As medical students, if we were lucky and trained in the right era, we were taught how to interact with patients in the clinic in a compassionate and professional manner so that patients would trust that we care about them and understand how to keep them well. As technology and reimbursement strategies evolved, barriers to this goal emerged, including lurking in the electronic medical record and the increasing pressure for shorter clinic visits. For patients, their clinic visit with us may have been the most important task they did that week, month or year. They may have taken a day off from work and lost wages, driven many miles, spent money on childcare, and worried about what they might hear, only to be shuffled in and out of the visit. I often worry that patients don’t feel that they’ve gotten what they deserve from the commitment they made to come to the office. When I first learned about telemedicine, my initial reaction was that it would make all of this worse. But I’ve since discovered that this is wrong.
The term telemedicine is actually quite broad, because it is an umbrella term that includes telemonitoring, tele-education, teleconsulting and telecare. Telemonitoring refers to the monitoring of patients through mobile apps, phone calls or other reporting systems to “track” your patient. Tele-education includes webinars and other forms of online teaching. Teleconsultation refers to programs such as remote intensive care units and emergency departments (EDs) or real-time neurology consultation. Telecare is the patient–doctor interaction via video conferencing — and I am the most intrigued by this! Based primarily on watching The Jetsons (Warner Bros., Burbank, CA) as a kid, I was sure that health care could be successfully delivered remotely. Once technology caught up to us, an entire new way of being a doctor has emerged.
Quality metrics such as ED visits, hospital stays and steroid and narcotic use were no different than the metrics we gathered prior to instituting the tele-IBD clinic.
The Institute of Medicine’s Triple Aim framework includes providing cost-effective care across a population and coupling that with an excellent patient experience. The newer Quadruple Aim framework adds to this by improving the clinician experience. These aims are difficult in day-to-day practice, but telemedicine can help. At Dartmouth-Hitchcock Medical Center in Lebanon, NH, we run a regular telemedicine clinic for patients with inflammatory bowel disease (IBD).1 One-half of our patient population drives between two and four hours round trip for an office visit. It is probably difficult for most of you to think of the last time you drove this distance for a 20- to 30-minute conversation. Although it is easier for patients, telecare is at real risk of tainting the quality of care delivered. So, we studied this and asked patients. These patients consistently felt that they had enough time with their health care professional and that his or her physician understood their current disease state, and most preferred to continue with telecare visits rather than coming to the office. Quality metrics such as ED visits, hospital stays and steroid and narcotic use were no different than the metrics we gathered prior to instituting the tele-IBD clinic. This was all while saving costs, improving the patient experience and spreading our reach of care for our northern New England patient population. If we add in a satisfying and relatively low-burden (and fun) experience for the health care professional, then we also showed that the Quadruple Aim framework can be achieved with telemedicine.
Telemedicine still has a long way to go. I went through a tedious process of obtaining state licenses in Maine and Vermont (in addition to my regular license in New Hampshire); however, the laws are changing. I am not receiving relative value units (RVUs) or reimbursement for these visits, but keeping patients who live a long distance as part of our IBD Center brings far more downstream revenue that is lost from giving away the relatively nominal telemedicine charges. This, too, will change, and I suspect that, in the near future, telemedicine visits will be covered just like any office visit and generate RVUs.
The Jetsons first aired in 1962 and depicted a utopian society set in 2062, where people lived in houses in the sky, had talking dogs and drove flying saucers. Their far-out imagination is fun to consider, but their prediction of doctors taking care of patients using telemedicine came true nearly 50 years earlier than expected. There is no question that telemedicine will be part of our future. It is just a matter of learning how to use it properly and letting the regulatory and reimbursement aspects catch up to the technology. We must also respect the fact that technology is not perfect. The Jetsons also predicted video-assisted endoscopy with a device called the “peekaboo prober.” It misdiagnosed George, who was told he was dying. It turned out the device was wrong: he lives on eternally.
Dr. Siegel is a consultant for Abbvie, Amgen, Celgene, Lilly, Janssen, Sandoz, Pfizer, Prometheus, Sebela and Takeda, and has received grant support from the Crohn’s and Colitis Foundation, Broad Medical Research Program, Abbvie, Janssen, Pfizer and Takeda. Dr. Siegel is a member of the Clinical GI & Hepatology Editorial Board and the National Scientific Advisory Board for the Crohn’s and Colitis Foundation.
1. Li, S.X., Thompson, K.D., Peterson, T., et al, Delivering high value inflammatory bowel disease care through telemedicine visits. Inflamm Bowel Dis. 2017;23:1678-1681.