I’ve practiced medicine for thirty years, in a tremendous number of settings, but my experience the past few months as a front-line telemedicine primary care provider has taught me many things about the state of healthcare that has not been obvious to me from the vantage points I’ve held in the traditional healthcare ecosystem. I am just now learning how good technology is an excellent care access solution for patients needing help with basic medical problems who are having a very difficult time accessing health care through its traditional, clinic-based front doors.
The video telemedical consult is really a technology-enabled form of the old-fashioned house call. Often, I perceive things about the patient’s environment from the video that is not as apparent to me with patients who visit me at my office, where patients often are putting forth their best efforts. In the more intimate setting of their own home, patients do not dress up for the visit and often the entire family seems involved in the consult, babies crying in the background, parents or spouses whispering things for them to not forget to tell me. I see patients complaining of a sick headache, laying in their bed in their PJs looking, well, sick.
Consider the Telemedicine Jobs People are “Hired” to Do
Clay Christenson’s concept of successful disruptive innovation as improved solutions for “jobs people hire you to do” is particularly relevant to my recent experiences in telemedicine, because I am discovering just how many jobs I am being hired to do that are an improvement for many people compared to the traditional health care system. Here are seven examples.
1. Patients hire telemedicine because they cannot conveniently get access to primary care when they need it.
Telemedicine solves for all sorts of lack of access. Patients call because they cannot get off work to make an appointment with a primary care physician office Monday through Friday 8:00 am – 5:00 pm and don’t want to pay the higher urgent care co-pays they can’t afford. They call because they need a refill on a chronic medication and their primary care physician is too booked up to see them. They call because they have an acute problem and their primary care physician is too booked up to see them. They call because they live in a rural area and their primary care physician has moved/retired/left town and the closest alternative is 50 miles away. They call because they never had a primary care physician in the first place. Telemedicine consultations are available 24/7, unconstrained by geography.
2. Employers hire telemedicine to improve benefits for their employees.
By treating simple, non-complicated conditions like urinary tract infections, rashes, and upper respiratory tract infections, employees do not miss as much work but can also receive a physician’s work excuse note, when appropriate, to remain at home when suffering from influenza or acute viral gastroenteritis or other medical conditions that put the workforce at work through presenteeism (when people come to work inappropriately due to fear of missed wages or requirements for a physician excuse they cannot meet).
3. Patients hire telemedicine to provide medical education about issues they cannot or do not want to speak to their primary care physician about.
Not a week goes by that I do not get a consult from someone who wants to understand more about a diagnosis they have been given, a medication they have been prescribed, a condition they fear they have, or something they feel uncomfortable asking their personal physician about or do not want their doctor to know about. The opportunity to have a broader discussion with a patient on their new diagnosis of hypertension and why taking a blood pressure medicine is a good idea, or sensitively talking about their newly diagnosed sexually transmitted disease can serve as an additional resource for patients whose physicians have been too rushed to have these conversations, or later, often in the evenings, they have questions they forgot to ask their physician about. Many of my preconceived notions that patients would prefer to discuss sensitive personal issues with a trusted physician with whom they have had a longstanding relationship have been upended by the frequent consult requests I have received about emotionally sensitive issues for patients.
4. Patients hire telemedicine to help them quit smoking.
One of my most favorite type of consult is for smoking cessation. In my traditional primary care clinical practice, asking patients about their smoking history at every visit is a quality measure requirement for pay-for-performance payer contracts that has become another administrative requirement that seldom leads to meaningful conversation about smoking cessation. In contrast, patients calling for a prescription to help them quit smoking are at that point of motivation when there is a real opportunity to make a difference in their long-term health. These patient-initiated conversations happen when and where the patient wants them to happen and allow rapid access to smoking cessation drugs. I bet there will be data available soon supporting a higher smoking cessation rate from telemedicine-initiated prescriptions than for those that originated from traditional care settings.
5. Patients hire telemedicine to provide them access to appropriate treatment for conditions they have been able to diagnose with over-the-counter diagnostic tests, such as the newly available urinary tract infection tests.
With the advent of consumer-directed testing products on the market, many patients are uploading to their telemedicine chart pictures of positive urine dipsticks, cholesterol testing results, and other consumer-directed laboratory tests. Sometimes, such as an uncomplicated urinary tract infection, well-researched data indicates evidence-based medicine protocols can be utilized to provide care equal, if not better than office-based alternatives. Research done decades ago at Kaiser Permanente, for instance, demonstrated the safety and effectiveness of a three-day course of sulfamethoxazole / trimethoprim antibiotics via telephone protocol for uncomplicated acute cystitis in women. Yet many primary care providers still insist patients come in for an office visit with urine dipstick testing prior to receiving an antibiotic. With the new availability of over-the-counter urine dipstick testing, patients can now use telemedicine to skip the hassle of the office visit, the waiting room, and the co-pay.
6. Employers hire telemedicine to reduce the cost of healthcare benefits.
One patient told me her employer benefit plan reduces her emergency room co-pay if she calls the telemedicine company prior to going to the emergency room. Based upon the symptoms she described, going to the emergency room was appropriate in her case and I told her to proceed there immediately. But often, that’s not the case, and telemedicine consultations can significantly reduce emergency room visits for non-urgent conditions.
The electronic health record I use for telemedicine videos and phone calls is the most-user friendly one I’ve ever used and is particularly helpful in patients typing in their chief complaint in their own words prior to the visit. Family history, medications, prior consults, and allergies are all part of the electronic record, and evidence-based clinical guidelines are easily accessible in real-time for the most common conditions. Patient education material is electronically provided for many conditions, along with the ability to provide electronic specific instructions to the patient, a work excuse if needed, or, for some patients, referrals for mental health, dermatology, and, in some cases, specialist consultations, if appropriate. The usability of the electronic health record is vastly more efficient than any I’ve ever experienced. The iPad touchscreen-enabled electronic health record provides benefits information, allergy, images, family history, drugs, chronic conditions, and prior visits on one well-designed screen, with easy documentation, clinical guidelines, and patient education information transmitted almost instantly.
7. Telemedicine offers an honest glimpse into social barriers.
Sadly, my experience with telemedicine has provided me with direct experience to the social determinants of health. The amount of morbid obesity in the patient reported height and weight data seems much higher than what I experience in my private practice. The lack of access to dental health is much greater than I ever imagined. Nearly every day I have consults from patients with toothaches, cracked teeth, or gum swelling who have not seen a dentist in years due to lack of ability to pay for a visit or due to no appointment availability for weeks out. Many patients tell me directly they are calling because they need a refill on a chronic medication and cannot afford the co-pay required for an office visit. My experience is consistent with findings Oliver Wyman published earlier this year:
- At least 1 in 3 Americans didn’t see the dentist last year.
- An estimated 42 percent of Americans don’t have dental insurance.
- Health plan members diagnosed with dental and gum conditions are 25 percent more likely to suffer from heart disease, twice as likely to visit the emergency room or hospital and spend on average two times more annually on overall healthcare costs.
The imperative for health plans to integrate dental services into their benefits structure in newly designed models of care is corroborated by my telemedicine experience, which offers glimpses to a more effective digitally accessible service delivery.
Addressing Telemedicine Critics
The concern some critics have regarding telemedicine as inappropriately over-prescribing antibiotics is not unfounded. There is enormous pressure from patients to get an antibiotics prescription from a telemedicine consult for what are more likely than not viral upper respiratory infections. The evaluation and assessment process remains a crucial component of the experience. However, the telemedicine company I work for provides evidence-based clinical guidelines, monthly feedback on antibiotic prescribing rates for urinary tract infections compared to peers and guideline goals. The McIsaac criteria can be used to guide therapy for acute pharyngitis quite effectively. Because the experience of telemedicine is new for most patients, there are still not established norms for patients with respect to the experience. There is often a vending-machine mentality that has to be called out and corrected. They are not calling a telemedicine consults to “order a medicine”, but to get a consult with a physician for a medical concern.
The telemedicine company has monthly patient satisfaction survey feedback and quality reports. My telemedicine antibiotic prescribing rate for all upper respiratory infections is around 15 percent, far lower than what is known to be primary care office-based prescribing rates in national studies. In my private practice as part of a large integrated health system, I have never been provided in data regarding my antibiotic prescribing rate, not to mention monthly reports, and have no idea what my prescribing rate is.
As the telemedicine industry continues to mature, there will be much opportunity to provide increasingly sophisticated solutions to the health care delivery system including improvement in patient education, chronic disease management, and augmentation of primary care services as the shortage of traditional primary care continues to grow. Evidence-based protocols may allow extension of some services to include advanced practice providers into telemedicine practices. Non-facility based mental health services can provide solutions for that shortage. For patients with rare diseases, local expertise is often not available. Telemedicine, if properly designed, can provide world-class expertise irrespective of geography. Provided the underlying physician-patient relationship based upon trust, understanding the limitations of a particular technology and scope of practice constraints, and continuing to build upon evidence-based protocols and continuous quality measurement are paramount in the design of the telemedicine experience, the growth of this industry will be unstoppable.