Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

The Possibilities and Pitfalls of Telemedicine

2/26/2015 2:21:52 PM | 1 comments

In January, I was told I would have to reschedule my annual check-up because my primary care physician was going on vacation later that month during my previously scheduled appointment. “No problem,” I told the office. “Just give me the next available appointment.” To my surprise, it was in 2016. The experience really drove home to me what millions of Americans go through to access healthcare services.
To better serve patients, our healthcare system must evolve. And in addition to boosting quality, improving patient experience and reducing costs, that means removing the barriers that delay and prevent care in the first place.
The Affordable Care Act (ACA) was designed to improve access by expanding coverage. However, as anyone who has tried to schedule a doctor's appointment lately can attest, having an insurance policy doesn't necessarily equate to a timely office visit. To achieve the goals of healthcare reform, we have to start thinking differently about how we deliver care.

A Numbers Game

One of the biggest barriers to access is the shortage and geographic distribution of physicians. The Association of American Medical Colleges estimates that by 2025, physician shortages in all specialties could climb as high as 130,600. Meanwhile, 20 percent of Americans — including half the populations of Mississippi and Louisiana — live in an area with too few primary care physicians.
Due to these imbalances, primary care providers are already stretched thin in many areas of the country. This creates a real bind for the newly insured. Even if they can find a doctor who's accepting new patients, they might have to wait months for an appointment. And if an acute illness or injury strikes, they often have no choice but to head to the nearest urgent care center or emergency department (ED).
So how do we reconcile the increased number of people seeking care with a deepening physician shortage? One option is to leverage technology— specifically, telemedicine systems that allow providers to deliver care to patients who aren't physically present and, in many, cases are strangers.

The Possibilities

Telemedicine (or more broadly, telehealth) is an old idea. Most of us have probably rung up the "advice nurse" at our doctor's office or insurance company. Unfortunately, in most cases, this person is constrained by a protocol and really isn't able to tailor their answers to the patient's needs.
Fortunately, advances in technology have expanded telemedicine's horizons. Faster broadband allows us to conduct "face-to-face" video consults with patients just about anywhere. And the proliferation of wireless devices capable of measuring and transmitting vital signs, weight, oxygen saturation and blood pressure has made it possible for doctors to monitor patients in faraway hospitals, Antarctic research stations, and going about their daily lives at home and work.
Here are just a few exciting examples of what telemedicine can achieve:
  • One telehealth program for patients with congestive heart failure reduced 30-day hospital readmissions by 73 percent and six-month readmissions by 50 percent. Physicians monitor discharged patients' weights and vital signs using in-home wireless devices. Patients also receive coaching, education and checks for medication adherence.
  • The California Healthcare Foundation (CHCF) provides special cameras to safety-net clinics to aid in screening for diabetic retinopathy. The digital images are transmitted to specialists for examination. (CHCF is currently holding a contest to promote the development of a computer algorithm that would screen the images electronically.)
  • In 2013, the Network for Excellence in Health Innovation published best practices for telemedicine in intensive care units (ICUs). Where there is a shortage of critical care specialists, some hospitals turn to tele-ICUs for remote monitoring and consultation. Development of this practice could help hospitals everywhere meet the needs of the growing elderly population.
  • CEP America is currently exploring telepsychiatry to expedite the care of mental health patients in its EDs. Specialist consults allow emergency physicians to treat and discharge some low- and moderate-acuity patients rather than boarding them until an inpatient psychiatric bed becomes available. It is hoped that the program will improve patient outcomes and free up valuable ED resources while reducing the cost of care.

Considerations for Adoption

Telemedicine works best within an integrated system that connects the patient's providers and fosters continuity of care. To ensure quality and prevent errors, it's important that consults be recorded in the patient's health record, and that all members of the care team have access this information. (Fortunately, growing cross-compatibility between telemedicine systems and EHRs is making this easier.)
Unfortunately, the popularity of telemedicine has prompted expansion of retail services that treat distance patients on a one-off basis. In many cases, the patient's regular physician never hears about the telemedicine consult, so there’s no continuity of care. This approach exacerbates the fragmentation within our medical system and works against the goals of quality and efficiency.
Privacy is another consideration. While patients and their doctors may be excited about technologies like smartphones, these aren't always as secure as we'd like to believe. While apps may provide patients with a useful means of self-monitoring, it's crucial that medical consults be delivered via a HIPAA compliant system.
Finally, it's important to recognize the social barriers to telemedicine. Many of our most vulnerable patients — those who are elderly, economically disadvantaged or homeless — lack access to an Internet connection and videoconferencing equipment. However, with problem solving and creativity, some providers are bridging the gap. (For example, the Veteran's Administration is encouraging recently homeless veterans to adopt a remote monitoring program through a combination of technical and peer support.)

What Are Patients Saying?

As far as patients' preferences go, telemedicine appears to be more attractive to Millennials than Baby Boomers, at least for the moment. Surveys show that people over age 55 tend to value strong patient-physician relationships over ease of access. However, this could change as coverage expands, the physician shortage deepens, and patients have more difficult scheduling appointments.
Of course, acceptance of telemedicine services also depends on the skill and sensitivity with which they're delivered. Delays, rushed visits, and lack of rapport are frustrating to patients whether the interaction takes place in person or via video. Regardless of their age, condition, or comfort level with technology, patients will only embrace this new type of care when it feels personable to them. And when it does, the possibilities are exciting.

[Image credit: "The Doctor is in your Pocket" by Juhan Sonin licensed under CC BY 2.0]

Kevin Riggs
Great concept! Our CEP site in Nashville currently does teleneurology and they love it. It does open up the possibility of providing much needed care to the remote and underserved population. Thank you for the post!
3/3/2015 10:55:09 AM