January 24, 2019

Virtual Exam Room

How telemedicine is changing medicine — and the obstacles the technology still faces

By Kasey Fuqua

 

Healthcare in the United States is facing a slew of challenges: from increasing costs to a shortage of health professionals and lack of access to care. While there’s no silver bullet for these issues, telemedicine services show promise as cost-effective care. Even as healthcare systems grapple with drawbacks of telemedicine technology, the use of these services continues to grow—and in Hampton Roads patients may be seeing the benefits.

Increased Access to Specialty Care
Telemedicine services began as consultation services like teleneurology and teleradiology. These services, largely offered at remote facilities, give patients quicker access to more physicians. Riverside Health System has been using telemedicine consultations for about 15 years at their hospitals and skilled nursing facilities in Tappahannock, the Eastern Shore and Gloucester.

Liz Martin

“We’re providing a specialist to a site that needs that specialty coverage,” says Liz Martin, Senior Vice President for Care Management and Telemedicine at Riverside. 

At Chesapeake Regional Medical Center, teleneurology allows for quick assessment of acute stroke patients in the emergency department. 

Lewis Siegel, MD

“It’s a reality that it has become more of a challenge to have physician consultants available for patients at all times,” says Lewis Siegel, MD, Chief of Department of Emergency Medicine and Medical Director of the Emergency Department at Chesapeake Regional. “Telemedicine gives us the ability to have the patients seen in a timely manner and keeps open the options for rapid treatment of stroke.”

Faster consults can help emergency departments meet their door-to-needle goals for stroke care, though it’s not an ideal solution for physician shortages in rural areas.

“I don’t think you can replace having physicians be there in person,” says Dr. Siegel, “but in situations where you don’t have that option, it allows a lot of input and more expeditious care.”

Meeting the Demand for Mental Health Services

Telemedicine is also giving more patients greater access to mental health services. Nearly all health systems in Hampton Roads also offer some telepsychiatry programs, whether in emergency departments or at skilled nursing facilities. These programs cut down on physician travel time by allowing them to offer care at many locations from one office. With less travel time, they can provide more patient care.

To meet the growing demand for pediatric mental health services, Children’s Hospital of The King’s Daughters offered tele-mental health as its first telemedicine service line. The program has grown quickly thanks to positive patient response.

Ody Granados

“In mental health telemedicine sessions, there is a self-reported increased level of comfort and sharing,” says Ody Granados, Director of Telemedicine Services at CHKD. “Telemedicine provides a medium where patients feel more able to divulge things they may not talk about in a face-to-face encounter.”

CHKD has established telemedicine “endpoints” at multiple practices, consisting of a private room with seating for patients and parents, a large screen, and a camera. Through a secure connection, patients can receive mental health services and assessments.

“If a pediatrician determines during a well-child check that a child needs a mental health assessment, they can offer the possibility of that appointment right then via telemedicine,” says  Granados “It really provides convenience for the family and it’s proved to be a very popular service.”

Faster, More Convenient Primary Care
Virtual visits or e-visits with primary care providers are also saving patients time. Multiple hospital systems in Hampton Roads offer the visits for minor conditions like rashes, acne, or urinary tract infections.

Since January 2018, Sentara has been rolling out telemedicine primary care visits. Unlike services like MDLive or Amwell, patients meet with actual Sentara medical group physicians via their smartphone, tablet or laptop. 

The visits are integrated into the EPIC electronic medical record, making it easier for physicians to offer this service. Any physician from their medical group with a webcam can see patients via telemedicine. Even documentation is easier and faster thanks to smart phrases that can be used in the moment.

Mark Haggerty, DO

Mark Haggerty, DO, medical director for Sentara Virtual Care Services and primary care provider in Virginia Beach, says telemedicine could help primary care physicians manage well controlled chronic conditions that don’t require in person care as frequently. Telemedicine may also help patients who have difficulty traveling to the office due to their health or transportation needs.  

“With virtual care at my disposal, I have another form of access, which can alleviate primary care visit congestion thus allowing me to take care of more acute needs” says Dr. Haggerty. “While the face-to-face time with patients may not change, I am taking up less of their overall time and reducing rooming time and documentation required by my staff.”

Education for Patients and Providers
Patient care isn’t the only possible use for telemedicine services. Riverside uses their telemedicine infrastructure as much as possible, including as a cost-effective method to provide patient and provider education.

“We use our technology to collaborate across the system,” says Martin. “We’ve used it for meetings, clinical collaborations, and to educate future healthcare workers on the uses of telemedicine.”

For patients, they are now providing education both before and after procedures. For example, patients no longer need to come in for a visit before a colonoscopy. Instead, they can learn about prep through a video in the patient portal and a nurse visit via telemedicine.

For patients who are remotely monitored, telemedicine provides an opportunity for real-time education. These patients use special scales, blood pressure cuffs, or other devices to send health information to their providers. Nurses can quickly spot problems and call the patient to teach them what to do.

“Remote monitoring helps us manage the patient’s condition and teach them how to self-manage,” says Martin. “The goal is that patients wouldn’t be on monitoring forever, because we can help them understand how to ask for support and what to do when they can see their vital signs going out of range.”

Reimbursement Still a Roadblock
Though providers see the value in telemedicine care, poor reimbursement continues to be an obstacle for the growth of telehealth services. Currently, Medicare does not reimburse for acute care services unless they are offered to remote areas. Some private companies will cover telemedicine services, but it varies from payor to payor.

Virginia has been a more progressive state when it comes to telehealth reimbursement. Medicaid does reimburse for certain services, such as remote monitoring of patients with diabetes, live video psychiatric care or live video speech therapy. Consultation services, such as teleradiology, are also covered.

Dr. Haggerty says that Centers for Medicare and Medicaid Services (CMS) are making changes to reimbursements that favor telemedicine. For instance, in 2019, prolonged preventive health services will be covered. They are also lifting some location limitations so that certain services, like teleneurology, can be covered anywhere, not just in rural areas.

“If that trend continues, telemedicine will make a lot more sense from a revenue and overhead perspective,” says Dr. Haggerty. “But right now, we still want our patient population to be well served. If this program advantages them, we still want to take care of them whether or not this will be covered.”

CHKD faces unique challenges in the rollout of its telemedicine programs. While Medicare reimburses for adult care, Medicaid often does not reimburse for the same pediatric services. 

Granados says he expects Virginia Department of Medical Assistance Services to update telemedicine reimbursement regulations within the next two years and is hopeful that pediatric services will receive better coverage.

Riverside Health System has found alternative ways of making telemedicine more financially sound. As part of the Bay Rivers Telehealth Alliance, the health system has received grants to provide services to populations on the Northern Neck, Middle Peninsula and Eastern Shore. Services include mental health care at nursing homes or other facilities and school-based health programs.

Martin says the data Riverside collects through its telemedicine services may also play a role in improving reimbursement. As evidence reveals that telemedicine education and remote monitoring help patients avoid ER visits and hospitalization, insurance companies may be more likely to see the benefit of covering such services.

Physician Reluctance Slows Growth
Though reimbursement for telemedicine services is only likely to expand, many physicians have real concerns about how technology affects patient care. Telemedicine may prevent physicians and patients from developing a strong relationship. Lack of information about a patient, like heart rate or bowel sounds, may lead to incorrect diagnoses.

“My concern with telemedicine in general is that there may be a tendency to potentially overtreat with medications, especially antibiotics,” says Dr. Siegel. 

Still, in its current forms, most telemedicine manages to avoid these possible problems, and physician support is growing. Martin says that many physicians who experience telemedicine through specialty coverage are more open to other telemedicine services. As more physicians are exposed to the technology and its efficiency, the adoption rate is becoming quicker.

As technology becomes easier to use, physicians are also more likely to buy in to telemedicine. Integration into the EMR is just one step toward making telemedicine part of routine care.

At Sentara, Dr. Haggerty and his team are working to facilitate training for interested practices and help them establish an appropriate workflow for telemedicine services.

“While there are a long list of things that can’t be done by virtual care, there’s also a long list of things that can,” Dr. Haggerty says. “Providers may want to use this technology differently to optimize their practice and satisfy their patients. People are going to use this in a variety of interesting and different ways.”

Patient Demand Climbing
Whatever the benefits or downfalls of telemedicine, it’s clear that patient demand is growing. Dr. Haggerty believes that the Millennial population may feel more comfortable with telemedicine care because of their reliance on technology. They may also be more comfortable selecting a physician who offers telemedicine.

“I think the patient as the customer will be driving a lot of growth in telemedicine,” Dr. Haggerty says. “Already we are seeing patients’ expectations turn towards easier, less hassle care. It’s possible that patients may not go to doctors who don’t provide at least some telemedicine services.” 

Granados agrees, citing a study by Deloitte that all other things being equal, patients would rather have a doctor who offers telemedicine services than one who didn’t. Parents of pediatric patients (today’s Millennials) were also more open to telemedicine services than older patients. 

“This is not going to decrease in use, only going to increase in use,” says Granados. “The writing is on the wall. This is what our patients want.”

As demand grows, reimbursement changes, and more physicians come on board, telemedicine is likely to be widespread across the country. 

 “It’s going to improve access,” says Martin. “It will reduce costs and improve outcomes of care. As we see those things happen, telemedicine will become just another exam room.”