How Technology is Redefining Outpatient Care

Advances in telemedicine are redefining who is deciding to form outpatient clinics and how they should run. "If you don't have a virtual model of practice somewhere within a practice, then you're behind the times," says one virtual practice owner.

Forget patients checking in at the receptionists' desk. Maybe forget waiting rooms. Forget brick-and-mortar clinics. Forget leaving home to get to them.

Technology is redefining what it makes to be an outpatient clinic. It's also redefining the requirements to start one. And those things are redefining who is deciding to form clinics, and how they should run, if the old ways of running them are not as friendly as possible to the clientele—or the workforce.

Over the past few months, I've been reminded of this again and again. Before he left to head up Geisinger, UCLA Health psychiatrist-turned-CEO David T. Feinberg, MD, speaking at the twice-annual Vocera Patient Experience Summit last fall, described how the organization went from a patient satisfaction rating of 38% to 99% on survey questions such as, would patients refer UCLA Health to a friend?

Feinberg said that UCLA is "the only academic medical center with kindness in its purpose statement" as described in the 2011 book "Prescription for Excellence: Leadership Lessons for Creating a World-Class Customer Experience From UCLA Health System" by Joseph Michelli.

But Feinberg said healthcare has a long way to go with patient experience. "They wrote books about us to say we're 99th percentile, and as I tell my team, I think that means we're the cream of the crap." It still means "out of the last 100 people we've taken care of, we've failed 15."

Greater Access; Less Waiting
So Feinberg pushed for improvements. Realizing that even the California Department of Motor Vehicles allows online appointment scheduling, Feinberg resolved to improve the appointment system at UCLA Health. "We now offer same-day access for 27 specialties," Feinberg said. "We now answer the phone at UCLA, 'Hello, this is UCLA Health. Would you like to be seen today?'"

The system also opened more clinics in its Los Angeles service area, such that no patient would have to drive more than four miles for primary care "because if it's six miles, it could be a 30-minute drive, depending on traffic." At present, UCLA Health has four hospitals and 150 clinics.

By issuing smartcards to patients, UCLA Health staff are now capable of being alerted when patients arrive in parking lots. "We know it takes about six minutes to get from the parking lot upstairs… We don't want you to wait, so we get the clinic room ready for you," he said.

"We convert our waiting rooms into clinical space so patients don't wait, or we keep them in really small waiting rooms for doctors waiting for patients. The doctor says, 'We've been expecting you. I brought in the other specialists I think we need. Some are here physically. Some are here by telemedicine.'"

"Actually the first thing we like to say is, 'We apologize that you came in. It means our home monitoring didn't work, that you actually had to come in. But now that you're here, we're going to make it effective and take great care of you and you're back in your car in 30 minutes and you're on your way, and we continue to monitor you in between visits.'"

I've heard of other clinics where there is no appointment desk, but instead roaming receptionists checking in visitors via iPad.

Virtual Consultations
The truly visionary clinics are moving as quickly as they can to make physical visits unnecessary. As of today [May 19, 2015], One Medical Group now offers free teledermatology consultations to its existing patients, who pay an annual membership fee. Just another feature of the practice, added on as technology allows it, kind of like an app upgrade.

Tom X. Lee, MD—Reinventing Primary Care

A few months ago, while researching a story on virtual care, for HealthLeaders magazine, I spoke with Mona Counts, PhD and Charlene McFeeley, NP, two co-owners of The River Practice, which they claim is the first virtual nurse practitioner-owned-and-operated clinic in the U.S. Counts told me she came out of retirement when technology enabled her to see patients via telemedicine. "I was kind of hesitant, thinking my older patients, especially the real geriatric ones, would not want to touch the technology," she told me. "Heck, they jumped on board like you wouldn't believe."

The River Practice uses virtual care technology from ExamMed to exchange information with other electronic health records to better serve its patient population in rural Pennsylvania, even reaching out to assist free clinics in the area.

McFeeley is managing partner of The River Practice and also VP of Healthcare Initiatives for ExamMed. She started working with ExamMed in early 2015.

Other nurse practitioners are scattered across southern Pennsylvania. Even though Counts lives in one of the state's poorest counties, she told me, "I will guarantee almost every [patient] has a smartphone of some kind."

Part of what makes River Practice work well is that patients are, in many instances, continuing relationships they already had with the nurse practitioners—relationships built over years of seeing them in person. "They don't want to go sit in emergency departments," McFeeley told me. "They want to continue to access the providers that they have tremendous relationships with."

Virtual practices are starting to pop up all over. New York-based Maven Clinic, described by Tech Republic as "the first digital health clinic for women" offers services for pregnancy prevention, pregnancy, prenatal, and postpartum care. Women are already using the fledgling online clinic to avoid weekend trips to urgent care centers, and can even obtain second opinions while preserving their anonymity—a level of comfort impossible for women to attain at a bricks-and-mortar clinic.

The takeaway is that this kind of creative thinking in outpatient services is catching on like crazy around the country, taking many different shapes, all touched in one way or another by enabling technology. As McFeeley puts it, "the literature now supports that if you don't have a virtual model of practice somewhere within a practice, then you're behind the times."