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Asynchronous Virtual Visits Save Time, Provide Effective Care

Analysis  |  By Alexandra Wilson Pecci  
   June 26, 2018

Despite lagging regulations and reimbursement challenges, one provider says individual health systems can change how they do business using virtual visits.

Virtual visits conducted asynchronously were just as effective as in-person office visits in helping maintain blood pressure control, a new study has found.

Virtual visits have shown success over several years at Massachusetts General Hospital in Boston as written in an study coauthored by Ronald Dixon, MD, a physician at MGH and head of clinical affairs for virtual diabetes clinic Onduo in the Journal of General Internal Medicine.

The visits in this study were conducted on a web-based platform that Dixon developed to allow for "structured asynchronous online interactions," as opposed to synchronous visits where there's a real-time conversation via telemedicine.

How the Model Works

MGH's primary care practices started offering eVisits for certain common chronic conditions in 2012.

Instead of coming into the office for their routine follow-up care, patients can schedule an eVisit, log in to the platform on the day of their virtual appointment, and answer relevant questions from their provider, eliminating travel time.

Patients will receive a response from their doctor within 24 hours or less.

"The same types of questions that a clinician would ask you in the office, we presented in questionnaire format," Dixon says.

Some of those questions are: Are you taking your blood pressure? What are the readings? The platform uses branching logic, which tailors consecutive questions based on previous answers.

Answering "yes" to a question about whether a patient is taking her blood pressure readings would lead to one follow-up question, whereas answering "no" would lead to a different one.

The Study

For this particular study, researchers focused on virtual visits for hypertension from December 2012 to February 2016.

They followed 893 MGH patients participating in virtual follow-up visits, and 893 Brigham and Women's Hospital patients with similar demographic factors, chronic conditions, and cardiovascular risk factors.

The virtual visit platform allowed patients to enter up to five blood pressure readings taken since their last visit, report on whether they were taking medications as directed, describe any side effects, and ask questions.

Primary care clinicians reviewed patient responses, made adjustments to treatment as needed, and recommended repeat virtual visits, follow-up phone calls, or in-office visits.

The study found that the virtual visits were just as effective as in-person office visits in helping maintain blood pressure control. They found no significant difference in outcomes, including the need for specialty visits or inpatient hospitalization.

The study also found that visits to primary care decreased in 44% of patients in the virtual visit group, compared to 41% in the usual care group.

"It was a way to create feedback for the patient and the provider around the chronic disease," Dixon says. "You're actually managing a patient and you're making decisions about medicines and looking at the chart … We're just doing it in a more efficient way. "

In fact, Dixon points to a 2014 study that he coauthored showing not only that patients and physicians like the virtual visits, but that "clinician time spent for the overall encounter was significantly shorter than for an in-person follow-up visit."

It showed that conducting and documenting a virtual visit requires about one-fifth of the time a clinician needs for an in-person, office visit.

Reimbursement and Regulatory Challenges

The wrinkle here is, as always, how to pay physicians.

"The challenge, of course, is a fee-for-service environment," Dixon says. He adds that shifting primarily to value-based payments is "the only way" for this model to succeed.

In writing about barriers, the study authors write that, "Reimbursement for asynchronous visits is limited in traditional fee-for-service and is governed at the state level.

For example, licensure requirements, particularly the need to have state-level credentials, preclude clinicians from providing virtual visits to their out-of-state patients."

While regulations lag, Dixon says individual health systems can change how they do business.

"It's up to the system, and Partners [HealthCare] has incentivized this by having more of a value-based payment model," he says.

Asynchronous Model Useful With Other Chronic Conditions

Dixon also points out that hypertension is just one of dozens of chronic conditions for which MGH uses virtual visits.

According to the hospital, virtual visit availability has been expanded at MGH to all primary care and several specialty care practices to follow up on the care of roughly 65 chronic conditions.

It will soon be extended to practices at other Partners HealthCare facilities, beginning at Brigham and Women's Hospital.

"It requires flexibility on the leadership side and innovative thinking around how you incent physicians to do things," Dixon says. "An asynchronous model really can scale. It just needs the right incentive system, and that requires cooperation from your administrative leadership."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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