As more individuals obtain health insurance, the debate about how to provide greater access to care at a reasonable cost becomes ever more relevant. Now, telemedicine is emerging as a crucial building block in the delivery of care, according to panelists at a recent forum hosted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care here.
Panelists, from left to right, Curtis Lowery M.D., from the University of Arkansas for Medical Sciences in Little Rock; Kenneth McConnochie, M.D., M.P.H., from the University of Rochester Medical Center in Rochester, N.Y.; and Adam Darkins, M.D., M.P.H.M., from the U.S. Department of Veterans Affairs, take questions from the audience during a Robert Graham Center policy forum on telemedicine.
Implementation of the Patient Protection and Affordable Care Act is leading to increased demand that physicians interact with more patients, said the speakers, pointing to telemedicine as a potential solution. The quality of patient care is not compromised by telemedicine, the panelists noted, because it is delivered through different channels. Physicians can consult with more patients, and patients can meet with their physicians in a shorter time period. In terms of economic advantages, telemedicine can save a great deal of time for patients who otherwise would have to leave work, and it can reduce ER visits.
"Telemedicine is not different medicine," said Jason Mitchell, M.D., director of the AAFP's Center for Health IT. "It's a different interaction. Providers interact with patients and develop an intervention. Telemedicine does not mean telehealth. It's an integration of technology and care."
In a state with a large rural population, such as Arkansas, the need for telemedicine is especially acute because 73 of 75 counties in the state are designated as medically underserved.
- Increasing demand for health care, particularly in underserved rural areas, is creating more demand on physicians, including family physicians.
- At a recent Robert Graham Center health policy forum, speakers provided examples of how telemedicine was working in three separate situations.
- The technology holds promise for the future of health care, according to the physician speakers.
"I don't think where you live should determine whether you live or die," said Curtis Lowery, M.D., professor, chair, and maternal-fetal medicine director of the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) program at the University of Arkansas for Medical Sciences in Little Rock.
The ANGELS program, which is a consulting service for Arkansas' family physicians, obstetricians, neonatologists and pediatricians, received a $102 million federal grant to expand its telemedicine program. Sites are spread throughout the state, thereby increasing access to specialty care that many patients previously could obtain only by traveling to Little Rock. The practice uses a T-1 Internet connection with video conferencing technology. In addition, it is compliant with the Health Insurance Portability and Accountability Act and has 24-hour technical support.
Via the videoconferencing technology, physicians can examine a fetus using ultrasonography. Communication methods between physicians and patients do not change significantly whether they occur in an office or online, said Lowery. "You can talk with the patients the same way. Everything else is virtually the same."
For example, if the physician notices a medical anomaly in a patient in a rural location, that patient would need to schedule a visit to the main Little Rock facility. In addition, said Lowery, if a patient needs to hear bad news, he or she usually prefers to be close to home or in a familiar setting accompanied by family members.
Lowery noted that the telemedicine system could be expanded for increased use in primary care settings. It is not designed to compete with physicians in the state, he added. "Our goal is not to take away patients. We want to support the practice in rural areas."
According to Kenneth McConnochie, M.D., M.P.H., director of the Health-e-Access Telemedicine Program and professor of pediatrics at the University of Rochester Medical Center in Rochester, N.Y., parents with young children consider time and lower expenses to be valuable commodities. By increasing its use of telemedicine, the medical center reported a 22 percent reduction in ER visits among schoolchildren. McConnochie pointed out that the average telemedicine visit costs $75 compared with $750 for a typical ER visit.
"We asked parents about whether they think (the visit) loses its value," McConnochie said after the panel discussion. "They said it is so much more convenient. They save time from leaving work or school and save money. The convenience dominates over everything else."
McConnochie noted that 85 percent of pediatric primary care office visits and 40 percent of ER visits could be handled via telemedicine. If a child is injured or gets sick at school, a telemedicine specialist can be at the school in one hour. The parent does not have to schedule an appointment with a physician. In such cases, the triage nurse serves as the care coordinator, helping the family make an initial decision about care and often explaining the telemedicine process.
In larger networks, telemedicine allows individuals to take greater control of their ailments, which is a way for patients to "self-manage" their condition, said Adam Darkins, M.D., M.P.H.M., chief consultant for telehealth services at the U.S. Department of Veterans Affairs (VA). According to Darkins, 90,000 veterans in the VA network have a chronic health condition, but they are able to live independently at home because of telemedicine.
Training for telemedicine is not offered in medical schools, so Darkins noted that ongoing training of staff members is necessary for the programs to work. Telemedicine can transform medicine as much as electronic health records have if the commitment to quality management and consistent technical support is made.
Health care professionals and policymakers need to think strategically about building a telemedicine network that can serve a large pool of patients, said Darkins. "When you develop large, interoperable networks in rail, roads or air traffic, the same mistakes are made, such as overcapacity or nonstandardization."
Although capable systems are important, he added that health care professionals should not focus on technology exclusively. "The talk is all about technology, but it's really all about relationships," Darkins said. "You can have all of the technology, but if you don't have the relationships, it's not going to work."
McConnochie warned that without a protocol to determine the quality of patient service, the volume of payments could increase at the expense of patient care quality. Telemedicine can work more effectively if the current fee-for-service payment model is replaced by a bundled payment system, he said.