Expand Patient Engagement With Telemedicine

By Scott Westcott, Contributing Writer

Telemedicine offers a clear opportunity for healthcare providers to connect with patients in cost-effective, efficient, and engaging ways. Yet while telemedicine continues to grow, challenges to widespread adoption remain.

Telemedicine — consider it the modern version of the age-old house call. This remote diagnosis and treatment of patients offer physicians and other caregivers the opportunity to readily communicate and share information electronically via — among other things — virtual video visits, text messaging, and monitoring services.

Thee American Telemedicine Association estimates as many as 15 million people used telemedicine services in 2015 — a 50 percent jump from 2013. The use of this technology is being accelerated by the swift proliferation of smart phones and other personal electronic devices that enable convenient two-way conversation platforms for patients and their doctors, and it offers many benefits to healthcare.

Practices can operate more efficiently by sending appointment reminders, participating in virtual visits, and sharing health information electronically. Patients benefit from more frequent communication with their caregivers, greater convenience, and the ability to play a more active, engaged, and informed role in their own health.

Yet challenge remains. Some physicians and staffers have been hesitant to adopt the technology as it represents a significant shift in how they have traditionally interacted with patients. Also, adequate reimbursement remains a barrier as some health plans are slow to recognize telemedicine interactions as reimbursable events. Further, the debate continues about the development of standards or regulations to govern how healthcare providers interact with patients.

Recently, Eric M. Wallen, UNC Urology program director and professor in the Department of Urology; Dr. Brian R. Forrest, M.D., CEO and founder of Access Healthcare who also lectures and consults frequently about the Direct Primary Care Model; and Dr. Kevin Biese, associate professor and vice chair for education and residency director for the Department of Emergency Medicine as well as a clinical adjunct professor in the Department of Internal Medicine, Division of Geriatrics at the University of North Carolina at Chapel Hill School of Medicine, offered up their insights on the current state of telemedicine, as well as what the future might hold for the technology.

Q: What strategies have you found to be successful for implementing telemedicine at your facility?

Wallen: For me, the best setting to begin the process is when rounding on in-patients. If I see a patient using a smart phone in their room, I know we can make telemedicine appointments work successfully. I broach the subject right then and there, letting them know why I think it is such an efficient way to interact. Then I follow up by verifying their email address is in our EMR. Once I have that in place, I send them an invitation through an app. It’s been important for me to work with my scheduler to be sure an appointment slot is reserved during my day so I have the dedicated time for that particular patient. I suspect that someday I will commit as much as half a day for telemedicine appointments.

Forrest: The major key to making telemedicine successful in practices is utilizing it as an additional or bonus service, rather than as a replacement to conventional medicine. I see my patients for traditional in-office visits, and I also use telemedicine to meet with them, virtually allowing me to improve patient engagement in creative ways that did not exist before. For example, it is imperative doctors have a complete list of all of the products a patient is taking to avoid drug interactions. If a patient leaves some of their medications or natural supplements at home, that can be a challenge. With telemedicine video appointments, I ask the patient to show me the labels. I have found many potential interactions I never would have known about without actually reading the labels myself.

Biese: The best approach is helping doctors and other providers implement mobile health in a safe, guided, structured way in their own healthcare setting. Creating processes that make it easy for doctors to take good care of their patients within their existing workflow will help make this innovation sustainable.

Q: How are you using telemedicine to transform care?

Wallen: Quick, post-op check-ups to allow for visualization of healing of incisions are one method. Another is a chronic follow-up patient who needs five minutes of interaction to touch base regarding a stable issue such as prostate cancer. These appointments, which include review of lab results and discussion of functional issues, must continue for several years after treatment. When issues are stable, though, the patient can accomplish this by video from home or work without making a trip to my office. Perhaps the most important type of interaction is one where telemedicine is used to frequently assess a patient who is at risk of readmission with the goal of education and reassurance at home. If we can do that, we decrease trips to the emergency room and help address small issues that can stack up and cumulatively result in readmissions.

Forrest: Telemedicine creates opportunities to expand patient engagement. This often offers greater convenience, but it also can prevent trips to the ER or urgent care after hours or create better chronic disease follow-up. For example, patients can show you how they are taking their blood pressure at home and share more frequent updates, where additional office visits would have otherwise been burdensome.

Biese: Utilizing the power of mobile technology, we can make the healthcare system much more efficient for providers, payers, and — more importantly — for patients. For starters, telemedicine solutions allow us to connect the right resources with the patients who need them. These products transform healthcare by allowing providers to stay open later and see patients in off hours. This means patients don’t have to go to doctors who do not know them or don’t have access to their records — both of which can negatively impact outcomes. Mobile health also allows specialists, who are often concentrated in urban areas, to see patients who live far away without always needing to travel into the office. Additionally, sometimes these appointments can be done in conjunction with the patient’s primary care physician to better maintain the care chain.

Q: What obstacles are impeding the effective use of telemedicine?

Wallen: State licensure limits telemedicine to provider resources within specific states. There is also a large variation in provider and patient education regarding telemedicine’s availability and benefits. Payer support of telemedicine appointments is also somewhat limited at this point, but I expect this to improve over the next several years due to patient demand. Recognition by healthcare systems that telemedicine appointments can be used to effectively address patient satisfaction as well as population health issues will further drive this. When I think about the quick, just-checking-in type of caregiver/patient interaction, telemedicine has tremendous potential to improve health. This is why some large healthcare systems are beginning to integrate it into their EMR.

Forrest: For most practices, the largest barrier to using telemedicine is reimbursement. Although a few payers have agreed to reimburse for certain telemedicine visits, the amounts have been too small to justify the time and costs associated with getting a telemedicine program under way. However, for Direct Primary Care and Concierge practices, where providers are compensated for keeping patients healthy rather than the number of office visits, telemedicine already makes perfect sense. The second biggest obstacle is understanding when telemedicine use is appropriate. Patients and physicians are often confused about when they should see each other in person and when a telemedicine visit works best.

Biese: There are two main factors currently impeding effective use of telemedicine, the first being lack of clarity regarding reimbursement. Good care can be given in appropriate situations via mobile health or telemedicine and should be reimbursed at levels that encourage this cost-saving and patient-centered approach. The second factor is a lack of understanding what constitutes good mHealthcare. Good mHealth allows patients to speak with their doctors in the context of an ongoing therapeutic relationship. It also encourages patients to seek in-person care when mobile health is not adequate to meet their needs. This type of best practice should be encouraged and one-off, mobile health visits by providers located far away from the patients — who know neither the patient nor the local healthcare resources — should be discouraged.

Q: Are clearer standards necessary to ensure more effective use of telemedicine?

Wallen: Definitely. Providers are concerned about medicolegal issues surrounding telemedicine interactions. I find this somewhat ironic given telemedicine is essentially an improved version of a phone call, and most are comfortable on the phone. Over the next few years, I expect clearer guidelines to evolve, a list of the rules of engagement, so to speak. I see this much like the agreements we all have to click on every time we update the software on our phones for the various apps we use for banking or making plane reservations. This will be helpful in adoption of this technology, as we’ve started to see with guidelines from Medicare and other payers for telemedicine interactions. Additional guidelines are also needed as some currently only allow for limited types of providers to engage in telemedicine, such as MDs. This narrow approach restricts healthcare’s ability to address physician shortages in several primary care and specialty areas. Other capable providers — such as nurse practitioners, physician assistants, and registered nurses — could make a tremendous impact on health using this tool to work with patients.

Forrest: Some clarity is needed. However, creating too many standards could actually be counterproductive. If telemedicine becomes over regulated, it could actually make physicians much more wary of using it.

Biese: Clearer standards like those created by the North Carolina Medical Board in 2014 are helpful. Doctors need to know what they can and cannot do when taking care of patients using mobile health. This provides for safer care.

Q: The government, vendors, healthcare providers, payers, and patients will all play a role in the future of telemedicine. Which of these stakeholders will ultimately drive this effort forward?

Wallen: I think patient demand will ultimately drive the success of telemedicine. Think about how much easier telemedicine makes it for a busy parent with multiple children to get a pediatrician to assess a simple rash. I work with patients who drive several hours round trip to get here, and simple postoperative check-ups take 15 minutes as a telemedicine appointment as opposed to several hours if they needed to drive to the office. Patients are already asking if they can use this method of follow-up. This kind of care has several benefits, including improved access and higher patient satisfaction. These patient-driven metrics are major drivers for healthcare.

Forrest: If patients as customers demand telemedicine as a service, then it will thrive in Direct Care models and eventually payers will catch up.

Biese: Patients will drive mobile healthcare forward because they accomplish many of their life tasks using mobile devices and are increasingly demanding that the often difficult-to-access healthcare system use mobile health as well. It is important that medical boards, regulators, providers, and payers all keep up with the demand to ensure safe, quality care that is easier to access.

Q: What technical challenges currently stand in the way of effective use of telemedicine?

Wallen: I think most Wi-Fi and phone networks are sufficient for telemedicine right now, but more and cheaper networks will help — Google Fiber, for example. The next level of usage will be achieved by more patient and caregiver awareness of telemedicine as an important resource to improve health.

Forrest: The most critical challenge is equipment and connection bandwidth. If a patient does not have a mobile device or lives in a high-speed Internet desert, then telemedicine is not even possible. Many mobile carriers still have large gaps in geographic coverage for rural areas.

Biese: The technical capacity to provide good mobile health already exists. We can, however, always get better at making more imaging modalities, EKG modalities, and other assessing technologies more available to patients in their homes. Another big challenge is helping doctors know how to adjust to a mobile health setting. The technology has to be presented in a very patient-centered way as seamlessly as many of the other apps the patients are used to.

Q: What would you advise providers who are considering or just starting to use telemedicine?

Wallen: Start by trying it for the simplest interaction with one or two tech-savvy patients to build your confidence in the software and your satisfaction with the interaction. You might target a patient who expresses reluctance to come in due to work or family obligations. Once you try it a few times, you’ll want to get your scheduler involved in soliciting patient interest in telemedicine at registration, sending invitations, and putting them on your schedule for you. Also, find out what payers will cover. You may be surprised that many are paying for these appointments. For those involved in their institutional EMR design and updates, ask about integration of telemedicine into the system. You’ll believe in telemedicine as the logistic and reimbursement obstacles fall away.

Forrest: I suggest using a simple solution that avoids duplication of eff ort or extra documentation. TouchCare, for example, took only minutes to set up, didn’t require training, and worked seamlessly into my day. I also suggest using telemedicine to find creative ways to interact with patients between appointments to optimize their continuity of care.

Biese: I would suggest other doctors download an app like TouchCare and try incorporating mobile health on a few of their patients in simple, noncomplex medical situations. The American Telemedicine Association has guidelines on which conditions are most appropriate for using mobile health.