March 2, 2009

Telemedicine: Miles Don’t Matter
By Lindsey Getz
For The Record
Vol. 21 No. 5 P. 20

From remote monitoring to simple phone consultations, connected health is becoming more ingrained in the healthcare landscape.

Telemedicine (or connected health) is transforming the traditional view of medicine. It’s essentially the delivery of some form of healthcare (information or services) via telecommunication—whether by telephone or via the Internet. This can include myriad components, including video conferencing, where a patient and a doctor can see and talk to one another despite not being physically present in the same location. Or it may mean the use of remote medical devices that track and transmit health data from patient to physician. Some patients even use telephone services to communicate with their doctor instead of scheduling an in-person visit.

The primary benefit of any connected health program is that patients don’t have to leave their home—even those with a chronic illness can be monitored from their desired location. Also, various forms of telemedicine can help patients determine whether a trip to the doctor or emergency department (ED) is necessary. This is especially beneficial considering it’s been found that patients often overuse their local EDs. In fact, in any given year, more than one half of ED visits are for nonemergencies. Typically, patients know it’s a nonemergency but feel there is no better option.

In 2006, a survey of California hospitals found that nearly one half of ED patients thought their medical concern could have been resolved by their regular physician but claimed they were unable to obtain timely access to care. In telemedicine programs, doctors can receive real-time medical data from patients, who in turn can receive immediate consultations that may allow them to forgo a trip to the ED. The technology also benefits patients who live in rural areas or those who don’t have easy access to transportation.

While people are accustomed to communicating about their finances or legal situations over the phone or via the Internet, healthcare is still primarily practiced in face-to-face meetings. Few doctors communicate with patients over the telephone and even less communicate via e-mail. But telemedicine could begin to change those realities.

“Using various monitoring and messaging systems, we can unlock all kinds of value because we give patients enough information that they become, in a sense, their own care providers,” says Joseph Kvedar, MD, director of the Center for Connected Health, a division of Partners HealthCare that applies consumer-ready technologies to enhance the patient-physician relationship and deliver quality care where and when it’s needed. “It’s like checking yourself in at the airport. It makes you wonder why you needed a person to do that for you in the past. The airline is counting on passengers to do some work for them. And in the same way, we as healthcare providers can now count on patients, using remote monitoring programs, to do some work for us. It lowers the cost of healthcare while delivering quality care to the patient.”

In essence, telemedicine gives patients more control over their health, a turn of events that most consumers approve of, according to Kvedar. “When we started this work, there were a number of people who speculated this would drive a wedge between patient and doctor or that the patient would feel cheated,” he says. “But, in fact, we get very strong patient endorsements almost universally. The common theme is that patients all say they feel more connected—like the program is a lifeline to them. It’s the reassurance that someone is looking at their vital signs and can intervene in real time if the patient is experiencing any changes to their health status—before a crisis arises.”

Remote Monitoring
Remote monitoring technologies convey real-time physiological information on a patient’s condition over the Internet or via phone lines. “We look at remote monitoring—incorporated into devices like a pacemaker, for instance—as a means to generate information that a physician can use to evaluate and care for the patient without having the patient come in for a physical face-to-face meeting,” says Madeleine Smith, senior vice president of payment and policy at AdvaMed, the Advanced Medical Technology Association. A recent AdvaMed report chronicled how these technologies can play a vital role in managing costly and debilitating chronic diseases. The findings were based on a review of various published studies.

“Remote monitoring is increasingly recognized as a valuable tool for enhancing care quality in chronic disease management,” says Max E. Stachura, MD, director of the Center for Telehealth at the Medical College of Georgia and the report’s lead researcher. “For patients, these technologies mean fewer office and emergency room visits, fewer and reduced duration of hospitalizations, less travel time and expense, and increased access—especially for the elderly, the physically challenged, the homebound, and rural patients. For clinicians, they mean more informed decision making, enhanced patient compliance, and more efficient case management.”

The report involves patients with chronic illnesses such as diabetes and heart and lung problems. One finding showed that when patients with severe respiratory illness requiring long-term oxygen therapy were remotely monitored, hospital admissions decreased by 50%, acute clinical problems decreased 55%, and hospitalization costs fell 17%. Also, a study of 400 diabetes patients found that those monitored by in-home glucose meters and video conferencing showed significantly greater improvement in reducing average blood sugar levels than those who did not receive such monitoring.

The Center for Connected Health is implementing several connected health programs for chronic disease patients at Partners HealthCare-affiliated hospitals in Boston, according to Kvedar. For example, one of the center’s initiatives is the Connected Cardiac Care program, which is being offered to heart failure patients at risk for frequent hospitalizations. Data from a pilot study found that Connected Cardiac Care can reduce rehospitalizations by improving patients’ understanding of their condition and providing ongoing nursing support and a review of vital signs, such as heart rate and blood pressure, while the patient is at home.

“This program allows patients to self-monitor and transmit their vital signs and symptoms to a telemonitoring nurse who helps patients understand the link between lifestyle choices and their disease, and, importantly, coordinates care with their physician,” says Kvedar.

Telephone Consultations
Phone-based medical services give patients immediate access to physicians over the telephone. Instead of making an appointment and taking the trip to see the doctor in person, patients can receive a telephone consultation. “Patients love it,” says Michael Gorton, founder and CEO of TelaDoc Medical Services, a popular phone-based medical program. “We offer a guarantee that the doctor will call them back within three hours or their consultation is free. It’s a lot faster than having to wait for a face-to-face visit. And we’ve gotten better and better. In 2007, our average callback time was around 45 minutes. In 2008, that average time was under 25 minutes. A patient needs to talk to a doctor, and they call back within 25 minutes.”

“We all know how long it takes to wait in a doctor’s waiting room,” adds former Wisconsin Gov Tommy Thompson, who serves on TelaDoc’s board of advisors. “Instead, you can stay home and call your doctor, and you’ll hear back almost right away. It’s adding a service to our healthcare system that is badly needed.”

Another benefit is that TelaDoc travels with you, says Thompson, who previously served as the secretary of Health and Human Services. “You can have a doctor any place, anywhere, and at any time,” he says. “That’s a luxury that most people don’t have. It fills a big void in the healthcare system, especially for the traveling public. Americans are so busy today. We’re always traveling and often getting sick, but we don’t know where to go to the doctor in a new city. But with TelaDoc, your doctor goes with you, and that’s something that’s very comforting.”

Gorton says that TelaDoc is not designed to replace that in-person consultation. “This isn’t designed to do everything,” he says. “It’s only designed to handle minor issues. But the doctor can listen to you, look at your medical record, and determine pretty quickly what your issue may be and whether you need to come in to see a doctor or not. It prevents you from making that visit when it’s not necessary.”

Patients have reported high satisfaction levels for the program. In patient survey data analyzed by Mercer, the researchers found that most employment-age TelaDoc patients (80%) selected the highest rating for the service overall. This is somewhat lower than the proportions of patients selecting the highest ratings in academic studies of satisfaction with telephysician services (90% to 98%) but higher than the proportion of patients who selected the highest satisfaction ratings for face-to-face primary care (70% to 78%).

TelaDoc’s standard charge for a consultation is $35, of which $25 is typically paid by the payer. It ends up being less expensive for the patient, says Gorton. “And doctors make more, too,” he adds. “We tried to find something in healthcare that wasn’t working as efficiently as it could and added efficiency to it. A doctor in a normal practice setting is a business man, and he has a lot of bills to pay. But when using TelaDoc, he only pays himself. By getting rid of those extra bills, the doctor can make more and charge the patient less.”

Obstacles to Overcome
According to most experts, the biggest deterrent to advancing the further use of telemedicine is payment. Smith says that while much effort has been focused on seeking reimbursement for physicians using remote-monitoring technologies, there is still progress to be made. “Right now, Medicare only pays physicians for patient evaluations that are done during face-to-face visits,” she says. “Physicians receiving the patient’s data electronically or through the phone would not be paid to examine it.”

 “Physician reimbursement has been the key barrier preventing remote monitoring technology from being more widespread,” adds Julie Cohen, vice president of government affairs at AdvaMed. “One of the benefits of this technology is that it sends real-time information on a patient and will help physicians determine whether a patient needs to go to the emergency room, the physician office, or perhaps neither, which can prevent wasted time and resources in a hospital or physician’s office. But it’s difficult for doctors to get behind the technology and add more work to their day when they’re not getting paid.”

Malpractice liability and other legal concerns, as well as security and privacy issues, have also come into play as potential obstacles to the growth of telemedicine. Plus, there are issues surrounding requirements in some states that physicians must secure a license to practice telemedicine with a state resident.

Nevertheless, telemedicine continues to make inroads as industry leaders search for solutions that will cut costs and improve care. “Connected health is a powerful tool for managing chronic illnesses in ways that providers might not typically recognize,” says Kvedar. “We’re so used to thinking things like electronic medical records make us more efficient and smarter, but this technology makes the patient smarter and draws them into their own care. That’s a powerful thing.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.