Removing Barriers to Virtual Doctor Visits

In the digital age, telehealth should be a no-brainer. But barriers have slowed adoption by doctors and patients. Telehealth enthusiasts are looking for some help from the legislature to lower some of those barriers.

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Editor's Note: This story first appeared in North Carolina Health News and is reproduced here with permission. 

When Cody Hand’s 3-year-old daughter fell and chipped her front tooth, he took her to the emergency department at WakeMed Hospital in Raleigh, North Carolina But the doctor there was unsure what to do about her tooth, so Cody dialed up a friend who’s a pediatric dentist.

The doctor, dentist and Hand then did a FaceTime consult on Hand’s iPhone.

“It was a non-secure link,” said Hand, who happens to be the vice-president for governmental affairs for the North Carolina Hospital Association. “But that was OK with me. It was just a dental issue.”

“But it shows how telemedicine can work,” he said.

In many ways, most of the U.S. is behind the curve on using telemedicine. In the developing world, doctors have been doing X-ray consults via smartphone for years and the Native Health Service in Alaska has been using a form of telemedicine since the 1970s, when the NHS provided satellite hookups to every remote clinic in a Native village.

In North Carolina, telemedicine remains a health care resource that’s been underutilized. But it looks as if that might be changing. A telepsychiatry program is in the process of scaling up statewide after a successful pilot. More hospitals and more providers are getting wired to do things like stroke care from a distance, and the costs of getting set up are coming down.

But there are still roadblocks to widespread acceptance by physicians. That’s why telehealth leaders were at the North Carolina legislature last month – to ask for some help.

Seven Minutes

“Patients are very accepting to telehealth,” said Alan Stiles, a neonatologist with University of North Carolina Health Care who’s been working to get hospitals in the UNC network more wired.

Stiles came to the state House of Representatives Health Committee last month to talk to lawmakers about telehealth initiatives throughout the state.

“Many studies have been done, and in seven minutes the patient is no longer aware that they’re doing a videoconference with their provider,” he said of the state’s telepsychiatry program, which is in the second year of a statewide scale-up.

But Stiles said grant funding of initiatives such as the telepsychiatry program are an inefficient way to approach telehealth.

He said the problem is that “as soon as the grant funding or the state money goes away, the programs just close and the patients lose access.”

That happened at the Roanoke Chowan Community Health Center in Ahoskie, North Carolina. The center had a telehealth program supported by state dollars until 2013. But when the state money went away, the program went away, even though it had saved Medicaid millions and kept patients healthier.

“I’m not taking any more grant money,” said Kim Schwartz, head of the clinic. She said the clinic still has some telehealth services, all supported by contracts with private providers, mostly in other states.

Until recently, Stiles said, the state boards of medicine and pharmacology frowned on telehealth, fearing it would be used to do shoddy patient care. It used to be that doctors couldn’t prescribe medication via telehealth, and pharmacists were forbidden to give medications if they believed there was no physician visit behind the prescription.

But both boards have been working on new rules around telemedicine to ensure quality interactions.

Stiles said many doctors are afraid of being sued if something bad should happen to a patient with whom they’d had a telehealth session. He also told lawmakers that there hasn’t been a single malpractice claim in the close to 20 years he’s been involved in remote care.

“We don’t do tons of it. But we do some, and there hasn’t been any issue,” he said. “Nationally, there is also the same trend; there are very few malpractice suits that come up. But to convince physicians that’s true is another discussion area. That’s hard to do.”

But the biggest issue, Stiles told lawmakers, is reimbursement. Currently, there’s no “parity” law for time spent on a telemedicine visit.

He encouraged the state to follow the lead of those that have parity, whereby “you’re paid the same whether you do a face-to-face with the patient or whether you do it by telemedicine.”

Without payment parity, Stiles said, the spread of telemedicine will continue to be slow.

Remote Surgery

Lou Martin is one doctor who has embraced telehealth, so much so that he’s started seeing patients using a robot on one end.

Martin performs orthopedic surgery at the North Carolina Specialty Hospital in Durham, then goes home to Wilson, about 70 miles away. Instead of driving back and forth every day, he uses a robot to do post-operative rounds on his patients back in Durham.

The robot has allowed Martin to “see and interact with my patient.”

He said that as he drives it down the hallways, people try to give him high-fives. “But I don’t have arms with the robot.”

Martin gave lawmakers a live demonstration, driving the robot down the hospital hall and into a patient’s room – all from a podium in the committee room (see video below).

Martin said nurses accompany him on his robotic rounds to assist.

“We’re interacting over the patient together,” he said.

He said the robot also helps promote interaction with the patients and other staff, and that it promotes efficiency.

“We have access, it’s easy to use, the patients like it, the nurses like it, and I think it’s a great way to promote continuity of care and safety, because I get to see my patients,” Martin said.

He asked legislators to help advance telehealth by enacting parity and malpractice legislation.

Dr. Lou Martin demonstrates to the North Carolina House Health Committee how he can conduct follow-up care to surgery patients using telehealth.

Technical Glitches

Blue Cross and Blue Shield of North Carolina has been providing insurance coverage for telehealth for some time, said Darcie Dearth, a company spokeswoman. She said it’s a great way to get access to care to people in rural areas.

However, Dearth said her company has issues with creating parity between telehealth and regular physician visits, saying the market has yet to “assess the value” of telehealth.

“It’s a new market, and I think it’s jumping the gun in terms of assessing value, especially now when the system is trying to move away from fee-for-service health care,” Dearth said.

“Should it be singled out so much when it’s only one tool in the toolkit for providers?” Dearth asked.

But Stiles said it still takes doctors time to make the visit, and they should be paid the same rate as for a face-to-face visit.

And Roanoke Chowan’s Kim Schwartz said organizations such as hers spend the money but don’t realize the savings.

“Telehealth doesn’t save patients money. It didn’t save us money; we had to pay for it,” she said. “But it saved the system money.”

The state is in the second year of the telepsychiatry grant, to the tune of $2 million per year in recurring funds, so right now there’s money for this year and for the foreseeable future.

Still, Stiles worries about state funding, which is always at risk. But one of telehealth’s champions is Rep. Susan Martin (R-Wilson), who happens to be married to Lou Martin, the orthopedist who spoke to the committee.

“For Lou, he doesn’t get to bill separately for the follow-up care,” she said.

Martin noted that some of these payment issues may work themselves out as the health care system moves toward “bundled” payment, where insurers pay for an entire episode of care – from the initial visit to assess the need for, say, knee surgery, to the surgery itself, to the follow-up visits – instead of paying for those visits individually.

“Then it makes sense for them to invest in telehealth,” because it saves the doctors time, she said. But for consultant visits or individual visits, there’s still not a way to get paid.

The legislature will probably do something to create a way for providers to bill for telehealth, but Martin said she wasn’t yet sure what a bill would look like.

 

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