELOPMENTS IN TELEMEDICINE Continued innovations in computer technology and telecommunications have a caused a surge in the use of telemedicine Advancements in digitation of information  Allows for convergence of text, sound, pictures and technology  Store and forward versus interactive television Migration towards wireless communication and globalization of services for care givers and patients

6. RISKS WITH NEW TECHNOLOGY With advancements in technology and new technologies come increased risks Increased opportunities for error in diagnosis and treatment Errors often more visible and may result in more severe outcomes

7. RISKS WITH NEW TECHNOLOGY (cont.) Pressure on institutions and physicians to implement and use new technology which can increase risks Risks to hospital or other healthcare institution if telemedicine group not subject to suit – hospital or contracting institution left “holding bag”

8. AREAS OF CONCERN No real, consistent technical standards or guidelines to ensure interoperability and reliability  Difficult to establish an accepted definition for standard of care No direct U.S. regulation of U.S. technology, which allows for inconsistency Licensing and credentialing requirements for care providers in different institutions, different states or different countries can create problems Contracting provisions need to clearly define scope of services and which providers are qualified to render care

9. AREAS OF CONCERN (cont.) Public belief that technology can improve lives, resulting in unrealistic expectations; there is a propensity to sue when procedures fail Absence of face-to-face interaction with patients or other care providers Mechanisms must be in place to ensure technology is reliable and up-to-date, with minimal transmission errors or technical glitches

10. PRIVACY / INFORMATIONAL CONSIDERATIONS Technologically reliable security mechanisms are necessary to ensure privacy HIPAA compliance must be taken into account Duty to disclose physician training, success rates, alternatives Patients have more access to information and require more information as consumers, which impacts standards for disclosure

11. REWARDS OF TELEMEDICINE Increased access to medical care for many patients, including those in remote areas Increased availability of medical care to allow for around the clock consultations Allows for increased access to subspecialty expertise for patients

12. REWARDS OF TELEMEDICINE (cont.) Makes training available to care providers who may not otherwise have such access Technology has proven to be invaluable in military and natural disaster scenarios

13. SUMMARY – POINTS TO CONSIDER Expectations are that telemedicine will become even more prevalent in health care. The access to and availability of telemedicine has been greatly expanded and will continue to expand. Mechanisms should be implemented to regulate and monitor these advances so as to maximize their benefit and minimize risks.

14. SUMMARY – POINTS TO CONSIDER (cont.) The desire for cutting-edge technologies and time- saving treatment and diagnoses must be weighed against the importance of face-to-face interaction – protocols should be instituted to ensure interaction particularly in high risk circumstances. Great care should be taken in establishing contract provisions for telemedicine and the credentialing process should be well-defined Insurance professionals must be aware of these issues in evaluating risks for care providers and patients.

15. Audience Q & A

16. Many thanks to... Angela Williams Russell Charles Citrin, M.D. Susan Durbin Kinter Joshua Stein

17. REFERENCES “Technology Trends in Telemedicine” Express Healthcare Management, Indian Express Group, Issue Dtd. 16th to 28th, February 2003 (India) “Emerging Trends in Telehealth” Kumekawa, Joanne K., Business Briefing: Next-Generation Healthcare, pgs. 62-64 Future Technology Trends, Health Resources and Service Administration, U.S. Department of Health and Human Services, November 1999 Telemedicine 101: Telemedicine Coming of Age, Brown, Nancy, Telemedicine Information Exchange, January 13, 2005, http://tie.telemed.org/articles.asp?path=telemed101&article=tmcoming_nb_tie96.xml http://tie.telemed.org/articles.asp?path=telemed101&article=tmcoming_nb_tie96.xml Innovations in Health Technologies and Its Impact on Medical Malpractice – Robert W. Goodson, Wilson, Elser, Moskowitz Edelman & Dickler, LLP, Presentation 2005. A Comprehensive Portrait of Teleradiology in Radiology Practices: Results form the American College of Radiology’s 1999 Suvery, David B. Larson, Yasmin S. Cypel, Howard Forman and Jonathan H. Sunshine American Journal of Roentgenology, 2005. 185:24-35