Potential and Hurdles in Telehealth

The American Telemedicine Association (ATA) conference took place this week in Austin. It has generated a ton of telemed and virtual care news this week. I didn’t attend, but it’s great to read about all the successful implementations and new ventures in telemed.

When I think about telemedicine — which I now equate to virtual care — I’m not only talking about video. I’m also talking about voice-only and asynchronous communications. That’s really, really broad. We all (patients, providers, payers, vendors, caregivers) should be paying close attention to telemedicine because 1) virtual care is a big part of the future of healthcare and 2) we should understand some of the stupid things that are prohibiting its adoption and scale (not all the reasons are stupid).

I could go on and on, repeating what everybody has written and said about the virtues of telemedicine. While I think those generic reasons like convenience, cost, accessibility, and continuous care are relevant, there’s another reason why I’m 100 percent certain that telemedicine works and can be done with technology today. The reason is my family and many of our friends receive most of our care virtually.

Let me step back a bit. At HIMSS, I gave talk for a blog sponsor and told a real-world story about my use of mobile-based virtual care. I crazily decided to drive to HIMSS this year. The drive was 15 hours. We wanted to stretch the trip into a family vacation to New Orleans and Lafayette. I did the drive over two days with my kids because my wife was at her annual clinical conference in Florida. The plan, which miraculously worked out, was for her to fly to meet us the day we arrived in New Orleans.

Back to the drive. My son has psoriasis and it flares from time to time. It was flaring on the trip to HIMSS and I couldn’t remember which of the many steroids I was supposed to use — my wife is a dermatologist, so we have more types of steroids than you can imagine. I sent my wife a picture from my phone over MMS. She got it on her phone. She asked me where I was and where I thought I’d be stopping next. She looked up a pharmacy and called in a prescription because she wanted me to use something that I’d forgotten to bring.

And that was it. It was an all-mobile clinical consult, assessment, and treatment. It occurred over state lines. I realize this is a unique use case. I’m simply trying to show that technology isn’t the problem, and providers can and do feel comfortable treating remotely in certain situations if they don’t have a fear of malpractice.

Beyond that specific story, as I was seeing all the news from Austin this week, I was thinking about how we normally get care for anything, and how our friends and family tend to get care. It’s all virtual. We almost never go to a doctor except for procedures or well visits for our kids. Most of our friends and family do the same thing. Some examples:

  • My daughter had recurrent parotitis of childhood (I say “had” because thankfully it seems to have stopped.) We would e-mail or text our peds ENT pictures of her swollen cheeks along with some basic info about flare-ups and he’d usually just call in prescriptions for us.
  • I have high blood pressure. I send my blood pressure readings to a PCP friend every year or so when I need a refill or adjustment of meds. Come to think of it, I don’t even have a PCP and haven’t since leaving Kaiser.
  • My wife had some strange papules on her tongue this week, so she took a picture on her phone (her friend actually took the picture) and sent it to an oral surgeon who sent her back links to PubMed.
  • My wife gets e-mails or texts weekly from family in Florida about rashes and different skin lesions.
  • Our kids had some strange symptoms, so we e-mailed our pediatrician and he assured us it was nothing and to hold tight. It resolved.

We do all of this because we’re very busy and it is convenient (and I guess because we don’t mind making our friends and colleagues work without getting paid for it.) I think our friends are willing to trust us to follow their instructions and seek appropriate follow-up if needed. No one seems to care about issues with practicing over state lines, reimbursement, liability, or workflow (since we’re willing to inconvenience our friends at any time of day or night).

Stepping back, how can doctors receive almost all medical care virtually? It’s not really different than getting free legal advice from a lawyer or free tech support from a tech-savvy family member. Specifically in healthcare, the reasons above represent the core of what is holding back virtual care.

Trusting patients. What patients do you trust as historians? What patients do you trust to follow recommendations and follow-up in-person when needed? That’s a really hard question. We want engaged patients. We want educated patients. We want to know our patients better through things like patient center medical homes. But a lot of the growth we see in virtual care is fragmented and is delivered outside the regular care settings and relationships, so it’s not done by providers with existing relationships to patients. That seems to go against solving the trust issues. Funny, you can see how all of my thinking ties back to integrating virtual care into existing care relationships.

Medical licensing. Have you ever researched setting up a virtual care service? If so, you’ve probably come up against the maze of nonsense that is the rules of the state medical boards. States vary a ton when it comes to providing care across state lines and providing care without a physical exam. What are the reasons providers need a license in each state where they deliver care? Is there any progress being made to fix these issues?

This broken state-based system has created the need for the American Wells and Teladocs of the world. Do you want to setup a national virtual care service? Just tap one of these as a clinical partner and forget about finding docs in all 50 states. It’s what CampusMD is doing by utilizing the provider network of Health Nation.

Liability. I think this is resolvable as long as providers have an avenue to escalate care to in-person care. I actually think the additional documentation you get with virtual care might potentially help with liability.

Reimbursement. As much as we cite reimbursement issues, I’ve come to believe this is the easiest problem to fix. Payers are already starting to pay for virtual services and this will only increase in time. With more evidence of efficacy and cost savings, things I think are inevitable, reimbursement rules will change.

Workflow. I remember talking to Joseph Kvedar about this at an event at Robert Wood Johnson last year. He believes, and I agree now, that workflow and reimbursement go together. Once you solve the reimbursement issues, workflow issues will be fixed. It’s not that simple and it’s not overnight, but one will follow the other.

Going back to the ATA. From where I’m sitting — which was not at the ATA this week — it seems like we’re making huge progress in expanding virtual care, but we have some big hurdles to overcome. If you were at the ATA, I’d love to hear first hand impressions.

Travis Good is an MD/MBA involved with health IT startups. More about me.

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    Travis, This is very interesting, The big issue is moving Gvt to 21st century.

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