It’s 2 a.m. You wake up to discover your 3-year-old daughter has a high fever. What do you do?
Today, your options are limited. You can call the pediatrician only to reach the answering service, which instructs you to dial 911 in case of an emergency. You can drive 20 minutes to the emergency department where you and your daughter could wait several hours. Or you can endure a sleepless night until you can reach a doctor the next morning.
But what if a pediatrician could come to your house and advise you what to do? It could happen today. But it wouldn’t be a traditional house call.
Existing technologies could transform health care delivery
If you’ve ever used Skype to talk face-to-face with a loved one across the country, you understand how technology can eliminate distance and time.
As a parent, how much would you pay for the ability to reach your doctor instantly? How would you feel if such a service reduced – rather than increased – what you’re paying now for your health care? It could happen.
Video creates the potential for doctors to achieve economies of scale. Meaning, a small number of physicians can provide high-quality medical care to a large number of patients – and for much less than providing that same care in their offices. For many patients, this convenience would be “priceless.”
Imagine: Instead of having to leave work so a doctor can look at a rash, a patient would be able to send a digital photo to a dermatologist who could immediately diagnose the cause and send an electronic prescription to the nearest pharmacy. Direct Dermatology, a California-based telemedicine company, claims 42 percent of Americans live in areas that are underserved by dermatologists. This underserved population would certainly embrace this option today. And once they do, wouldn’t all patients want the same convenience, even in geographies with an adequate physician supply?
What about when a man’s back pain flares up during a trip abroad? He could go to the local emergency room and hope there is a translator who speaks English. Or he could obtain advice from his physician back home through a video consultation. A writer for the Harvard Business Review called these “virtual visits“ a top 10 innovation that will transform medicine. However, the author points out many challenges still must be overcome before such visits with transform health care.
California-based Direct Dermatology claims the average wait time for a dermatologist ranges from 1 to 4 months. The telemedicine company promises consultations with U.S. board-certified dermatologists 24/7. (Photo courtesy of CrunchBase)
Medical technology can do more than just provide convenience. It also supports higher quality.
For example, the typical patient in an ICU is monitored continuously but is seen by the responsible physicians only once or twice each day. Imagine if a team of centrally located specialists could support this care and follow the patient’s progress hourly through vital-signs monitoring, the patient’s electronic medical record (EMR) and video technology. Today, there are expensive ICU robots that can assist with this function. However, with the increasing quality of cameras and the ease of transmitting video through computers and mobile devices, all ICU beds could have individual, inexpensive systems installed to help patients achieve a more rapid recovery.
The same combination of approaches could be used to provide immediate consultation for patients in the ER. For example, a small number of neurologists could evaluate patients in dozens of ERs whenever they’re presented with symptoms of a stroke. Compare this approach to waiting for the local neurologist to drive from his home or medical office. With technology, life-saving care with better quality outcomes at a lower cost is within reach.
When I talk with CEOs about their own care, they say they would be willing to pay more for these high-quality, convenient services than they do for the medical care they receive today. They just don’t believe it’s possible. That perception would change rapidly if executives knew such services were available at a reasonable cost – both to them and their employees. In fact, it would disrupt the entire health care world.
Why these technologies don’t yet apply to health care
In the past, video connections were unreliable, phones weren’t “smart” and EMR use was limited to just a few organizations. But all of that has changed. While doctors would need to be licensed in all of the states in which they provide “virtual care,” that’s not what’s holding up progress.
What’s stifling these medical innovations is the reimbursement system. If you are paid to see patients in your office, then that is what you do – even if virtual care could be provided twice as conveniently at half the price.
What the future might look like
Overcoming technological and regulatory issues is challenging but doable.
Translating potential into practice will require three shifts in health care: First, payment to doctors and hospitals has to be prepaid to reward increased efficiency. Second, physicians need to work together within and across specialties to aggregate the volume required to achieve economies of scale. Finally, doctors need to agree on how high-quality medical care should be provided for particular medical problems. This way, patients can receive the same level of excellence seven days a week, regardless of which physician is providing the video consultation at the time.
In last week’s article, I noted that some of the least cost-sensitive patients (the ones with the best health insurance who, in their day-to-day lives, expect the convenience that technology affords) will likely be the ones who first demand this virtual concierge service. But once this process starts – and once people recognize that the cost to provide this service is less than the current model – it has the potential to produce industrywide disruption.
Once mass adoption begins, the increasing volume will lower costs further and accelerate the process of adoption.
The 2 a.m. house call may be available before we know it.
Medical peripherals can combine with a smartphone to create the function of an ultrasound machine, an EKG reader, or an otoscope, to name just a few diagnostic devices. But without buying anything extra, nearly every consumer mobile device has a camera of some sort built-in. That means that when it comes to dermatology, most patients have, right in their pockets, the tools to gather much of the data their doctor needs to treat them.
Teledermatology was a major topic at the American Telemedicine Association conference in Austin, Texas, in particular the “store and forward” kind, which is teledermatology where patients take pictures and send them to their dermatologist, who sends a treatment plan back — rather than conducting the examination in realtime. Just as the country is experiencing a dermatologist shortage, sufficiently high quality cameras are becoming widespread enough to support remote skin care.
At ATA, a number of direct-to-consumer teledermatology providers spoke about their different approaches to teledermatology. Mark Seraly represented DermatologistOnCall, an online platform that connects patients to dermatologists, David J. Wong spoke on behalf of Direct Dermatology, an online dermatology practice, and Ryan Hambley talked about startup YoDerm which hones in on diagnosis, treatment and prescription for acne specifically. Jeff Benobio, a Kaiser Permanente dermatologist, rounded out the panel, but as an integrated healthcare system Kaiser Permanente’s stood out as the only one who wasn’t thinking in terms of D2C.
“Dermatology is all about what it looks like,” said Seraly, noting that most of a dermatologist’s early training is making diagnoses from photographs. “Every dermatologist, I am confident, when they leave their training they are already naturally trained teledermatologists.”
The presenters agreed that patients’ cameras are good diagnostic tools.
“We’ve been surprised, we’ve been amazed that patients send good, high-quality photos. Patients know that if it looks bad to them, it’s not going to look any better to me, as a dermatologist,” said Wong. He added that there are limits to teledermatology, and that they will send patients to in-person specialists for certain procedures like a full body skin check, but that’s a minority of cases.
With a shortage of dermatologists nationwide that’s projected to worsen, teledermatology allows existing doctors to see more patients.
“Access is a huge problem,” said Wong. “Delayed diagnosis in melanoma is something we see all the time, because they can’t get in to see us. We have a great opportunity to really define the ways and best practices to provide this care.”
Services like Wong’s Direct Dermatology give patients detailed instructions to photograph their skin complaints. The doctor can study the securely forwarded photograph before visiting with the patient remotely. Depending on what state they’re based in, teledermatologists can prescribe most medications (Hambley said the only acne medications his dermatologists don’t prescribe are isotretinoin and birth control). Visits actually last longer than many in-person dermatology check-ups, and they produce a record future complaints can be compared against — something that doesn’t always happen in the clinic.
One problem with online dermatology is that it represents a change to how people think of consuming healthcare. Seraly, Wong, and Hambleys’ services are entirely online, and they rely on patients thinking to look online for their dermatology care in the first place.
“One of the big issues for us is educating the market,” Hambley said. “There arent very many people out there searching the internet for these telemedicine services. For services like YoDerm, that’s definitely a big barrier.” YoDerm charges patients $59 per visit and doesn’t accept any insurance. Accepting insurance can be a tricky proposition for teledermatologists — according to Dr. Marc Goldyne, a UCSF Medical Center dermatologist who also spoke at the conference, store and forward is only explicitly covered by insurance in seven states.
Anna Orlowski, a lawyer who spoke on another panel at ATA, said that so far there have been no reported cases of a malpractice lawsuit related to teledermatology specifically, and the liability for a teledermatologist is likely low, since the law considers dermatology to be a low-risk specialty. Nonetheless, YoDerm provides malpractice insurance as part of its compensation of independently contracted dermatologists.
Benabio of Kaiser Permanente represents an alternate model for teledermatology, one tied to a more comprehensive health system. Benabio shared how “store and forward” telemedicine works in context at Kaiser Permanente.
“So [a primary care doctor] has a patient who comes into his office with rashes,” he said. “He tries all the regular stuff, he’s getting nowhere. So he takes a picture, sends it to me, I can look at it, say ‘Duh, it’s pityriasis rosea,’ you knew that. The value proposition is: I just took a regular primary care doctor and made him into a ‘Super Doc’.”
But Benabio thinks startups like Direct Dermatology, DermatologistOnCall, and YoDerm have a big role to play in keeping patients with easily treatable skin conditions out of the larger healthcare system in the first place, and reducing the burden on dermatologists in the system.
“One of the biggest challenges is for healthcare to get the hell out of the way and let these entrepreneurs solve this,” he said.
Telemedicine is an idea that has been talked up for decades, but it looks as if it’s finally coming into its own.
Thursday’s news that iRobot’s medical robot, which would let doctors talk to and monitor patients remotely, stoked interest across the web. But ‘robodocs’ are just one way telemedicine could keep healthcare costs down, improve care and increase access to patients in remote communities.
The American Telemedicine Association (ATA) estimates that 10 million Americans directly benefited from some sort of telemedicine service in the past year, with clinical applications, like those for radiology and emergency room services leading the pack. A report this month projected that telehealth would grow 53 percent in 2013 and six-fold by 2017.
Aside from the rise of sensors, expanded broadband access and the ubiquity of connected and mobile devices among patients and doctors, several health-specific trends are making remote care more of a reality. More patients are coming online, meaning that fewer doctors will be needed to serve more patients; payment models are shifting from fee-for-service to managed care approaches that emphasize patient outcomes; and hospitals are under more pressure to keep re-admission rates down. Remote monitoring and communication technology could play a critical role in addressing each of those issues.
Some telehealth innovations, like the iRobot that lets doctors visit a patient’s bedside via an electronic avatar and 15-inch screen, seem like the stuff of science fiction. San Francisco-based Scanadu is developing handheld tools that have been likened to the StarTrek “Tricorder.” A recent product lets you check your temperature, blood oxygen levels, pulse and other vitals by holding the device close to your body. Then it sends the information to your smartphone, where it can be sent on to your doctor. To encourage more innovation in sensor-based mobile technology, the X Prize Foundation even developed the Qualcomm Tricorder X Prize competition (in which Scanadu is a participant). A “Magic Carpet” developed by researchers at GE and Intel, uses sensors in home carpets to monitor seniors’ activity and then predict and detect falls.
Other telemedicine services aren’t as sexy but could still go a long way in getting improved care to people who need it. Corporate giants like GE, Intel and Cisco have, for years, provided videoconferencing and remote communication platforms to hospitals to enable, people in rural communities, seniors and the chronically ill to interact with doctors from home. But new applications and companies are bringing telehealth into more specialized areas and the everyday.
Startups like Direct Dermatology and Iagnosis help patients seek skincare help from doctors via technology. iCouch and Breakthrough provide online counseling services, and Ringadoc targets consumers with a network of doctors available 24/7 to give advice and even write prescriptions from phone consultations. This week, the iExaminer App from Welch Allyn received FDA clearance to make iPhone-enabled remote eye exams more feasible. And a company called CampusMD this month announced a nationwide telehealth program to provide students with round-the-clock, remote access to doctors.
Still, despite increasing innovation, legacy barriers still stand in telemedicine’s way – for example, licensing issues related to interstate telemedicine and Medicare and Medicaid reimbursements that are limited. And then there’s the expense and time commitment needed to implement new platforms and train providers, as well as the skeptics who raise confidentiality and ethical questions (and not without good reason).
But more insurers, like Aetna and Cigna, and big employers, including GE and Delta, are backing the trend — earlier this month, WellPoint, one of the country’s biggest insurance companies, said it would support telehealth services for all employer and individual plans. And the ATA reports that other groups, including state legislator, patient groups and medical societies, are making new inroads in at least pushing for more favorable policies.
Four or five years ago, there were virtually no telehealth services targeting consumers. But Jonathan Linkous, ATA’s CEO said 400,000 consumers used an online service in the past year to receive remote health care.
“When a consumer realizes how much more benefit they’re going to be able to get [from a telehealth service], they’re going to wonder why [their doctor] doesn’t support it and go to another doctor,” he said. “We’re right at the tip of that now.”
Skin problems account for about 25% of all visits to primary care physicians. For many of these visits, the patient and physician would benefit from a consultation with a dermatologist, but the current shortage and geographic maldistribution of dermatologists often prevents or delays these necessary consultations.
To address this problem Direct Dermatology offers a web-based, HIPAA-compliant technology platform that enables same-day and next-day consultations by US board-certified dermatologists. Using a store-and-forward telemedicine model, referring providers receive assistance with the diagnosis and management of skin diseases. Today Direct Dermatology contracts with more than 40 clinical sites and performs more than 300 consults per month, many of which are for rural and community clinic providers and patients.
In the video below, Dr. David Eibling, medical director at Health Plan of San Joaquin, discusses the need for telehealth solutions such as Direct Dermatology.
To use the service, clinics need only a digital camera, computer, and Internet connection. Patients can use Direct Dermatology services by visiting their primary care provider or by uploading images to the Direct Dermatology platform. In both cases patients receive a diagnosis and a prescription if needed.
In November 2011, CHCF made a seed investment of $240,000 in Direct Dermatology. In December 2012, CHCF invested an additional $500,000 to help the company provide greater access to teledermatology services throughout the state.
CHCF invested in Direct Dermatology because of the company’s impact and growth performance to date, and because the foundation sees enormous potential for telehealth solutions to improve access to and quality of medical care for patients in traditionally underserved areas of California.
To learn more, visit the Direct Dermatology website through the External Link below.
Telemedicine mixes teleconferencing, document-sharing and mobile technology in order to improve healthcare quality, largely for those who lack access to care. Here are 10 ways that telemedicine implementations are changing the delivery of healthcare services.
Telemedicine uses a variety of electronic communications media, ranging from teleconferencing to image-sharing to remote patient monitoring, to provide clinical services to a patient. As the American Telemedicine Association points out, telemedicine is associated with, but not the same as, telehealth, which also refers to nonclinical services such as research, training and administration.
The use of telemedicine technology dates back to the late 1960s, when physicians ran a microwave line under Boston Harbor to connect Massachusetts General Hospital with Logan International Airport in order to examine patients at the airport clinic while avoiding Boston traffic.
Today, telemedicine is used in medical fields such as dermatology, behavioral health and cardiology as a way to provide better care to communities underserved by physicians, hospitals or both; it is also considered a way to significantly reduce the cost of treating health conditions, including hypertension, diabetes and sleep apnea, which benefit from continued monitoring of a patient’s condition.
Here’s a look at 10 ways that telemedicine technology is changing the delivery of healthcare—along with a note of caution for organizations that are taking advantage of relaxed regulations to expand their use of telemedicine services.
1. Diagnose and Treat Strokes Faster
The sooner a stroke victim receives treatment, the better the chance of survival. In many cases, treatment hinges on the capability to identify key symptoms and administer medicine known as tissue plasminogen activator (tPA) within three to five hours of suffering a stroke. Unfortunately, emergency room physicians don’t always have the expertise to make these decisions, and small or rural hospitals don’t always have a neurologist on call.
Enter telestroke services, which have been shown to improve stroke treatment in several ways:
Patients treated in hospitals that were part of a telestroke network in Georgia received tPA approximately 20 minutes faster than patients in hospitals outside the network.
Telestroke helped facilities in remote parts of Alberta reduce ER transfers to the University Hospital in Edmonton by up to 92 percent. Such ambulance or helicopter transports are costly, time-consuming and sometimes dangerous.
Videoconferencing led to more accurate diagnoses and treatments than telephone conversations in the Imperial Valley of California and in Boston.
Neurologists and radiologists in Arizona were able to use smartphone image-sharing applications that proved to be as accurate as desktop-based picture archiving and communication systems 92 percent of the time.
2. Provide ICU Physicians, Nurses a Second Set of Eyes
Telemedicine technology is increasingly making its way into the intensive care unit. Rather than replace the physical ICU outright, the tele-ICU, as it’s called, provides a “second set of eyes” for nurses or physicians who must treat several patients at once amid alarms and other distractions that may make them miss a medication dose, sudden change in blood pressure or other important signal.
Wall-mounted cameras let tele-ICU staff assess patients and communicate with bedside physicians. (Image courtesy of Critical Care Nurse .)
Staff of the tele-ICU have the same access to patient data such as vital signs, lab results and physician’s notes as on-site critical care staff, and they use one- or two-way cameras to perform bedside assessments or confer with physicians. Because the remote physicians don’t face the same distractions as those in the hospital, they can more closely monitor a patient’s progress and suggest new treatment or drug options. As one patient at a Phoenix hospital told the Arizona Republic in 2011, his remote physician provided better care than hospital staff despite being based in Israel.
3. Let Patients Undergo Rehab at Home
When patients are discharged from the ER or the ICU, the care process is often just beginning. This is especially true for patients who are recovering from a stroke or suffering from other neurological disease such as multiple sclerosis, Parkinson’s or dementia. In many cases, these patients find it difficult to travel to a health care facility regardless of whether they are in an urban or rural setting.
The use of telemedicine technology in rehabilitation addresses these issues in several ways— conducting cognitive or psychiatric assessment, leading group therapy sessions (hosted at a clinic or senior citizens’ center, for example), providing patients with online resources and remotely monitoring a patients’ pedometer readings to ensure that an exercise regimen is up to par.
Telemedicine can also assist in recovering from lung disease, as it lets patients participate in online education sessions and attend supervised physical rehabilitation at a nearby satellite location.
4. Help Patients Reduce Their Risk of Heart Disease
Cardiovascular diseases are the leading cause of death around the world. Drug treatments or social/lifestyle changes can help prevent many cases. However, patients must work closely with their doctors to quit smoking, lose weight, change their diet or begin an exercise program, and making frequent office visits can be difficult for both parties. Here, telemedicine technology may be the answer—for example, researchers in Philadelphia found that patients were nearly twice as likely to participate in cardiovascular disease management programs if they could send/receive information to/from a healthcare provider online (as opposed to traditional paper- or office-based information sharing.)
5. Encourage Diabetics to Embrace Healthier Behavior
In the United States, healthcare costs related to diabetes—multiple inpatient and outpatient visits, for example—are close to $100 billion a year. Research from the eHealth Initiative suggests that telemedicine improves the health of diabetics, especially older adults.
To succeed, two things need to happen. First, a physician’s interaction with a patient must boost self-efficacy, or the belief that the patient can, in fact, engage in activities that improve glycemic control.
Second, treatment plans must set goals for successfully changing patient behavior—which is becoming increasingly easier thanks to mobile health technology that helps patients count calories, keep an eye on vital signs, log workouts and monitor medication doses and schedules—and nurses and dieticians must check in with patients regularly to monitor their progress.
This diagram shows how information would flow in a home-based system for managing a patient with inflammatory bowel syndrome. (Image courtesy of InTech .)
In the former case, something as simple as routine three-minute phone calls with a health care provider will encourage patients to take blood pressure medication, refill prescriptions and remember their appointments—all of which reduces the number of inpatient and ER visits they must make.
In the latter case, patients can describe symptoms to physicians over email, perform a number of self-tests and participate in step-by-step educational programs related to their particular disease. In both cases, mobile health technology eases chronic disease management by literally putting care management applications and devices in patients’ hands.
7. Improve Oral Health With Store-and-Forward Telemedicine
Teledentistry typically makes use of store-and-forward telemedicine, which lets a doctor (or dentist) acquire medical images or other relevant data, assess it and send it to another physician for review. (Of the main types of telemedicine technology, store-and-forward is the least interactive, as it does not require two or more parties, nor does it involve a physical examination.)
The main benefit of telemedicine in dentistry, then, is sharing records among dentists and dental specialists to determine if a certain procedure is necessary and, if so, how soon it must take place. Specialists can also help dentists spot problem areas and suggest preventive measures to a patient so that costly, complicated procedures can be avoided. As with other uses of telemedicine, this collaboration helps patients in rural or other underserved communities who don’t otherwise have access to medical specialists.
8. Link Patients, General Practitioners to Dermatologists
Dermatology is a prime candidate for the use of store-and-forward telemedicine technology. The information that is shared is often an image—and applications that help people share images are not in short supply. The images tend not to contain any of the personal health information (PHI) or personal identifiable information (PII) that raises HIPAA security and privacy red flags.
Teledermatology is being used in two ways:
Direct Dermatology, a company founded by a Stanford dermatologist, has introduced technology that lets patients take a picture of a skin problem and send that to Direct Dermatology along with their medical history; within two days, the patient will receive a report back from the company, along with any necessary prescriptions. This use of teledermatology targets rural patients without easy access to a medical lab or clinic and builds on the findings of a 2010 study suggesting that online dermatology visits are as effective as in-person appointments.
Dermatologists in the Netherlands, meanwhile, have been using telemedicine technology to confer with general practitioners since 2005. In this time, studies have shown that daily consultations prevent unnecessary patient referrals in 74 percent of cases and reduce the cost of care by 18 percent.
9. Provide Mental Health Consultations to Children
Traumatic events can have a dramatic effect on children, especially if they already suffer from mental health disorders such as depression, anxiety or hyperactivity. That’s why the Robert Wood John Foundation and the University of Texas Medical Branch established a Telemedicine for School-Based Mental Health program in Galveston, where the aftermath of hurricanes Katrina and Rita in 2005 and Ike in 2008 left many children in emotional distress.
A report prepared at the conclusion of the six-year project showed that the teleconferencing counseling sessions were the first consultations with a mental health professional for many students. (Sixty percent of participants did not have health insurance.) Overall, nearly 70 percent of parents and guardians said the sessions helped their children perform better in school, and the telemedicine program as a whole helped Galveston County fill a need to treat students with severe mental health challenges, the report says.
10. Improve Rural Healthcare Around the World
As stated, telemedicine technology offers much promise for patients in the rural United States. Its biggest impact, though, may be felt in Africa and other parts of the developing world where healthcare services are equal parts scarce and inaccessible. Remote consultations can help address relatively minor conditions before they become major—treating cataracts before they cause blindness, for example, or ensuring that new mothers receive the educational resources they need to raise a child and take care of their own medical needs.
However, there remains a tremendous need for equipment such as computers, printers and scanners at hospitals in rural areas that rely heavily on subsistence farming and lack business and community development. That said, mobile health applications, including a bar code scanner that can determine if a drug is counterfeit, may be the answer, as people in the developing world are more likely to own cell phones than PCs.
The use of telemedicine technology is not without its risks. Both patients and physicians must have appropriate hardware and software security in place to ensure the safe transmission of PHI and PII such as a Social Security Numbers and detailed medical records. Your organization’s telemedicine risk management strategies, then, need to address numerous issues.
First off is the federal government’s telemedicine conditions for participation. This outlines what facilities must do to provide and receive telemedicine services, especially as it pertains to the credentials of participating physicians, the privileges they have and the licenses they (and other caregivers) need. Remember that different states have different licensing rules.
In addition, your organization should draft a detailed set of telemedicine guidelines that lists all partner facilities, addresses which types of healthcare providers (nurses, radiology techs and physician assistants, to name three) can participate and clearly states how the information gathered during telemedicine treatment will enter a patient’s electronic health record.
Taking such steps will help protect your facility from telemedicine fraud, which can target loopholes in prescriptions, insurance reimbursements and the anti-kickback statute.
Rising healthcare costs and the demand for improved care are driving many facilities to explore the benefits of telemedicine. While technological barriers and skeptics remain, many studies have shown that telemedicine can complement, and in some cases improve, the overall patient experience. Expect more even use cases for telemedicine technology to emerge.
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