Telemedicine’s Potential for Medical Practices
Unlike the crew of Star Trek’s Voyager, we are not quite at the point where we can access a virtual holographic doctor on-demand (although there’s probably an office in Amazon’s skunk works hashing out a plan to turn Alexa in a licensed medical provider); nevertheless, there has been tremendous growth in the telemedicine area that may assist in improving care quality, reducing costs, and providing for an enhanced patient experience.
Telemedicine itself is a complex and varied field – there are technologies such as e-visits which are encounters between a provider and a patient, remote patient monitoring, store-and-forward or asynchronous telemedicine which is an encounter that doesn’t take place in real-time but involves the review of electronic documentation followed by a recommendation for follow-up care.
The multitude of different means for care delivery creates the opportunity to customize solutions to meet a patients’ needs. In addition to meeting the patient’s needs, there is potential for telemedicine in all its variants to improve a provider’s satisfaction with their vocation – especially as providers must now live both in a fee-for-service and fee-for-value world.
As providers look at more fully transitioning to a value-based payment paradigm and begin examining different network models – be it joining a health system as a contracted or employed provider, forming a supergroup, affiliating with a multi-specialty group, or joining a looser group of connected providers in a physician-led clinically integrated network or independent practice association (IPA) – telemedicine provides an avenue to better profit from such a transition and to improve the patient’s care experience at the same time.
When most people think of telemedicine, whether they know it or not, they are imagining e-visits. Simply put, e-visits – which are sometimes referred to as televisits – are usually audiovisual encounters that occur in real-time between a provider and patient that are both at separate locations.
There are a lot of platforms out there for such services and, indeed, many health plans and employers have partnered with specific vendors and contract physicians to provide e-visit services. Often, e-visits are used for lower intensity urgent care visits.
Such visits can be used – when appropriate – to reduce Emergency Department utilization. Additionally, they provide patients with a way of receiving some care without having to leave their home and at an affordable cost.
If one is uninsured or has a high-deductible to cost for an e-visit is often around $45-55. There are also specialties providing these services. For example, telepsychiatry has grown and is continuing to grow and other specialties such as rheumatology have been experimenting with ways to leverage telemedicine to address their specialty’s shortage.
Medical practices, specifically, can use e-visits in a few unique ways. If the practice is, for example, a surgical group where there are numerous uncompensated encounters post-op, if it is medically responsible, it may be more efficient for both the provider and the patient to receive some or all the post-op appointments via e-visits.
Such virtual visits can also be used by specialist providers to monitor new or changed medication regimens.
Both uses can allow a provider to more quickly see patients and, possibly, save a patient from having to drive or have a caregiver drive them into a practice that may -especially in rural areas – be a significant distance from their home and involve missing work.
Such a process will save the front desk staff check-in time and save the patient waiting room time; moreover, the provider will be able to see more patients since the logistics of having patients check-in and meeting with a medical assistant or nurse is removed.
Primary care practices can also benefit from e-visits.
Providers have had success with using telemedicine for routine follow-up visits such as those for depression or ADHD medications. Some have also used them for hypertension follow-up to assess how a patient uses their home blood pressure cuff.
Visits that might lead to a loss of revenue because the patient is diverted to an urgent care after hours can be captured by the primary care practice which might provide uncompensated on-call care prior to diverting to an urgent care.
If a practice has a relatively high cancellation rate, e-visits can be used to augment a practice’s income as well. Pediatric practices, likewise, can increase patient satisfaction an encourage a stronger continuity of care by providing telemedicine.
For example, pediatric groups could provider e-visits early in the morning – the provider can even be at home – to assess children for parents who are concerned that they may be too sick for school.
Also, as with adult primary care, there already exists significant uncompensated care or care that is diverted to Emergency Rooms or Urgent Cares that can be converted back into income for the pediatric practice.
Remote Patient Monitoring
Remote monitoring is a completely different area of telemedicine that has had significant potential and, already, great results.
Remote monitoring or telemonitoring involves using technology such as tablets and specialized versions of blood pressure cuffs, spO2 monitors, glucometers, thermometers, and scales.
Typically, using Bluetooth, the devices are connected to the tablet and the patient’s data is the relayed from the tablet to a monitoring tool or application used by physicians, nurses, or care managers.
Reminders from the care providers can be sent to the tablet, and the patient can report their medication adherence. If metrics deviate from expected norms, care providers can intervene earlier in the process and, hopefully, keep the patient in their home rather than have it exacerbate and lead to additional complications and hospital/ER utilization.
While, initially, the patient may seem inconvenienced by having to use these devices and interact with the tablet, once the habit is formed, the patient’s day-to-day life will be more convenient as they will likely experience fewer flare ups of their chronic condition, and they will, hopefully, spend less time in the hospital or at a doctor’s office.
For providers, as they are being pushed – willingly or not – into value-based arrangements or even population-based payments, additional tools are needed to manage the cost and increase the patient satisfaction for populations with costly and life-limiting disease such as CHF of COPD.
In elderly populations, cost and utilization linked to these two diseases is often significant. Remote patient monitoring, if implemented well, can provide higher quality care and lower costs as shown here for CHF and here for COPD although, to be fair, some studies have found little to no benefit, so it appears that there will still be a debate on the use of the technology.
Providers, especially those in value-based arrangements such as one of the Medicare ACO models (notably the NextGen ACO or the traditional Medicare Shared Savings Plan) can work with their partners to see where, for their population, remote patient monitoring can provide a benefit.
Unlike e-visits which can be implemented more-or-less population wide, remote patient monitoring will likely need to occur in a much more targeted manner to be effective.
Store-and-Forward or asynchronous telemedicine is probably the most technologically straightforward; however, it is also the one least discussed.
It lacks the flashiness of real-time e-visits or the technological sophistication of remote patient monitoring.
The process for store-and-forward involves sending data – usually text, pictures, and x-ray/radiology images – to a provider for their review.
One of a few things will then occur.
1.) The receiving provider will furnish a recommended course of treatment to the patient if the transmission occurred directly from the consumer.
2.) If it was another provider that submitted the information, the receiving provider will amend or concur with the treatment plan or diagnostic thinking of the submitting provider or
3.) The receiving provider will state that the complexity is such that a visit is required.
Studies have found that with some specialties, store-and-forward technology has led to a decrease in wait times and eliminated the need to see specialists in person; thus, freeing up visits for those who have a medical need that cannot be resolved remotely.
While there are certainly challenges around its use – notably, it is hardly ever paid for by health plans, providers that are responsible for the entirety of a patient’s healthcare cost and utilization can, in a responsible way, reduce both under the right circumstances.
Specialties such as dermatology, ophthalmology, and infectious disease are some of the most straightforward to implement via store-and-forward.
An additional benefit is that store-and-forward telemedicine strengthens the patient’s relationship with their primary care provider by keeping patient within their practice.
Should I take the Leap?
Deciding to take the take the leap and implement one or more variants of telemedicine in a practice is a big decision to make.
There are costs incurred, training that must be undertaken, and there is likely also the concern that patients won’t respond well to it.
These are all valid and good concerns for a practice to have; their business is to provide high quality, efficiently delivered care to patients, and if it isn’t done to a certain degree of satisfactions, patients are apt to look elsewhere for their care.
The best advice is to look at the practice’s strategic goals for the next few years to see what telemedicine modality will make the most sense. Are you in primary care practice looking to fully embrace PCMH?
Perhaps then extending hours through e-visits might be a good test case. A dermatology practice may look at store-and-forward.
A cardiology practice that is part of an ACO may look at partnering with the ACO on a remote monitoring initiative.
As with any project – and especially an IT project – there will be hurdles and frustrations; nevertheless, telemedicine has thus shown promise to increase efficiency and lower some costs in healthcare, and its consideration ought to be part of any practice’s strategic planning discussions.