Telemedicine..... the current reality and the future potential.....

[Guest guest]

Fellow IMPs…… Well, I am glad to have gotten such a great conversation going, but I think maybe we have spiraled into some remote location…..off the beaten path….fearing that Telemedicine will replace PCPs. First of all Telemedicine is not synonymous with primary care and it is not meant to replace primary care. Let me clarify how it works and what I envision, then I would love feedback because this group has insight. Here in Rochester it is still new (about 10+ years in the making)….still in its infancy, although that does not sound like a short time, it is fora cutting edge medical movement. In California, all Medicaid patients are required to be seen through Telemedicine for appropriate visits because it is cost effective. In some cases Telemedicine is better than being face-to-face. For example, have you ever tried to look into a sick child’s ear?! You are lucky to get 30 seconds to look and see a TM and then you have to remember what you saw, you may not get a second chance, and that is if he/she lets you see it in the first place. With telemedicine you get a digital picture or a video. If it is a picture you can zoom in, you can put previous pics side by side to compare this pic to the last visit or the other ear. You can see things you can’t normally see on a sick, wiggly child. In some cases they find a more reliable diagnosis and treatment with Telemedicine than a face-to-face visit. In that way, it is totally better but takes some getting used to. Okay, so we have that and now let’s take this scenario one step farther. Let’s say you are on call and you come across something very atypical and you want a second opinion from someone who knows the patient better than you. You can call them up and they can remotely look at the same pic you are. This would be awesome for rashes, while face-to-face is better to look at skin, if you have pics of the skin and you want a second opinion you don’t have to try and describe it. You can see it and show it to the other person. There is always someone else who can consult on the case, even if they are not in the area. Eventually it would be great to be able to consult with derm on a tough case without having to wait weeks or months to get them in. So, telemedicine is great for consulting and for getting good images that you can look at and zoom in on. Telemedicine is not appropriate for all kinds of visits, so it cannot replace the face-to-face visit that we all value so much. For example, if a child is having an asthma exacerbation and needs a nebulizer treatment, can’t do it. The technicians do not administer medications and this kind of visit is not appropriate. I personally would want to be face-to-face with this person anyhow. If someone is having chest pain, while some locations may be equipped with EKG (ours are not, I don’t believe), you want to have that person somewhere that they can receive emergency medical treatment or at least with someone who can medically treat them. So, telemedicine is not appropriate for anyone who may need onsite medications or emergency medical treatment or complicated diagnostic tests. There is actually less people involved in the patient’s care with telemedicine than non-IMP traditional medicine. In a traditional office setting, there is the receptionist, the medical assistant and/or nurse and the provider (MD/NP/PA/DO/DC etc). With telemedicine, they call and schedule a telemedicine visit and they arrive to meet the technician, who in some cases they have met before because they have come to this site before. The tech takes all the info and enters it into the computer and then we skip ahead to the visit with the provider on-call. They get to interact with that person. In some cases the parent has to leave and get the child home because they are sick or they have to go pick up another child. So the provider may have to call the parent after looking at the images and the details etc. Not ideal but helps get the patient the help he/she needs. At this time the tele sites are in urban areas that are not close to hospitals or afterhours clinics. One site is located in a church that offers a breakfast on Saturday mornings and the tech goes around to the people at the breakfast (many are there for a free meal) and talks with them to see if they have any needs. If anyone is sick or has not had their BP followed-up on, the tech can offer a Tele visit in the same building. So, patients who otherwise would not go to a medical office may be able to get the care they need. The people in that community get to know the techs and trust them and the providers become a resource for the patient. If they have a PCP, then the Tele provider bridges the gap. If they don’t then the Tele provider gets the patient what is needed and tries to reconnect them to someone else or if needed follows up on their chronic problem until they can get a PCP. Telemedicine can serve the underserved. I am going to say one more thing….some of these sites I would not feel safe going to on a regular basis, so to hire someone for a clinic in these areas may be a challenge, but if one provider can cover several locations remotely, it is more cost effective and provides quality care to patients who need it and otherwise may not get it. Here is another scenario…..they do tele visits with the mobile unit in the Rochester city school district. So, we have a child who is thought to have “pink eye” let’s say…..what happens? Typically the nurse, calls the parent to take the child to their pediatrician or PCP. The parent has to leave work and get the child to the PCP to determine if it is indeed contagious and possibly take the child back to school if it is not and return to work….best case scenario. If the parent is a single-parent and the only one providing an income for the family this is a stressful situation. With Tele the nurse can schedule a visit for the child at school, have the child evaluated and the provider can call the parent at work for further history and then tell the parent if the child needs to leave school or not. The provider may even *BE* the child’s PCP if he/she does tele visits. If the provider decides that it was not bacterial conjunctivitis but rather allergic conjunctivitis and the child can stay in school, then the parent never lost time from work, the child did not lose as much time from school and the PCP is still in the loop with the child’s care. There is nothing like seeing someone face-to-face and providing that personal care, but realistically there is only so many health care providers and fewer and fewer PCPs to provide care. There are so many opportunities to use telemedicine to improve health care, but as many of you have brought up, it can take away from health care, what we, as IMPs, are struggling to return to health care. Technology can be wonderful but it can take us away from the patient as well. It can bring us closer, though, if used properly. If you had a patient that was on vacation and called you because they were ill and telemedicine was prevalent enough that they could go to a local tele site, you could still “see” that patient remotely. As IMPs, this is more in line with what we are equipped to do than traditional providers. We are already using technology to remove barriers between us and the patient and to keep costs lower. My father-in-law gets at least one case of bronchitis during the winter. He tries to take an antibiotic with him when he migrates with my mother-in-law to Florida for the winter. Well, his PCP prescribes it ahead and he knows when he should start it and if there is any question he calls and talks to the doctor. One year, he went without the script and got very sick. He had to go to a local clinic which the insurance would not pay for and it was hundreds of dollars out of their pocket just to get the treatment he needed so it would not progress into pneumonia. It was a major hassle and very stressful. If telemedicine was in place, his PCP could have seen him and treated him even if the PCP was in NY and my father-in-law was in Florida. Of course, the licensing laws would need to catch up with health care and so forth, so providers could see their patients even if their patients are remotely someplace else. The point is that this could increase access to health care, not replace personal relationships. If a patient likes me as a provider but lives a few hours from me, it would make a follow-up visit easier. I could see the patient for a thorough visit but if I have to follow up on a medication change or they have an acute illness, I could see them more frequently than if I had to try and get them to the office. Imagine doing acute, after hours visits from your home!! Instead of running into the office over the holiday to see someone who needs you, you could step into your in-home office or your walk-in-closet….LOL…..and do the visit and return to the festivities. Yes, the more people who are involved with patient care the less the provider knows about the patient. When nursing aides started giving bed baths in the hospital, nurses had less of an opportunity to evaluate patients for skin breakdown and lost another opportunity for personal care. Personal care time provides a time for patients to receive that personal touch, one –on-one time to talk and build rapport with their caregiver. Unfortunately, one person cannot do everything. We have to choose what we are willing to delegate and I think we need to see how we can better utilize the time we have with the patient. We need to increase access to quality patient care without burning ourselves out. If a patient could see you through telemedicine, they would not need to go to the local after hours clinic unless you were unavailable. You would see your own patients more often and even if you were on vacation and wanted to have time off from the office, you could check in with the visits that happened while you were away. Here we have Doe, you are at your summer cottage on the lake and you don’t want to be on-call (although you could because you have your laptop with you). has a cough and just can’t take it anymore, so he schedules a visit and goes to the local tele site, and another provider sees . You decide to check in on your patients and because you have access to the TeleAtrics web-based record, you listen to the sound wave file of his lung sounds and are reassured they are clear and there is nothing to worry about. You also read the note from the provider who saw the patient (which was sent to your office, but you are not there, you are at the cottage). You see that ’s cough was diagnosed as post-nasal drip secondary to acute sinusitis and a script was e-scribed to his local pharmacy for an antibiotic. You rest assured that you are still on top of things and the provider treated the way you would have and go back to the beach for another swim. You don’t have a cottage? Just pretend, okay? All that being said, there is a saying “The road to hell is paved with good intentions.” While I see how telemedicine could be used to enhance health care, there are people out there….in the evil empire….who could use it to degrade health care to an unlicensed assistive personnel, a conversation with a computer and very little human contact with a medical professional when a patient needs it most. There is always a potential for things to go the wrong way, but I look at it like this…..we IMPs need to be on board so we can demonstrate our progressive mindset to patients (innovation is a positive attribute) and because whoever jumps on board first has the greatest influence for the direction it goes. I trust the intentions of IMPs and I could see it becoming revolutionary and moving health care to new levels where patients have better access. Telemedicine should not replace what we have in the office with a patient, but it can provide health care when it otherwise might be challenging to get and allow us to check in on our patients more readily. When someone has to pack up the kids and come 1 hour to see you at your office they are less likely to keep their appointment. Someday, when there is a tele site 10 minutes from their home and they could check in for a quick follow-up before their next face-to-face visit with you, they will actually have better quality health care and more continuity as they stay more closely connected for proactive, preventive healthcare. Just some thoughts to keep in mind. There are pros/cons of everything, but I think that if we use our resources appropriately, then telemedicine could improve things rather than degrade them. What do all of you think? Tammy Tammy L. McGarvey, MSN, RN, FNP-BCBoard Certified Family Nurse Practitioner