The National Aeronautics and Space Administration (NASA) took one small step toward introducing telemedicine to the healthcare community in the 1960s, issuing suits specially equipped to monitor astronauts' biomedical responses while in space. The technology also provided the space travelers access to medical care thousands of miles away. Using similar telecommunications and information technology, today's physicians have the opportunity to take a giant leap toward changing the way healthcare is delivered in the United States. No summer at Space Camp required.
Distance doesn't matter
Remote monitoring doesn't just shrink the physical distance between patient and provider, but it can speed up the frequency of interactions as well--even for ordinary folks. For example, the Connected Cardiac Care program offered through Partners Home Care and the Center for Connected Health in Massachusetts allows patients to easily transmit their blood pressure, weight, and other vital signs every day to a home care nurse, who can provide immediate feedback to help patients manage their conditions. This program and others like it have helped countless patients with chronic illnesses learn to improve their health and avoid hospitalizations, says Joseph C. Kvedar, MD, director of the Center for Connected Health in Boston.
Another flavor of telemedicine, videoconferencing, can help bring specialty care closer to patients. For many elderly Georgia residents, access to psychiatric care was once about as achievable as a trip to the Mir space station, according to William McDonald, MD, director of the Fuqua Center for Late-Life Depression at Emory University in Atlanta. "Psychiatry in Georgia is concentrated in Atlanta, Savannah, Augusta, and a little bit in Macon. You go 10 miles outside of those cities and there are no psychiatrists," he says.
But thanks to videoconferencing technology and a grant from the state in 2006, Medicare patients outside Atlanta are now able to avoid the trek to an often-intimidating mental health center in the city. Instead, they get an hour of face time with a psychiatrist from the relative convenience and comfort of their local hospital or PCP office. Videoconferencing sites are strategically placed throughout the state, each having its own dedicated space and support staff.
Using the fiber-optic T1 lines provided by the state of Georgia, "the picture is almost perfect; the sound is excellent," McDonald says. As an added benefit, the locality of the meeting makes it more feasible for family members to attend, making the encounter more productive. The patient's PCP or referring doctor has the option to sit in on the session, but will more often follow up with the psychiatrist after the evaluation, he adds. The psychiatrist and any other providers in attendance are paid by Medicare for the visits.
Communication-centered care saves time
Even in nonrural areas, patients often go through a significant ordeal to see their doctor, notes Alan Dappen, MD, founder of Doctokr (pronounced "doc talker") Family Medicine in Vienna, VA. Instead of requiring patients to call the office, describe their problem to a receptionist, and make an appointment for the next day, week, or even month--only to spend five minutes in the exam room--Dappen is available to his patients by phone and e-mail 24 hours, seven days a week.
"Instantly we can start talking. Half of the time, I know what we have to do after I hear your story. More than half of the time, the next step isn't seeing you," he says. With immediate access to the patient's electronic medical record and sophisticated decision-support tools, Dappen can usually determine whether a patient's symptom is a drug side effect, for example, or a more serious problem that needs to be addressed in person.
If either Dappen or the patient feels an in-person visit is necessary, an appointment is made, which happens about 25% of the time. House calls are available as well.
Time is money
The reason more doctors don't deliver more care via the phone and Internet is because payers rarely reimburse such services, says Devon M. Herrick, PhD, senior fellow at the National Center for Policy Analysis (NCPA) and author of the report, Convenient Care and Telemedicine. "Physicians don't have the time to do a free service, but they'd be very willing if our system had a way of compensating them," he says.
Recent announcements by Aetna and CIGNA that they will reimburse for e-visits may help remove that barrier, agree Herrick and Kvedar. "This is really a tipping point. When two of the largest national payers open the door, I think volume will start to increase fairly quickly," Kvedar says.
In 2002, when Dappen opened Doctokr , he decided not to wait for the system to change and dropped all insurance plans. He adopted a cash-only time-based payment model, putting the onus on patients to submit claims to their insurance companies if they desire.
Because of the overhead savings achieved by removing this administrative work, most charges are under $40. Dappen estimates that the average Doctokr patient spends approximately $300 per year in healthcare costs. "That's total cost. If they wanted to get the same healthcare through the insurance model, it would be a whole lot more than $300," he says. "The first achievement of this practice is that I believe that I have reduced the system cost of healthcare by at least 50%." With patients increasingly controlling more of their healthcare dollars, Herrick suspects the opportunities will grow for entrepreneurs such as Dappen.
Nonetheless, Kvedar argues that one can make the business case for telemedicine based on efficiency alone, regardless of reimbursement. "There is a code for an e-visit, but for other things like remote monitoring and so forth, that's not how you win the game. You win the game by bringing more patients onto your panel and by getting your quality numbers up so you can get better bonuses from your payers," he says.
Quality is king
Remote monitoring, for example, provides physicians with a wealth of quantitative data--just the kind of data, in fact, needed to achieve pay-for-performance (P4P) incentives. "It gives you a population view, which is just what P4P is based on," Kvedar says. "You're being held accountable to keep all of your diabetics healthy. Either you have remote monitoring . . . or even some of these Web applications where patients input data--those are all tools where you can start to get a more rolled-up view of what's going on with your population," he says.
Various forms of telemedicine don't just allow physicians to monitor quality, but can ensure patients receive better care in the first place, Dappen adds. People often ask Dappen whether he thinks it's dangerous to connect with patients by phone without necessarily seeing them in person. "Wait until you see how dangerous it is when everyone except a doctor will answer the phone," he responds. Many times, a receptionist or a triage nurse doesn't know whether a certain type of headache is urgent or not, or whether a patient describing hearing loss in one ear needs attention within one hour or one week, he says. "There are millions of examples where time is of the essence. And we have a model that puts no value on a person's time, not just in terms of an economic or convenience cost, but to the fact that it sometimes impacts healthcare."
PPS sources
Alan Dappen, MD, founder, Doctokr Family Medicine, 360 Maple Avenue West, Suite D & E, Vienna, VA 22180, 703/938-4604;alan@doctokr.com.
Devon M. Herrick, PhD, senior fellow, National Center for Policy Analysis, 12770 Coit Road, Suite 800, Dallas, TX, 972/308-6470; devon.herrick@ncpa.org.
Joseph C. Kvedar, MD, director, Center for Connected Health, Partners HealthCare System, Inc., 25 New Chardon Street, Suite 400D, Boston, MA 02114, 888/456-5003; www.connected-health.org.
William McDonald, MD, director, Fuqua Center for Late-Life Depression, Emory University, 1841 Clifton Road NE, 4th Floor, Atlanta, GA 30329, 404/728-6302; wmcdona@emory.edu.