Telemedicine Starts with the Doctor's Voice

You've heard of manufacturers adopting just-in-time-inventory strategies? Well, healthcare providers should adopt just-enough-technology strategies.

Keep that in mind before diving deep into telemedicine. The term telemedicine is one of the vaguest technology buzzwords in this business, and it covers a multitude of approaches, everything from picking up the telephone to creating a "virtual ICU."

Now that all user-facing technology is going mobile, the demands of wireless networking and the demand for every provider to have an "mHealth" strategy mean more infrastructure, more planning, and more cost when crafting a telemedicine strategy.

But as I was researching a forthcoming story on mHealth for HealthLeaders magazine, I found David Gordon, MD, a board-certified cardiologist in Philadelphia who practices part-time in California and does utilization reviews for hospitals.

Gordon is making a difference in the lives of patients he's never met in person, and all he needs to do his work is his training, his experience, a telephone, and a Web browser. His story is the just-enough-technology success story of telemedicine.

For the past year, Gordon has been on-call part-time for Consult A Doctor, Inc., a company I first encountered at the American Telemedicine Association conference this spring. I wanted to know what kind of physician would work for this kind of service. My curiosity was further piqued when Aetna announced a partnership with Consult A Doctor in June.

So this is the story of one physician, but also of a healthcare industry in trouble and in transition. What does Aetna see in a service often summoned as an app on a mobile phone, which may simply result in a phone consultation between a patient and a doctor?

For answers, I turned to Gordon. Initially resistant to the computer age, Gordon grew to understand its uses and the role it would play in this age of primary care physician shortages. "Within the next five or so years, a third of the practicing physicians are going to be gone," he says. "With that as the backdrop, I was always fascinated with the concept of the computer and advancing medical care through it."

Like the rest of us, Gordon's seen the efforts to cope with the growing shortage of nurse practitioners and physicians' assistants, and the shift toward retail urgent care substituting for the tradition visit to a doctor's office or the emergency department.

He also knows that the future promises more than the ubiquitous smartphone of today. Two-way video conferencing got a big boost from Skype and Apple's FaceTime, but interoperability keeps it from widespread adoption, at least for now.

Which leaves us with voice: The telephone may be Gordon's most important piece of technology. It is the tool he uses to consult with patients.  And he says, it's working.

"What I have found out since I started [with Consult A Doctor] was the absolute utility and advancement of bringing medical care to individuals that otherwise likely would have held off until the last minute, or gotten no care at all, if they didn't have this opportunity," Gordon says.

"Either it was too costly, or they don't have a doctor, or going to the emergency department is not in the offing, or there's no proximity for them to be able to do that."

Gordon would love to do more work with Consult A Doctor, but he says the company has all the physicians it needs right now for the work available. Gordon has other sources of income, so it's okay, he says. "I'm open one to two days a week, low-acuity stuff, more second opinion-type help for them than primary treatment."  Payment from Consult A Doctor is made from a set schedule. "The money is okay money, but I would say that it's the least important part of it."

Because he is also licensed to practice in the state of Mississippi, Gordon gets a number of Consult A Doctor cases from that state. "There are a lot of underserved patients," he says. "Half of them don't have regular insurance, so to give you an example, when they call up, and they need an antibiotic, I have to work with them and figure out, which is the cheapest that will work.

"So I have to call Walmart for the $4 prescription, and talk to the pharmacist and go through what their formulary is, so we can come up with an antibiotic that will work that's not overly expensive for the patient.

"Believe me, you could put every patient on amoxicillin, which costs about a buck, and doesn't work on anybody, or you can really thoughtfully try and treat them. And if these individuals weren't signed up with telemedicine, they wouldn't get care, because they wouldn't have a place to go.""

Some consults are triage-like in nature, with Gordon simply giving advice. A fuller consult allows him to both advise patients and prescribe medications, although "not controlled substances, no Level 2, but anything below that," he says.

Gordon recounts the time a teenager's mom called, concerned about an outbreak of mono that had gone through her 16-year-old son's volleyball team. The son was showing symptoms of what could have been mono. He advised her to take her son in for an in-person checkup to rule out other serious possibilities such as a ruptured spleen.

"That was a very good call by that lady to call us, and it changed the whole way she was going to approach it, because she wasn't going to take him to the pediatrician," Gordon says. "She thought it was just completely and totally unnecessary. That's where we kind of are making the difference, because we're able to direct patients in the direction they need to go."

Talking to Gordon, I got a palpable sense of the highly disruptive nature of such simple telemedicine to the existing way healthcare is practiced in this country. Gordon presumes the woman has good hospitals where she lives, but for whatever reason, she chooses to call this service instead. And even though the doctor could not see the boy or his mother, it  was an absolutely respectful relationship between doctor and patient.

I ask Gordon if he thinks it's a healthier experience than going to one of those pop-up retail urgent care clinics.

"While most of them are staffed by nurse practitioners and physician assistants who are very good, it's very sterile and not warm," he says. "I'll be perfectly honest with you, the physician extenders are as disinterested as a general practitioner in the office trying to see 35 patients in a day.

"At least on the telephone, for whatever period of time that a consult takes place, both people are focusing on each other, and it's just very rare. I came of age in a different time. By the time I got out of medical school, the whole practice and orientation emphasis had changed, and it just gets worse every day in that regard."

Today's business models of patient-as-consumer or doctor-as-marketer just creates different levels of entry and different barriers, and it really doesn't serve the patient as well, Gordon says.

"It's wonderful really to say okay, how can I help you today, and they just start right in, and you're listening and focusing on everything that they're saying. You're not sitting there worried about some other doctor calling you on the phone, or another patient problem that comes in. It's just wonderful."

As we continue to deal with the exodus of primary care doctors, and the financial pressures on healthcare, I am convinced more than ever since talking to Gordon, that many of the simple uses to which technology is being put are making a material difference in the actual delivery of care.

Some of Gordon's observations are bound to be challenged.

I've known many nurses who can think out of the box just fine, for example. But we cannot ignore Gordon's experience, and the services putting him in touch with 500 patients in just the past year simply by picking up a telephone. While we look forward to the immersive telemedicine experience the future will make possible, let's not forget that.