Convenient Care and Telemedicine
Table of Contents
How Telemedicine Can Improve Care
Information technology has the potential for restructuring medical care in ways that can solve many of these problems, often while reducing costs and improving quality of care. The practice of telemedicine is relatively new, and still developing rapidly. Already, numerous studies point to the benefits of using telecommunications and other information technologies in innovative ways to care for patients.
Solution: Nontraditional physician practices. Many medical conditions and testing procedures do not require the physical presence of a physician or the time and expense of an office visit. To meet this demand, entrepreneurs are creating nontraditional medical services in which clinical care is available in more convenient locations, by telephone or through virtual offices on the Internet. They are staffed by physicians who will order tests, initiate therapies or treatments and prescribe drugs. For instance, many medical providers are beginning to integrate convenient Web-based services into their practices. Solantic is a small Florida-based chain of free-standing, walk-in urgent care clinics. 26 Patients can register online and fill out their medical history prior to arriving at the clinic. They can also sign up online for X-rays or lab tests without a doctor's office visit. 27 These clinics are open extended hours and on weekends. Competition from these new clinics may lead traditional physician practices to offer more convenient weekend and extended hours. 28
“Some physicians are available after hours and by telephone or e-mail.”
Some innovative physicians are becoming more flexible, providing patients with the services they need in a timely manner. These may include after hours office visits or even house calls. Or they might involve phone calls or e-mail, as shown by the following case studies.
Case Study: Flexible Physician Practices . Docto k r Family Medicine is the Virginia medical practice of Dr. Alan Dappen, who practices medicine mostly by telephone and e-mail contact. Patients can schedule an appointment or e-mail the doctor, all from the Docto k r.com Web site. In fact, Dr. Dappen's waiting room is a Web page.
Patients can also make appointments to be examined by Dr. Dappen in his office, and though he will even make house calls for some patients, he encourages most patients to consult with him by e-mail or telephone.
Dr. Dappen bases his consultation fees on the amount of time required. Charges are billed in five-minute increments and range from $25.50 for in-office visits to $17 for phone consultations with patients who have set up prepaid accounts. A simple call to renew a prescription or ask questions generally costs less than $20. The office will help with insurance billing and also takes PayPal. Patient records are kept electronically.
Case Study: Low-cost “concierge medicine” in Dallas. Concierge medicine is normally associated with personalized services for the wealthy. As noted above, these services can be expensive. However, in Collin County, Texas, a Dallas suburb, physician Nelson Simmons offers a version of that service for less than $500 a year.
About 70 small business owners pay $40 per employee per month for Simmons' plan. In return, employees get same-day primary care services and steep discounts on diagnostic tests and specialist care. Enrollees must pay out-of-pocket for specialist care, surgeries and diagnostic tests. But Simmons negotiates the rates, which are typically much lower than what others pay. For example, a tonsillectomy for a child costs less than half of the normal fee ($2,100 versus $4,800) and an MRI scan can be less than one-fourth of the standard charge ($350 versus $1,600). 29
Solution: Pay doctors for e-mail and telephone consultations. E-mail is a convenient and efficient way to consult with a physician. One recent study found that an electronic messaging system similar to e-mail reduced physician office visits and associated laboratory costs. When health plan members were able to e-mail their doctor, office visits and laboratory costs were approximately $22 less per member per year compared to those who lacked this service. 30 Kaiser Permanente also found that an electronic messaging system reduced office visits. 31
“Using e-mail reduces office visits.”
Greater reliance on e-mail and phone consultations would reduce physicians' need for office space, including exam rooms and waiting areas. One study found that it cost a dermatology practice $274 per hour to provide consultations by telephone to patients on Nantucket Island, compared to costs of $346 an hour for an office-based dermatology practice in Boston. 32 Patients share in the benefits from the elimination of office visits through lower fees, less waiting time and lower transportation costs.
A patient's medical condition may not require the physical presence of a physician or the time and expense of an office visit. A recent study found most patients willing to pay about $25 for the convenience of a “televisit” over an in-office visit. 33 To meet this demand, entrepreneurs are creating medical services staffed by physicians who will order tests, initiate therapies or treatments and prescribe drugs.
E-mail consultations . In 2000, First Health Group became one of the first major health insurers to reimburse physicians for medical consultations over the Internet. First Health agreed to pay $25 for each e-mail exchange between patients and doctors to encourage physicians to interact more frequently with chronically ill enrollees. The program's goal was to reduce inpatient hospitalizations that often result when symptoms are ignored. 34
Other insurers are experimenting with online consultations. In the Northeast, Dartmouth-Hitchcock Medical Center receives $30 for each online consultation from Anthem Blue Cross, Cigna and Harvard Pilgrim. BlueCross and BlueShield is starting such services in a number of states, paying from $24 to $30 for each e-mail consultation. Kaiser Permanente has also experimented with secure messaging between plan members and physicians.
Physicians who exchange e-mail with their patients find it often replaces rambling telephone conversations, since e-mail patients tend to spend more time composing their thoughts and creating focused messages. 35 Kaiser Permanente found that allowing enrollees to e-mail questions to their doctor through a secure messaging system called KP HealthConnect was associated with a 7 percent to 10 percent reduction in primary care visits. 36
“TelaDoc provides physician care by telephone at any time nationwide.”
Case Study: Convenient care by TelaDoc . TelaDoc Medical Services, located in Dallas, is a phone-based medical consultation service that works with physicians and health plans across the country. For instance, a traveling business executive who develops a rash or comes down with a sore throat can obtain less expensive and time-consuming treatment by making one phone call, rather than visiting an emergency room or expensive urgent care center. 37 Individual enrollees pay $35 for each consultation, which are available around the clock (compared to an emergency room visit costing an average of $383). 38 Eighty-eight percent of those who used TelaDoc reported they saved time and money compared to a traditional office visit or a trip to the emergency room.
When a member signs up for the service, his or her medical records are digitized and placed online so a consulting physician can access them from anywhere in the country. The member needs only a telephone to use the service.
For instance, when a member places a call to TelaDoc's call center to request a consultation, the system notifies several participating physicians, licensed in the state where the call originates, that a patient is waiting. The first physician who returns the call receives a $25 consultation fee, while TelaDoc retains $10. TelaDoc guarantees a call will be returned within three hours or the consultation is free. Customer surveys have found that most calls are returned within 30 to 40 minutes. 39 TelaDoc results have been positive:
- A physician returns a patient's phone call within 30 minutes (or less) 50 percent of the time.
- Seventy-five percent of the calls are returned within one hour.
- Less than 11 percent of consultation requests required patients to wait more than two hours for a return call. 40
This unique service has proven to be quite popular — TelaDoc enrolled its one-millionth member in the fall of 2007. Member experiences and satisfaction with the service are closely monitored through surveys. Participants are offered a financial incentive ($3 off the cost of the next consultation) to fill out a survey. Customer satisfaction is high [see the Appendix]: 41
- Nearly 93 percent of those who have used the service report they would use it again.
- Just over 90 percent would recommend it to a friend or family member.
- Members reported nearly identical satisfaction with their consulting physician.
- More than 90 percent of respondents reported they would rate the overall TelaDoc experience as either “excellent” or “good.” 42
Patients who see their primary care physician for an in-office visit often feel that they've been rushed or that their doctor doesn't listen to them. 43 But 95 percent of TelaDoc callers report they felt the physician listened to them and understood their problem. 44
The TelaDoc service is designed for patients who cannot access their primary care physician in a timely manner, or when those patients (or their doctors) are out of town. It is not intended to replace primary care providers. The most common conditions that patients call about are infections (respiratory and urinary tract), allergies, pain (skeletal, muscle and arthritic), minor joint trauma (sprains and strains) and gastroenteritis.
“TelaDoc physicians have access to patients' electronic medical records.”
Physician qualifications are also high — all but one of TelaDoc's participating physicians are U.S. board-certified in a medical specialty. Further, unlike most physician practices, TelaDoc stores patient records electronically. The physician can access the patient's medical history online, e-mail a prescription to a pharmacy and add information to the patient's electronic medical record. The use of these technologies improves care coordination and prevents adverse drug interactions.
Solution: Patient-directed health care to increase access in rural areas . The field of telemedicine began more than 40 years ago as an attempt to deliver clinical services to geographically isolated patients. Of particular interest was the need to provide people living in remote rural locations with access specialists. 45 One study conducted in a remote area of Australia found that providing remote medical consultations by satellite increased aborigines' access to medical care, improved health status and reduced costs. As a result of telemedicine, patients and specialists were flown in (and out) for consultations less often. There also were fewer emergency evacuations for medical reasons. 46
If Medicare and Medicaid allowed beneficiaries to control some of the dollars spent on their health care, entrepreneurial providers would offer services that are not now available. These might include retail medical clinics staffed by nurse practitioners, or consultations by phone with medical specialists.
“Physician or nurse call lines provide advice.”
Solution: Physician advisory services. Many health insurance policies (and employer health plans) include access to medical call lines to assist enrollees with information about simple health needs. Because patients often find it difficult to contact their regular physician by telephone after office hours, the firm Doctor On Call has taken the concept of a nurse call line one step farther. It provides individual subscribers (and health plan members) immediate telephone access to physicians. 47 Doctor On Call's licensed physicians answer questions about diseases and conditions and provide medical advice. However, its physicians cannot initiate treatments, order tests or prescribe medications. In other words, these physicians do not practice medicine over the phone. Rather, discussions are for informational purposes only and are not considered “medical treatments.”
With few options, people searching for peace of mind or reassurance (such as mothers of sick children) often turn to emergency rooms. Doctor on Call believes that in many cases merely speaking to a doctor by phone avoids an unnecessary ER visit.
Sometimes patients may avoid an unnecessary ER visit merely by speaking with a nurse on the phone. McKesson's ASK-A-NURSE® program works with health care organizations to offer health information services to employer groups, specific target populations or members of a community. The service can provide either limited or 24 hour-per-day access to nurses. 48 Another service, FoneMed, provides health plans with call centers staffed by nurses who use software-based medical protocols to answer patient questions and perform triage — that is, direct patients to the proper provider. 49
Nurse call lines also can provide impartial health information and wellness coaching in addition to chronic disease management. For instance, the firm CareNet hires registered nurses, dieticians and other health professionals as health coaches to help health plan enrollees make lifestyle improvements (such as exercise and diet) and set and achieve specific health goals, such as losing weight, lowering cholesterol, or controlling diabetes, hypertension and so forth. CareNet also offers care coordination, remote monitoring and a one-on-one relationship with a personal nurse to health plan enrollees who have chronic conditions. 50
Solution: Internet-based medical information. Patients no longer have to rely on their doctor for answers to every question. Medical information has become available outside doctors' offices through thousands of health-related Web sites on the Internet. The vast amount of knowledge available on the Internet has led to dramatic changes in how people obtain information about health and medicine. 51 Frequently, instead of visiting a physician's office for answers to their medical questions, people can search the Internet (keeping in mind that not every medical Web site is reliable). Estimates vary, but by most accounts there are approximately 20,000 health-related Web sites. 52 According to a recent poll, more than 80 percent of Americans with Internet access — about 113 million adults — have searched online for health information. 53
Solution: Electronic medical records. The use of electronic medical records (EMRs) — each containing an individual patient's medical history, test results and prescription information — has the potential to improve quality and reduce costs. 54
Only a small percentage of hospitals and physicians currently utilize EMRs, but a growing number of health care providers and independent services offer patients the ability to store and manage their own EMRs securely online, so that they are accessible to the individual patient and any physician the patient chooses.
“Electronic medical records controlled by patients and accessible to physicians can reduce medical errors.”
Because most patients see a number of physicians over time, remotely accessible medical histories will allow better coordination of care among different providers. In fact, EMRs are essential for a rapidly expanding area of telemedicine — the remote monitoring of patients with chronic diseases (see discussion below). 55 In fact, telemedicine may become the preferred way for doctors to monitor the infirm and manage patients' chronic conditions. Furthermore, remote access to EMRs by physicians makes telephone or e-mail consultations with patients more useful — and the ability of multiple health care providers to view and add to a case history facilitates collaboration among primary care physicians, nurses and specialists.
EMRs can improve quality by reducing errors. Policymakers have made replacing handwritten prescriptions with electronic prescriptions a national health care goal. Handwritten prescriptions are a major source of medical errors — causing nearly 200,000 adverse drug events in hospitals each year. 56
“Remote monitoring can improve care for chronically ill patients.”
Microsoft recently rolled out an online personal health record management service, called HealthVault , designed to make it easy for individuals to store personal health information securely on the Internet, to control access to their information by health care providers and to ensure the accuracy of data. A person's health history is password-protected; any attempt to access the records is recorded; any additions, deletions or edits are tracked. Microsoft expects technology companies to design products that work with the service. Take blood glucose monitors, for example. These meters could connect wirelessly to a patient's computer (using BlueTooth technology) and transfer data to a permanent health record like HealthVault.
Solution : Remote monitoring for chronic disease management. Traditional disease management programs for patients with chronic conditions generally involve multiple providers responsible for separate aspects of health care. A team of medical providers working together can improve outcomes for patients with chronic conditions by aggressively managing all aspects of medical treatment. 57 Unfortunately, this type of close supervision is labor-intensive and costly. Instead, disease management programs are beginning to use telemedicine. 58
Research has shown that telemedicine can improve adherence to protocols and increase convenience for patients with chronic ailments. 59 For example, for patients with chronic obstructive pulmonary disease (COPD), researchers determined that telemedicine lowered readmission rates. Patients were trained in the use of an inhaler for drug therapy (to improve lung function) and the use of a spirometer to monitor airflow to and from their lungs. Of those monitored from home, only 49 percent were subsequently readmitted to a hospital compared to 67 percent of COPD patients who were not monitored remotely. 60 [See Figure VIII.] A similar study of remote monitoring of congestive heart failure patients found that over six months the group monitored from home required only half as many rehospitalizations as the control group. 61
Telemedicine has also been found to benefit patients with asthma. Patients in a study of remote monitoring experienced fewer asthma symptoms and improved measures of peak airflow into their lungs. An added benefit was improved asthma self-management skills and better quality of life. 62 Likewise, a study of diabetes care found that patients monitored electronically had better controlled blood glucose than those in conventional care. 63 The effect was especially pronounced among diabetes patients with poorly controlled blood glucose levels prior to the study.
“Some medical tasks can be outsourced to qualified physicians in other countries.”
The high cost of disease management may also be reduced by outsourcing some tasks to medical personnel in developing countries. American health care providers could collaborate with qualified low-cost providers overseas who could perform labor-intensive tasks that do not require the physical presence of a physician. 64 In fact, American hospitals are increasingly using radiologists in India and other countries to read X-rays after hours. 65 NightHawk Radiology Services contracts with American-board-certified physicians living in Australia for overnight interpretations of X-rays and scans. This reduces the turnaround time for diagnoses, since these radiologists are available when it is night in the United States. 66 Indian radiologists working from Bangalore, India, can interpret ultrasounds, CT scans and MRIs like an American radiologist working in the United States. 67 Increasingly, information technology will make distance irrelevant and medical personnel will be able to provide medical services regardless of their location.