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A Leap Forward for Virtual Health Care

Have you ever sat in a doctor’s office waiting room wishing your physician could have visited you at home? In many states, physicians can now conduct evaluations directly through your laptop, smart phone, or tablet, and patients are responding with enthusiasm.

Roy Schoenberg, MD, MPH

Roy Schoenberg, MD, MPH

However, medical boards in some states have adhered to older rules that prevent use of telemedicine. A recent development will balance their legitimate concerns about abuse of this technology with its immense benefits, enabling states to realize the promise of telehealth in possibly reducing health care costs and improving patient outcomes.

In April, the Federation of State Medical Boards (FSMB) adopted new policy guidelines for the safe practice of telemedicine. States finally have a basic roadmap for ensuring that patients are protected in this fast-changing health care delivery environment. The new guidelines provide much-needed clarity on “Do’s and Don’ts” in the use of telehealth technology when practicing medicine and frame the principles of operation that must be adhered to in order to preserve patient safety and quality of care. They offer a detailed framework needed to revise outdated rules. I expect many state medical boards to tailor the guidelines to meet their own perspectives and cultures moving forward, but as a whole, health care will take these new rules as sign of the times and modernize to embrace telehealth.

In an event such as this, it is important to take a step back and acknowledge history in the making. The unanimous ratification of these new guidelines is probably the strongest message the house of delegates of the FSMB could have sent; decisive leadership such as this is impressive and rare. Telehealth adoption will come when people gain clarity that it is a safe and valuable way to deliver care; the FSMB has done a terrific job in preparing the landscape for large-scale use of telehealth.

The fact that the FSMB did not make any changes to the definition of telehealth is not an oversight. In fact, on the contrary, it is a reflection of the great diversity in this technology. Ten years ago, telemedicine was only a construct between physicians. Today, we have telehealth with multiple end points between patients, mobile health, wearable devices, home biometrics, health care kiosks, e-visits of sorts, etc. The FSMB tried to keep definitions very high-level in order to prevent these important guidelines from becoming obsolete over time, as many other guidelines and rules have before.

There are still barriers to the widespread adoption of telehealth. State licensure of physicians limits how helpful the technology can be to spread health care services to where they are challenged. Reimbursement by Medicare and Medicaid is essentially nonexistent, mostly because of the unknown impact on future costs. Physicians are still afraid they will be sanctioned if they don’t examine a patient in-person. There are more examples like these. The good news is that these barriers are quickly eroding. Most importantly, patients – our industry’s main customer – love telehealth.

In the end, the people will prove stronger than the industry’s outdated rules, and the floodgates will open. In ten more years, the term telehealth will be gone, and this technology will simply be an integrated part of mainstream health care.

Please share your perspective in the comments section below.

Cultural Competency Key to Positive Health Outcomes

Early in my pharmacy career, a hospital social worker referred to me a deaf patient. He had a reputation for being rude and belligerent to providers. After our first encounter, I was no exception. However, after looking at health care from his perspective – slow communication, unthinking providers, long waits in the clinic – I had an idea.

Joel Zive

Joel Zive

Instead of counseling him with a pad and pencil, I counseled him in front of a computer screen. I made the font larger, and we communicated in this fashion. He was ecstatic! I learned that many deaf people communicate with a device called a Telecommunications Device for the Deaf (TDD), with which they can type responses and often learn to do so rapidly. Because I accounted for his unique point of view and modified my interactions with him accordingly, our relationship changed for the better.

For a provider, cultural competency involves understanding patients’ perceptions of their role in health care. When a provider or prescriber has that insight, significant improvements can occur in therapeutic outcomes. For example, cultural competency can aid providers in preventing drug interactions by determining which complementary and alternative medicines their patients use, as well as help improve patient adherence to prescribed therapies. This is especially important in minority communities, in which the devastating effects of diabetes, hypertension, and other diseases take a disproportionate toll.

Establishing this insight takes time that busy practitioners don’t always have. Fortunately, providers increasingly rely on capable, cost-effective partners: community health workers (CHWs). CHWs work in a variety of settings, including community-based organizations, AIDS service organizations, hospitals, and clinics. They are often of the same ethnicity as many patients and live in the neighborhood; in many cases, CHWs have already developed trusting relationships with patients and may have a better understanding of the nuances of how they expect or want to be treated. CHWs are also in a position to uncover problems that patients are unwilling to share with their physicians and other health care providers.

The positive effects of CHW involvement as provider extenders are well documented. For example, at the Gateway Community Health Center in Texas, CHWs played a valuable role in improving outcomes among people with hypertension and diabetes.

A critical area that can be enhanced by community health workers is complementary medicine. St. John’s Wort is one example of an herbal folk remedy that is sometimes used and endorsed by generations of family members for the treatment of depression, but that many patients may not report to their health care providers. This is significant because St. John’s Wort should not be taken with antiretrovirals. CHWs may be more effective than those ‘wearing white coats’ in learning about use of complementary and alternative medications and, when needed, explaining the dangers of drug interactions with sensitivity and compassion.

Research continues into the benefits of employing CHWs in pharmacies. Four pharmacy school professors at the University of Florida – Folakemi Odedina, Ph.D.; Richard Segal, Ph.D.; David Angaran, MS, FCCP, FASHP and Shannon Pressey – did a pilot project to see whether a CHW paired with a single community pharmacy could uncover medication-related problems that were missed by the pharmacist alone and improve outcomes in hypertension (view this short video for more information). In an interview with Real World Health Care, Dr. Segal said they teamed a CHW with a pharmacist to work cooperatively for 11 months to enroll 30 patients with poorly controlled hypertension (>140/90 mm Hg). The CHW was able to gather information about which patients were using complementary medicines as well as the barriers people were experiencing that affected their adherence to prescribed medicines. Together, the CHW and pharmacist developed a medication action plan that was informed by the added information the CHW was able to collect from patients. While four patients were lost to follow up, the 26 remaining patients showed a significant reduction in systolic blood pressure. The pilot program is being scaled up to involve 30 CHWs with funding from the Department of Health and the CDC. Segal concluded that clinical collaboration between pharmacists and CHWs should also be used for other disease areas.

What other ways can community health workers benefit patients in addition to increasing treatment adherence and decreasing the risk of drug interactions? Share your thoughts in the comments section.

Four Ways Data is Transforming Your Health

The increasing availability of data about health care in the U.S. is empowering patients to take charge of their care and quietly revolutionizing how patients are treated. Last month, the Centers for Medicare & Medicaid Services released data on which services were provided by over 880,000 health care providers, how many times each service was provided, and what the providers charged. Yesterday, top health and technology experts for the federal government and the Brookings Institution gathered to discuss how the growing catalogue of public health care data is leading to profound improvements in America’s health care. The event was hosted by Brookings’ Engelberg Center for Health Care Reform in collaboration with 1776 DC’s Challenge Festival.

Jamie Elizabeth Rosen

Jamie Elizabeth Rosen

Here are the top four ways that data transparency is already beginning to transform Americans’ health. The benefits are expected to grow as the data is analyzed, matched with other sources, and organized into user-friendly and accessible formats.

 

1.    Selecting the best doctor

When Farzad Mostashari learned that his mother needed an epidural steroid injection, he wanted to find out which orthopedic surgeon was the best at this specific procedure. So he searched the millions of medical claims recently released by the Centers for Medicare and Medicaid Services (CMS) to discover which providers were the most experienced in this procedure.

An interesting result emerged. “There is one provider who does more than everyone else combined,” said Mostashari, who is a Visiting Fellow at the Brookings Institution, where he is focused on payment reform and delivery system transformation. “He’s probably pretty good.”

As health care data increasingly becomes available, patients will have more information to make the most rational decisions for their health care, said Kavita Patel, a physician and fellow in the Economic Studies program and managing director for clinical transformation and delivery at the Engelberg Center.

Patel asks her patients why they choose to see her. “Nobody’s ever said: ‘I looked up your quality scores and saw that your out-of-pocket costs are less than the average provider in your area,” Patel said of her 12 years in medical practice. “This is one of the first times that everyone in this room can take out a laptop…and look at this data.”

Mostashari added that the data can be used to identify outliers. For instance, he found that while the average orthopedic surgeon performed controversial spinal fusion surgeries on 7 percent of the patients they saw, some did so on 35 percent. This knowledge empowers patients to choose providers that best align with their health care values and preferences.

 

2.    Reducing costs

The newly-released CMS data enables comparisons of the prices different providers charge for the same services. This data reveals that in some cases providers charge vastly different rates to Medicare for the same services, Mostashari said. The Wall Street Journal provides a consumer-friendly database detailing the types of procedures, number of each, and costs per procedure charged by individual health care providers.

Last year’s release of hospital charges led some hospitals that were charging higher rates to uninsured and underinsured patients than their peers to seek advice from CMS. “Some hospital associations called us and said, ‘We want to change. Help us develop new accounting practices to set prices more fairly for those who are uninsured or underinsured,’” said Jonathan Blum, Principal Deputy Administrator at CMS.

The ability to access and analyze a growing amount of data on procedures performed and their outcomes also helps patients and providers avoid low value services and make decisions about the relative risks and benefits of different procedures. Patel pointed out an ABIM Foundation initiative called Choosing Wisely that equips providers and patients with lists of procedures that should be carefully considered and discussed to ensure that care is supported by evidence, not duplicative, free from harm, and truly necessary.

 

3.    Promoting accountability

When health care providers know that their records will be publically available for scrutiny, they are incentivized to ensure that they won’t be embarrassed by what people find. This can profoundly change which procedures providers choose. For instance, one analysis revealed a wide disparity between the percentage of black versus white patients who were tested for cholesterol levels. “Simply asking providers how often they were doing [cholesterol tests], without any payment incentive,” removed this disparity, said Darshak Sanghavi, the Richard Merkin fellow and a managing director of the Engelberg Center. “This is one example of how simple transparency can improve health care and ultimately save lives.”

 

4.    Expediting spread of best practices

Jonathan Blum, Principal Deputy Administrator at CMS, has seen data transparency expedite the uptake of best practices by health care providers and public health authorities. For example, when analyzing the data on dialysis providers, CMS found that there was an uptick in blood transfusions by certain providers in specific geographic regions. “Our medical team got on the phone and called the dialysis providers and said: ‘Did you know you are doing more blood transfusions than your peers?’” The result? Those providers decreased blood transfusions, improving health outcomes for their patients. The same pattern occurred for nursing home facilities that overused antipsychotic drugs.

“I want to convince folks that you can change policy, you can change procedures, you can make things safer,” Blum said. “Data liberation can help us build [accountable care organizations], help us build better payment policies, help us reduce hospital readmissions. There is tremendous opportunity ahead for us.”

Bryan Sivak, Chief Technology Officer at the Department of Health & Human Services, added that data transparency is affording entrepreneurs from outside the health care sector – such as startups Aidin, Purple Binder, and Oscar – the potential to transform the health care system.

“We’re sitting on the edge of an incredible moment in history,” he said. “Everybody is looking at things in a different way because everybody understands that we have to do things differently.”

“Government data is a public good and a national asset,” said Claudia Williams, Senior Advisor for Health IT and Innovation for the U.S. CTO in the White House. “It’s something we have to release if we can to allow innovation and change.”

How do you make your health care decisions? Have you used any of these new tools?

Categories: General

Patient of the Month: Sharon Harris Survives Lupus and Pays It Forward

Sharon Harris remembers February of 2002. She remembers where she was, what she was wearing, and what she was feeling. Most of all, she remembers the day she was diagnosed with lupus.

SharonHarris1

Sharon Harris, lupus awareness advocate and founder of Lupus Detroit

May is Lupus Awareness Month. Lupus is a chronic inflammatory disease that occurs when the body’s immune system is unable to distinguish between foreign illnesses and the body’s own tissue and organs. Inflammation caused by lupus can affect joints, skin, kidneys, blood cells, brain, heart, lungs, and other organs. Although there is no cure for lupus, there are numerous medications that can alleviate its symptoms.

Sharon had just graduated from Florida A&M University in Tallahassee when she received her diagnosis. “I was 22 at the time, fresh out of college,” Sharon said. “You’re taught while you’re growing up to learn your manners, respect your elders, and get a good education. No one tells you about an autoimmune disease that you will have for the rest of your life.”

Nor had anyone told her what having lupus would entail. “I immediately went into battle mode,” she said. “I had graduated from college. I had traveled 1200 miles from my family to make my journalism degree happen, and I was going to fight.”

“But, as soon as I got my fight on, that’s when all the pain started.”

Sharon experienced a flare-up of symptoms. It would be an understatement to say that the rest of that winter was difficult for her. Her hair began to fall out. She suffered from constant fatigue and pain. In the month of February alone, Sharon lost thirty pounds.

After beginning treatment on several different medications, Sharon started feeling better by that summer. One Wednesday during a Bible study, Sharon was asked what she would do if it were her last day on Earth.

“I said I wanted to see the world,” Sharon said. “Because if lupus was going to take me out, then it was going come and find me in Paris on the Eiffel Tower or on a beach in the Virgin Islands.”

By chance, Northwest Airlines (now Delta) had put out an ad to recruit flight attendants. It was a dream job for Sharon. The job provided her with better insurance, and on her off days she could fly to any location on Northwest’s roster. Just as she had hoped, Sharon got a chance to see the world. Amazingly, Sharon started to find that her experience with lupus was helping her have a healthier mindset. “It really made me think of life in a whole different way, and just literally live. Just really get out there and live,” she said.

Sharon eventually moved back to Tallahassee, opening an eyelash parlor and holding down an office job. At that point, she experienced another flare-up. “In October in Tallahassee it is still 100 degrees outside, and I was wearing a wool coat,” Sharon said. “I was so sick.” Sharon packed up and returned to her hometown: Detroit, MI.

Now, too sick to work and without a job, Sharon did not have health insurance. The lupus was attacking her kidneys and the medicine that she was prescribed cost upwards of $3,000 for a month’s supply. Despite pinching pennies to afford her daughter’s medication, Sharon’s mother was willing to refinance her house to save her only child’s life.

That’s when Sharon’s luck shifted. One day, she visited a local lupus organization with the intention of buying a t-shirt, and she ended up walking out with a new job. Her new public relations position did not include benefits but being employed allowed her to purchase health insurance.

Although she had insurance, her share of the payments for her four medications was unaffordable; one of the therapies alone cost more than $1,000 per month. That’s when Sharon found out about the HealthWell Foundation from a Google Alert. HealthWell is a nationwide non-profit providing financial assistance to insured patients who are still struggling to afford the medications they need (and sponsor of this blog).

“Literally, HealthWell saved my life,” Sharon said. “I didn’t have to incur any debt, my mother didn’t have to refinance her house, and HealthWell saved the day.”

SharronHarris2

And Sharon wanted to save the day for others like her. She has become a leading activist for lupus awareness, starting her own advocacy group called Lupus Detroit, which offers lupus patients emergency grants. Sharon points out that there are two colors that are used for lupus awareness, orange and purple. She opted for orange for her organization because the color is “louder” and garners more attention. “Lupus needs all of the attention that it can get,” Sharon said.

Sharon is currently in remission and has been doing well since receiving a grant from HealthWell in 2011 that allowed her to afford her medications. “I was inspired by the work that HealthWell does to help people with their medications,” she said. “I just don’t believe that someone should have to choose between paying for their medication and feeding their children.”

And neither do we, Sharon. Keep up the excellent work.

If you are inspired to help, consider raising awareness during Lupus Awareness Month and showing your support. Here are some suggestions:

  • Make a donation to HealthWell’s SLE Fund in honor of a family member or loved one who is battling lupus.
  • Celebrate World Lupus Day on Saturday, May 10th.
  • Put on Purple on Friday, May 16th and visit The Lupus Foundation of America’s website at www.lupus.org to learn how you can show your support.
  • Find your local Lupus Foundation of America chapter to learn about activities in your area.

Has lupus touched your life? Do you have plans to show support during Lupus Awareness Month? Share your story in the comments section.

Categories: Cost-Savings

KIDS: Providing Children and Families a Voice in Medicine, Research, and Innovation

The active involvement of patients in health care choices, diseases, research, and innovation is an area of recent focus for many public and private entities (e.g., FDA’s Patient-Focused Drug Development initiative).  As an innovative method to engage children, the KIDS (Kids and Families Impacting Disease Through Science) project was launched as an advisory group of children, adolescents, and families focused on understanding, communicating about, and improving medicine, research, and innovation for children. KIDS is a unique collaboration between the American Academy of Pediatrics (AAP) Section on Advances in Therapeutics and Technology (SOATT), local AAP Chapters, children’s hospitals, local schools, and other partners.

The objectives for the KIDS project are as follows:

  • Learn, teach, and advocate for medicine, research, and innovation that improves the health and well-being of children;
  • Engage in the process through projects and consultation activities with hospitals, researchers, and other partners in the public and private sectors;
  • Provide input on research ideas, innovative solutions, unmet pediatric needs, and priorities;
  • Contribute to the design and implementation of clinical studies for children (e.g., assent, monitoring tools, schedules, etc.);
  • Serve as a critical voice for children and families in the medical, research, and innovation processes.

KIDS launched as a pilot program in Connecticut in September 2013 and will be expanding to other states in the US (e.g., Utah, New Jersey). The KIDS Connecticut Team has participated in meetings at Connecticut Children’s Medical Center (Hartford, CT) and Yale-New Haven Children’s Hospital, a Research Summit at Pfizer’s Connecticut Laboratories, and an advisory session with Mr. David Tabatsky, author of Write for Life.

In addition, the team attended the AAP’s Healthy Children Conference & Expo in Chicago in March, at which they staffed an exhibit booth highlighting their work and the importance of research and innovation for children. They also conducted survey-based research by collecting more than 300 responses with a focus on participants’ opinions of the importance of research in their lives and the role of children in research. Three KIDS Team Members delivered an invited Learning Zone presentation for conference attendees discussing the importance of research, the work of the KIDS Team, and the vision for future expansion. Finally, the KIDS interacted with numerous AAP leaders and staff members throughout the weekend. Overall, the KIDS involvement in the conference was a resounding success as each Team Member was articulate and passionate about their work and the importance of medicine and research. Feedback from attendees, exhibitors, and AAP leadership/staff was overwhelmingly positive. The Team will also be attending the Pediatric Academic Societies meeting in Vancouver in early May and will be collaborating with a similar children’s advisory group located in that city.

In addition to a KIDS expansion in the US, SOATT is working with existing young person advisory groups and other partners to develop an international network of children advisors. The children, families, leaders, and partners are very excited about the potential opportunities for these teams and the future network to make a significant impact on the health and well-being of children worldwide.

Do you think it is important for children to be involved in shaping pediatric medical research? Have you had experience with kids getting involved in their health care? What was the outcome? Share your thoughts in the comments section.

If you are interested in participating in this project or would like more information, please contact Charlie Thompson (charles.a.thompson@pfizer.com).

Taking Charge at the End of Your Life

Tim Prosch is author of AARP’s The Other Talk: A Guide to Talking with Your Adult Children About the Rest of Your Life, a book that helps parents and their children create a partnership to plan for the years to come, guiding them through important conversations and decisions about finances, medical care, and day-to-day living—before a crisis happens.

Tim Prosch

Tim Prosch

What can happen if you put off your end-of-life health care decisions until “the time is right?”

The Terri Schiavo case, which culminated in 2005, can put the answer to this question in stark relief.

Fifteen years earlier, Terri had collapsed at home, suffered severe brain damage and was put on a feeding tube to keep her alive. For the next decade and a half, she was yanked back and forth in a virulent tug-of-war between her husband and her parents about how she would want to be treated. Ultimately the courts got involved, pulling her off her feeding tube for 3 days in 2001, again for 6 days in 2003, and finally for 13 days in 2005, when she finally expired.

All of this drama and heartache could have been avoided if her wishes had been put in writing and had been thoroughly discussed by all interested parties.

While none of us will ever know what Terri wanted done at the end of her life, it is safe to say that her on-again, off-again existence and her increasingly toxic family dynamic are not what she or anyone else would wish for.

 

How can you avoid Terri’s fate? 

To begin with, it’s important that you understand that health care at your end of life will be a family affair, not just a personal decision. In most cases, it is not about you personally taking charge. It is about you preparing and empowering your family to take charge as you approach that final stage.

The-Other-TalkThe reason for this collaborative approach is that it is highly likely that you won’t be physically, emotionally, or mentally able to direct the final proceedings. Collaboration addresses the challenge for someone acting on your behalf to weigh the options and make decisions and to articulate what should be done in a way that reflects your thoughts about the end of your life.

As a result, it is critical that you start these conversations now while you are mentally sharp. Quite simply, the longer you wait, the less effective these discussions with your family will be, due to the natural deterioration of the aging brain.

In preparing for the end game discussion, you’ll want to take steps in two critical areas: guiding principles and parameters for medical treatment.

 

Step 1. Establish Your Guiding Principles

The first step in making your family confident and empowered in taking charge when the time comes is for you to confront and define what “being alive” means to you as you near the end.

For some people, it is fighting for every last breath. “Even one more day would be important to me. I would do everything I could to hold on to life.”

For others, it is living intensely, yet comfortably, in the time remaining. “I would rather be able to do what I want, to be with my kids, to enjoy life, even if it’s for a shorter time.”

Of course, neither one is the better approach because it is such a personal choice. But if you start now to build a clear understanding of your preferences with your family and your doctors, you can dramatically increase your odds of getting what you want.

 

Step 2. Set Parameters for Your Medical Treatment 

Step 2 in taking charge of your life (versus abdicating it to the medical community) is to put your preferences in writing. Equally important is to distribute and discuss your wishes with your family members and your doctors to ensure that your goals are clearly understood.

An effective and relatively inexpensive way to accomplish this is to consult with your legal advisor, then draw up a health care power of attorney. This document establishes your designated agent who will make health care decisions for you if you are not able to do so.

If you are in the “do not prolong life at any cost” camp, you will also want to explore two health care directives: the living will and the do-not-resuscitate (DNR) order:

  1. The living will establishes that you do not want your death to be artificially postponed. It states that if your attending physician determines that you have an incurable injury, disease or illness, procedures that only prolong the dying process should be withheld and the medical focus should shift to comfort care. This document must be signed by two witnesses who will not benefit from your death.
  2. The do-not-resuscitate (DNR) order is different from the health care power of attorney and the living will in that neither your health care agent nor you can prepare it. Rather, it is a written order signed by your physician that instructs other health care providers not to attempt CPR if your heart has stopped beating and if you have stopped breathing during cardiac or respiratory arrest.

Once you have shared your “what being alive means to me” documents (the health care power of attorney and, if relevant, the living will and the DNR order) and thoroughly discussed them with family and doctors, you all should acknowledge the possibility of revisions. Every time your health status changes in some significant way, you should have another discussion to clarify your views and expectations.

It’s okay for you to move the goalposts on issues pertaining to the end of your life. You just need to make certain that the people in your world know that you moved them.

Do you have a living will or DNR? What did you learn through the process that you’d like for others to know?

Click here to learn more about The Other Talk and here to hear an interview with the author from AARP.

Virtual Health Care: Your Questions Answered by a Telehealth Pioneer

If you follow the latest developments in health care, you may have noticed: telehealth has taken off. Our country is focused on making health care more accessible for Americans, and naturally, telehealth has emerged as a key innovation that can help to make this a reality. It’s an effective way to deliver evidence-based medicine – and it’s something that we as physicians can embrace right now.

Dr. Peter Antall

Dr. Peter Antall

As President and Medical Director of the world’s first telehealth practice, Online Care Group, I’m often asked a handful of common questions about telehealth. Here, I share the most common questions and my answers with Real World Health Care’s readers.

What is telehealth?

To me, telehealth is simple. Telehealth is a live video visit between a doctor and a patient from home or work. This differs from traditional telemedicine, which mainly connected hospital facilities to each other and relied on big, expensive hardware in clinical locations.

With telehealth, the patient can have a video visit with a doctor using every day consumer technologies that are becoming ubiquitous: a smartphone, tablet, or computer. There are other forms of telehealth on the market that use only phone or secure email; however, these visits do not allow for the same level of clinical patient evaluation. I have met with medical boards and associations across the country and found that live video is greatly preferred because it represents the closest interaction comparable to an in-person visit.

Do patients really want to talk to a doctor virtually?

For starters, let me just ask you when was the last time you shopped, banked, booked travel, made a dinner reservation, filed your taxes, or communicated with friends and family online. Chances are – if you’re like many Americans – you’ve done more than one of these things today, probably on your phone or tablet.

While the health care industry has done a great job of supplying information to patients online and has even started to offer patients the opportunity to book appointments online, information and scheduling stop short of what patients want and expect from health care: quality interactions with clinicians. To date, health care ‘transactions’ have only occurred at the intersection of a physical location and the supply of available clinicians. The industry can do better.

Over the last several years, a number of studies have shown that patients are rapidly warming to the concept of interacting with doctors online. Estimates suggest that half to three-quarters of Americans are interested in online consults, and I’d expect this number to grow as more patients have access to telehealth services and as more doctors offer such services to patients.

If you think about the patient experience today, it’s not surprising that most folks respond so positively to the value of telehealth. Consider the national average wait time to see a doctor of 18.5 days, not to mention the excessive wait time in certain urban and rural areas. And once you’re in the doctor’s office, that wait can be long, too, which you know if you’ve ever spent two or three hours in an urgent care clinic or emergency room waiting to be seen. Retail clinics are an option, but these are generally not staffed by a doctor and are often not available outside of normal business hours.

On the other hand, a patient can see a doctor in just a few minutes from their phone or tablet. For example, our wait times at the Online Care Group currently average less than 2.5 minutes, and there’s no appointment or travel required. So it’s not surprising that 97% of patients rate the service “very good” or “excellent”.

How do you examine a patient during a telehealth visit?

Examining a patient through video is different from in-person, though the fundamental rules of medicine still apply. The most important elements of any consultation – online or in-person – is taking a thorough history, asking plenty of questions, and doing a visual examination. Having a video connection with a patient is really important in helping to understand the patient’s overall demeanor and level of discomfort and stress, just as in the exam room. This gives me great insight into the patient’s physical and mental well-being. In terms of a physical exam, I’ve developed protocols to help our doctors guide patients through self-exams in order to provide empirical feedback that’s useful in making certain diagnoses.

One of our main tenets is that doctors must use their own clinical discretion when treating patients online. Our physicians diagnose and treat only when enough data can be ascertained in the video consultation to do so. If not, our physicians triage the patient and refer out for in-person care. That may mean seeing their doctor in-person, going to the emergency room, or ordering tests at a local health center.

What about security issues?

As with brick-and-mortar medicine, it is extremely important to protect patient health information. The information regarding a patient’s health should remain private between the physician and the patient and be stored securely, in compliance with the Health Insurance Portability and Accountability Act (HIPAA). American Well provides a secure space for patients to safely and confidentially consult with a doctor online. This is imperative for an effective and safe telehealth practice.

What does telehealth have to offer me as a doctor?

Telehealth is not only convenient for patients; it offers doctors flexibility at work, reliable pay, and access to new patients. And not only individual and group practices, but even large medical practices and hospitals, are starting to use telehealth to attract and retain patients and to expand their reach.

By incorporating telehealth, hospitals under accountable care organization (ACO) contracts, or otherwise caring for patients under capitation, reap the financial benefits of having healthier patients. Private offices can offer open access and after-hours care or designate that a subset of visits, like medication follow-up, be managed through telehealth. Practices can also bring in other specialties virtually into their office, like certified diabetes educators, dieticians, or behavioral health specialists.

Can I make money with telehealth?

There is high demand from patients for urgent-care-like telehealth services. Today, physicians across the country – including those in our national telehealth practice – make a very good living practicing medicine online, providing care anywhere from 10-40 hours per week.

Another option is for doctors to offer telehealth to their existing patients. In many states, doctors are already being reimbursed for services delivered to their own patients by including GT modifiers in their billing (this modifier is used to indicate telehealth services via interactive audio and video telecommunication systems). Currently 20 states mandate private payer reimbursement for telehealth services and 45 states reimburse for some telehealth services. As our doctors move from fee-for-service to capitated payment models under the Affordable Care Act, they are absorbing the risk (“rewarded for performance,” as some might say). Telehealth is one way to improve efficacy and efficiency of patient care. Telehealth lets doctors increase the number of touch points for patients, which potentially can improve outcomes as well.

Is telehealth the future of healthcare?

Telehealth isn’t really a new form of healthcare; it is the same healthcare that Americans are using every day, delivered in a faster, less expensive, more convenient way. Although not everything can be treated via telehealth, it’s a great option for many types of acute care, chronic care, behavioral health, and wellness services. Patients, doctors, hospital systems, employers, insurers, regulators, and legislators are all rapidly changing the way they view health care in order to incorporate telehealth. In the coming months, the proof that telehealth is here to stay will become even more evident. It’s time to embrace the now of health care.

Have you ever used telehealth? Would you? Share your thoughts and experiences in the comments section.

If you have any questions or to learn more about where and how I practice telehealth, email me at peter.antall@americanwell.com.

Dr. Antall is the Medical Director of Online Care Group, a physician-owned primary care group that offers its clinical services online using American Well’s technology. American Well’s web and mobile telehealth platform connects patients and clinicians for live, clinically meaningful visits through video, supplemented by secure text chat and phone. For more information, visit AmericanWell.com

Categories: Access to Care

Four benefits of electronic health records

Leaders from industry, academia, and health care discuss the rollout of this technology at The Atlantic’s sixth annual Health Care Forum

Today The Atlantic Health Care Forum brought together leading policymakers and industry experts in medicine, public health, and nutrition to have conversations about the state of the nation’s health care system. The event was sponsored by Siemens, Surescripts, WellPoint, GSK and PhRMA. Real World Health Care attended to share insights from the panel “Health Care Tomorrow: Examining the Tools and Technologies that Will Revolutionize the Future Health Care System.”

Jamie Elizabeth Rosen

Jamie Elizabeth Rosen

Much of the discussion centered around electronic health records, which are increasingly being rolled out in huge hospital systems after the federal government incentivized their adoption to the tune of billions of dollars five years ago. Four themes emerged from the panel, which included top executives from Johns Hopkins Medicine, athenahealth, PhRMA, and Carolinas HealthCare System.

 

1. Enhancing collaboration.

Electronic health records facilitate a team-based approach to hospital care, as well as allowing for better coordination between hospital systems. “What we’re going to see is it’s going to drive team-based clinical care because everyone in the system will have access to the same medical records,” said Dr. Paul Rothman, Dean of the Medical Faculty and Vice President for Medicine at The Johns Hopkins University and Chief Executive Officer at Johns Hopkins Medicine. “You’re going to see an [increased] level of collaboration not only between delivery systems, but also between the patient and the health care provider.”

However, Ed Park, Executive Vice President and Chief Operating Officer, athenahealth, warned that the decades-old technologies that many hospital systems are using are limited in their capabilities. “The current crop of [electronic health records] are documentation tools instead of care management tools,” he said, adding that they are primarily for use by insurers and lawyers. “What I fear is health systems beginning to buy their way into their own prisons that are built of their own IT…as opposed to dealing in an open environment,” he said.

 

2. Enabling patient-centered care.

Electronic health records enable patients to reap greater benefits from telehealth. “Having your information on your iPhone: that’s not far away,” Dr. Rothman said. “[Patients are] going to do EKG’s at home. They’re going to be measuring their blood sugar at home. The patient will have control of the data.”

Electronic records also hold the promise of helping to solve age-old problems in the U.S. health care system, including keeping contact with patients to encourage them to take prescribed treatment regimens. “There is almost $350 billion a year in inefficiency because of lack of compliance and adherence with medications,” said John Castellani, President and Chief Executive Officer, PhRMA. “If you could just get an improvement in whether patients take the medicines that are prescribed, you could capture this great savings.”

“You have kids who have kidney transplants, and you can give them reminders on Facebook that they have to take their medications,” Dr. Rothman added.

 

3. Targeting therapies for increased success.

Electronic medical records can help health care providers ensure that they prescribe the treatments most likely to work for their patients.

“What I think is the promise of electronic medical records is our ability to find subsets of diseases through the broad diseases we treat,” Dr. Rothman said. “Asthma isn’t one disease. Obesity isn’t one disease. Diabetes isn’t one disease. We are going to be able to find subsets of diseases and target therapies [that work]. That’s when you’re going to see efficiency and return on investment.”

 

4. Harnessing the power of big data.

Our health care system has already begun to see the benefits of ‘big data’ with examples such as the discovery of drug side effects and interactions through mining consumer web search data. “We have to use the technologies to bring down the cost of the drug discovery process,” Castellani said.

“Just taking care of the patient, we capture data,” said Dr. Roger Ray, Executive Vice President and Chief Medical Officer, Carolinas HealthCare System. “That allows us to know when a patient…may be at risk for hospital readmission. Having the ability to mine [data]…makes a difference for patients.

“We all, each of us, remember with longing a simpler time when we could scribble and walk off and our job was done,” he added. “What we know now is that’s not very good for the patient. We had no standardization allowing us to help patients avoid lots of different bad outcomes they could have.”

 

Have electronic medical records impacted your health or that of your patients? Share your thoughts in the comments section.

Five Ways to Manage the Costs of Your Medicine

While a main precept of the Affordable Care Act is to expand access to health care, in some cases that improved access means more patients are being treated with medications that come with a cost. As a pharmacist, I have to be an insurance sleuth, use common sense, and teach my patients the old-fashioned methods of negotiation.

Joel Zive

Joel Zive

I work in solid organ transplant, HIV, and Hepatitis C medicine. I have patients on regimes ranging from 4 to over 20 medications. For my patients, obtaining consistent, reasonably-priced medications – both over-the-counter and prescription – is vital.

1. Make sure all the medications are at one pharmacy.  It’s important to keep a clinical eye on things for drug interactions. As a bonus, the pharmacist and the patient know what costs need to be examined.

2. Seek out insurance prior authorization.  Some insurance companies require prior authorization to cover certain drugs. Your pharmacist can help you seek prior authorization for medications that require it using software that creates forms specific to each insurance company. Ask if your pharmacist can fill out the form as much as possible before sending it to your doctor.

3. Contact the drug company.  Many pharmaceutical companies offer patient assistance programs or co-pay assistance cards to help eligible patients obtain free medicines, particularly for biologics and expensive drugs. These programs are especially helpful for patients who have insurance gaps and need the medications quickly. Depending on the assistance from a case manager or care coordinator, I have received authorization for medications right away or within 72 hours.

4. Search for a co-pay assistance program that covers your condition.  If your drug company does not offer a patient assistance program or you are not eligible based on your income and insurance coverage, it is possible that a charitable patient assistance program through a non-profit organization such as the HealthWell Foundation may be able to help you.

5. Seek discounts for over-the-counter medications.  Over-the-counter medications can put a strain on the wallet. In many cases, purchasing over-the-counter medications is more expensive than prescription medications covered by insurance. Other items like vitamins, natural supplements, and enteral formulas (also known as ‘milks’) require the patient to do a little negotiating. If you tell the pharmacy or vitamin store you will be taking these items indefinitely, they may be inclined to discount. Also, be on the lookout for buy one get one deals (BOGOs). Finally, enteral formulas can be quite expensive, so if you get prescribed a specially formulated one, ask if you can take a more basic formulation instead. Remember to let your prescriber and pharmacist know which over-the-counter medications and supplements you are using.

In conclusion, while the path to affordable medications is not always easy, there are individuals, programs, and strategies that can help you meet your health care goals.

How do you manage your medications? Share your tips in the comments section.

Categories: General

Our Top 4 Most ‘Liked’ Health Care Stories

This week is Real World Health Care’s one-year anniversary. Over the past year, we showcased solutions that are proven to lower costs, increase access, and provide more patient-centered care. In celebration of this milestone, we are sharing the favorite posts as measured by Facebook ‘likes’ from our readers, who have visited the blog over 10,000 times.

 

#4 – Keeping Boston Strong: How Disaster Training at Osteopathic Medical School Helped Save Lives

In May, former RWHC editor Paul DeMiglio told the story of Dr. Danielle Deines’ emergency response to the Boston Marathon bombing. Dr. Deines’ education at the Edward Via College of Osteopathic Medicine – Virginia Campus (VCOM) required her to participate in a two-day, mandatory training curriculum on Bioterrorism and Disaster Response Program, which immersed her in real-life disaster training, field exercises and specialized courses.

(Photo courtesy of VCOM)

(Photo courtesy of VCOM)

The day of the bombing, after crossing the finish line, Dr. Deines found herself triaging runners in medical tents to make room for the victims. “The back corner became the most severe triage area, nearest the entrance where the ambulances were arriving,” she said. “I saw victims with traumatic amputations of the lower extremities, legs that had partially severed or had shrapnel embedded, and clothing and shoes literally blown off of victims’ bodies.”

Read the post: http://www.realworldhealthcare.org/2013/05/keeping-boston-strong-how-disaster-training-at-osteopathic-medical-school-helped-save-lives/

 

#3 – Making Life Easier for Patients and Loved Ones: Meet MyHealthTeams

In April, Eric Peacock, Co-founder and CEO of MyHealthTeams, contributed a guest blog about the need for social networks for communities of people living with chronic conditions. These networks allow patients to “share recommendations of local providers, openly discuss daily triumphs and issues, share tips and advice, and gain access to local services,” he wrote.

“Sharing with people who are in your shoes offers a sense of community that can’t be found elsewhere – these are people who know the language of your condition; they understand the daily frustrations and the small triumphs that can mean so much,” he added.

Read the post: http://www.realworldhealthcare.org/2013/04/making-life-easier-for-patients-and-loved-ones-meet-myhealthteams/

 

#2 – When the Health Care Blogger Becomes the Cancer Patient

In August, even as she was still undergoing daily radiation treatments, contributor Linda Barlow shared her personal story of being diagnosed with cancer and the slew of medical bills she faced even though she had insurance.

Linda Barlow

Linda Barlow

“While these out of pocket costs are certainly hard to swallow – I can think of a hundred other things I’d rather spend my money on – for my family, they are doable,” she wrote. “We won’t have to skip a mortgage payment or a utility bill. We won’t have to dip into a child’s college tuition fund. We certainly won’t have to worry about having enough money for food. But I know – from my work on this blog and with its main sponsor, the HealthWell Foundation – that many families living with cancer aren’t so lucky.”

Read the post: http://www.realworldhealthcare.org/2013/08/when-the-health-care-blogger-becomes-the-cancer-patient/

 

#1 – What If You Want Politicians to Get Moving But You Can’t Move?

Neil Cavuto

Neil Cavuto

Last week, Neil Cavuto, Senior Vice President and Anchor, Fox News and Fox Business, contributed a moving guest post about his triumphs over multiple sclerosis (MS) for MS Awareness Week. His deeply personal blog inspired resounding praise in the comments section and 1,300 Facebook ‘likes’.

“If I can pass along any advice at all, it is…to simply never accept a prognosis as is,” he wrote. “Fight it. Challenge it. ‘Will’ yourself over it. Many doctors say it’s a naïve approach to the disease, but attitude counts a lot for me with MS, as it did for me two decades ago when I was battling advanced Hodgkin’s Disease. Then, as now, it was about one day at a time, and staying optimistic and positive all the time.”

Read the post: http://www.realworldhealthcare.org/2014/03/ms-awareness-week/

 

If you would like to suggest a topic, contribute a guest post, or learn more about short-term co-sponsorship opportunities, please contact us at dsheon@WHITECOATstrategies.com. As a blog currently sponsored solely by the HealthWell Foundation, an independent non-profit providing nationwide financial assistance to insured Americans with high out-of-pocket medication expenses, co-sponsorship helps us keep Real World Health Care alive and well as a resource for journalists, health care professionals, policymakers, and patients. Plus, co-sponsorship will increase your organization’s visibility among thought leaders in the health care sphere.

Do you have a favorite Real World Health Care post? Is there something you’d like to see more of? Post to the comments section or tweet at us at @RWHCblog.