Monday, July 13, 2015

Modern Doctors’ House Calls: Skype Chat and Fast Diagnosis - The New York Times



The same forces that have made instant messaging and video calls part of daily life for many Americans are now shaking up basic medical care. Health systems and insurers are rushing to offer video consultations for routine ailments, convinced they will save money and relieve pressure on overextended primary care systems in cities and rural areas alike. And more people like Ms. DeVisser, fluent in Skype and FaceTime and eager for cheaper, more convenient medical care, are trying them out.



But telemedicine is facing pushback from some more traditional corners of the medical world. Medicare, which often sets the precedent for other insurers, strictly limits reimbursement for telemedicine services out of concern that expanding coverage would increase, not reduce, costs. Some doctors assert that hands-on exams are more effective and warn that the potential for misdiagnoses via video is great.
Legislatures and medical boards in some states are listening carefully to such criticisms, and a few, led by Texas, are trying to slow the rapid growth of virtual medicine. But many more states are embracing the new world of virtual house calls, largely by updating rules to allow doctor-patient relationships to be established and medications to be prescribed via video. Health systems, facing stiff competition from urgent care centers, retail clinics and start-up companies that offer video consultations through apps for smartphones and tablets, are increasingly offering the service as well.
In Philadelphia, Jefferson University Hospitals now lets patients have video follow-up visits with internists, urologists, and ear, nose and throat specialists. Mount Sinai Health System in New York is starting to offer video visits for primary care patients. Mercy, a health system based in St. Louis, will soon open a $54 million virtual care center to house a number of telemedicine programs, including urgent and primary care video consultations for chronically ill and other high-risk patients who need frequent assessments and advice.
Advocates say virtual visits for basic care could reduce costs over the long term. It is cheaper to operate telemedicine services than brick-and-mortar offices, allowing companies to charge as little as $40 or $50 for consultations — less than for visits to emergency rooms, urgent care centers and doctors’ offices. They also say that by letting people talk to a doctor whenever they need to, from home or work, virtual visits make for more satisfied and potentially healthier patients than traditional appointments that are available only at certain times.
Modern Doctors’ House Calls: Skype Chat and Fast Diagnosis - The New York Times



Several Case Examples.



Hope Sickmeier, 51, a fourth-grade teacher in Ashland, Mo., used her Anthem insurance for a virtual urgent care visit one Saturday night, three days into a toothache that kept getting worse. A week earlier, she had gone to the emergency room with a migraine and owed a $200 co-payment.
This time she grabbed her iPad, downloaded the app for the visits and scanned a list of available doctors, choosing one with “a trustworthy face.”
When the doctor appeared on her screen, she told him her symptoms and, holding her iPad close to her face, showed him her painful tooth and the swelling in her jaw.
“I was in so much pain, I didn’t care that it was weird,” Ms. Sickmeier said. “He got right to the point, which was what I wanted. He prescribed antibiotics and called them into an all-night pharmacy about 20 minutes away.”
Hope Sickmeier, 51, a fourth-grade teacher in Ashland, Mo., used her Anthem insurance for a virtual urgent care visit one Saturday night, three days into a toothache that kept getting worse. A week earlier, she had gone to the emergency room with a migraine and owed a $200 co-payment.
This time she grabbed her iPad, downloaded the app for the visits and scanned a list of available doctors, choosing one with “a trustworthy face.”
When the doctor appeared on her screen, she told him her symptoms and, holding her iPad close to her face, showed him her painful tooth and the swelling in her jaw.
“I was in so much pain, I didn’t care that it was weird,” Ms. Sickmeier said. “He got right to the point, which was what I wanted. He prescribed antibiotics and called them into an all-night pharmacy about 20 minutes away.”

One night, when her face turned puffy and painful from what she thought was a sinus infection, Jessica DeVisser briefly considered going to an urgent care clinic, but then decided to try something “kind of sci-fi.”
She sat with her laptop on her living room couch, went online and requested a virtual consultation. She typed in her symptoms and credit card number, and within half an hour, a doctor appeared on her screen via Skype. He looked her over, asked some questions and agreed she had sinusitis. In minutes, Ms. DeVisser, a stay-at-home mother, had an antibiotics prescription called in to her pharmacy.

As recently as two years ago physicians and state licensing boards were skeptical about televideo since physicians ordinarily want to see and lay hands on their patients. Some state boards such as Texas even passed legislation to prohibit such visits. This case has now gone to apellate court when physicians sued the Texas Medical Board. The case is pending. Other providers, such as those in rural states can now reach out to far flung patients.  
In Philadelphia, Jefferson University Hospitals now lets patients have video follow-up visits with internists, urologists, and ear, nose and throat specialists. Mount Sinai Health System in New York is starting to offer video visits for primary care patients. Mercy, a health system based in St. Louis, will soon open a $54 million virtual care center to house a number of telemedicine programs, including urgent and primary care video consultations for chronically ill and other high-risk patients who need frequent assessments and advice.
But telemedicine is facing pushback from some more traditional corners of the medical world. Medicare, which often sets the precedent for other insurers, strictly limits reimbursement for telemedicine services out of concern that expanding coverage would increase, not reduce, costs.  Advocates say virtual visits for basic care could reduce costs over the long term. It is cheaper to operate telemedicine services than brick-and-mortar offices, allowing companies to charge as little as $40 or $50 for consultations — less than for visits to emergency rooms, urgent care centers and doctors’ offices.
With this in mind the future is clear.  When pharmacys opened "Minute Clinics" the same attitude prevailed, and today it is accepted widely. The pharmacy's  have set a high standard using only licensed nurse practitioners. It is fast and very efficient. In fact many of these clinics used EHRs  long before private doctor offices.
The convergence of wearables, remote monitoring, telemedicine, mHealth and smartphones make bed-partners for the new era in health care.

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