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Tuesday Sep 19, 2017

Telemedicine Advances Outpace Common Sense Regulations

I never saw my patient for her UTI.

She awoke one morning with classic symptoms of dysuria, urinary frequency and some urgency. It felt like a UTI she had before. No fevers, no suprapubic tenderness. So she logged into our mobile app, did a video visit with a physician assistant, got a prescription for an antibiotic and headed to work.

[Physician speaking to patient on video call]

I did see the patient a few months later when she came in for an IUD placement. Of course, she was totally recovered from the UTI at that point and grateful for our virtual service.

Telemedicine is a cornerstone of my primary care practice. Patients can do video visits, send photos of rashes or pink eye through our app and get treated for basic conditions through a questionnaire.

Patients love the convenience and have reported high satisfaction with telemedicine visits, according to a recent study(mhealthintelligence.com). But it's a care delivery model that's not yet widely adopted (or accepted) in primary care.

In a few specialties -- like dermatology, psychiatry and radiology -- telemedicine is a routine part of care. Telemedicine is vital in rural communities, where hospitals often lack on-site subspecialists and rely on remote monitoring of stroke or sepsis patients.

And although telemedicine in these avenues is promising, the holy grail of virtual care has been its application to primary care -- the daily, routine type of care that patients need but often don't have access to.

Payers know telemedicine will be crucial to population health management in cost-containment models. The possibilities are endless. Physicians can check in on post-op or recently discharged patients, review their meds and decrease readmission rates. They can discuss lab results. Imagine chronic care management of high blood pressure: Patients report their blood pressure, and physicians adjust medications and provide education via video.

But several barriers to expanding telemedicine in primary care persist, including cumbersome state regulations, variable reimbursement models and the culture of medicine. As large, multistate health systems are discovering, no two states are alike when it comes to delivering telemedicine.

State regulations dictate how and when clinicians can utilize telemedicine. Most medical boards require the establishment of a "physician-patient relationship(www.telehealthresourcecenter.org)," which involves examining, diagnosing, treating and following up on a patient. Some states explicitly require an in-person visit to establish the relationship, but others have outlined that a video visit will suffice(www.ama-assn.org).  

And although telemedicine is designed to break down geographic borders, licensing regulations can make it difficult for physicians. Licensing physicians across state lines is expensive, and since it's less costly for nurse practitioners and physician assistants to cross-license, large health care providers have seized this opportunity to utilize mostly nonphysician health professionals in their telemedicine staffing models. Does this mean physicians will miss out on opportunities in telemedicine?

Of course, on a local level, telemedicine is still hard to adopt for a physician's individual patients. With variable reimbursements models for telemedicine, it's difficult for family physicians to incorporate this into our workflow. In some states, insurance companies cover virtual visits, but others make patients pay out of pocket.

Finally, the culture of medicine potentially stands in the way of telemedicine. The issues are more operational: How can virtual visits fit into workflow? Will services be available 24/7? Which conditions are safe to treat virtually? And what are best practices or standards of care?

The American Telemedicine Association developed telemedicine guidelines for primary care and urgent care(www.researchgate.net) based on 600 studies. Conditions like UTIs, rashes, chronic disease management and conjunctivitis are particularly convenient to address via virtual visits.

However, there is still reluctance to treat many medical conditions virtually because the technology is still quite novel, and graduate medical education training in this area is limited. A recent study(www.healthcareitnews.com) indicated that telemedicine may actually reduce access to care because many physicians feel an obligation to follow up with some patients in person, inadvertently increasing their in-person patient volume. Another concern is that telemedicine may drive up health care utilization and costs(www.modernhealthcare.com).  

But for practices that, like mine, have incorporated telemedicine into our care delivery, the model works because we emphasize team-based care. Take my patient above. I was seeing others patients and couldn't be available on demand, so I wasn't the one who treated her UTI. Rather, a dedicated team handles telemedicine while our in-office clinicians treat patients in person.

The potential for telemedicine to change the landscape of health care is endless. Apps that use an otoscope attachment already exist, allowing a remote family doctor to peek into a patient's ear. Remote ECGs, urine specimen analysis and vitals can be linked to patients' charts.

Telemedicine is projected to be a $36.3 billion industry by 2020. Hopefully, family physicians will lead the charge to integrate this type of care.

Natasha Bhuyan, M.D., is a board-certified family physician in Phoenix. You can follow her on Twitter @NatashaBhuyan(twitter.com).

Posted at 04:45PM Sep 19, 2017 by Natasha Bhuyan, M.D.

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