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Telemedicine’s Intimate Glimpse Into People’s Lives

I’ve practiced medicine for thirty years in a tremendous number of settings, but my experience in the past few months as a frontline telemedicine primary care provider has taught me many things about the state of health care that were not obvious to me from the vantage points I’ve held in the traditional health care ecosystem.

Often, I perceive things about the patient’s environment from the video that are not as apparent to me with patients who visit me at my office, where they often are putting forth their best efforts. In the more intimate setting of their own home, patients do not dress up for the visit, and often the entire family seems involved in the consult — babies crying in the background, parents or spouses whispering things for them to remember to tell me. I see patients complaining of a sick headache, laying in their bed in their PJs looking, well, sick.

I am discovering how many advantages that telemedicine can have for people compared to the traditional health care system. Here are a few examples.

Why Do Patients Hire Telemedicine?

Patients hire telemedicine because they cannot conveniently get access to primary care when they need it. Telemedicine solves for all sorts of lack of access. Patients call because they cannot get off work to make an appointment with a primary care physician office Monday through Friday 8 a.m. – 5 p.m. and don’t want or can’t afford to pay the higher urgent care copays.

They call because they need a refill on a medication or they have an acute problem and their primary care physician is too booked up to see them. They call because they live in a rural area and their primary care physician has moved/retired/left town and the closest alternative is 50 miles away. They call because they never had a primary care physician in the first place. Telemedicine consultations are available 24/7, unconstrained by geography.

Patients Seek Medical Education From Telemedicine Providers

Patients hire telemedicine to provide medical education about issues they cannot or do not want to speak to their primary care physician about. Not a week goes by that I do not get a consult from someone who wants to understand more about a diagnosis they have been given, a medication they have been prescribed, a condition they fear they have or something they feel uncomfortable asking their personal physician about or do not want their doctor to know about. 

The opportunity to have a broader discussion with a patient on their new diagnosis of hypertension and why taking a blood pressure medicine is a good idea or sensitively talking about their newly diagnosed sexually transmitted disease can serve as an additional resource for patients whose physicians have been too rushed to have these conversations. Additionally, oftentimes in the evenings, patients have questions they forgot to ask their physician about. 

Patients Use Telemedicine to Help Them Quit Smoking

One of my favorite type of consults is for smoking cessation. Patients calling for a prescription to help them quit smoking are at that point of motivation when there is a real opportunity to make a difference in their long-term health. These patient-initiated conversations happen when and where the patient wants them to happen and allow rapid access to smoking cessation drugs. 

Telemedicine Can Lower Cost of Benefits for Employers

Some employers hire telemedicine to reduce the cost of health care benefits. Telemedicine consultations can significantly reduce emergency room visits for nonurgent conditions. One patient told me her employer benefit plan reduces her emergency room copay if she calls the telemedicine company prior to going to the emergency room. 

The electronic health record I use for telemedicine videos and phone calls is the most-user friendly one I’ve ever used and is particularly helpful, as it allows patients to type their chief complaint in their own words prior to the visit. Family history, medications, prior consults and allergies are all part of the electronic record. And evidence-based clinical guidelines are easily accessible in real time for the most common conditions. 

Telemedicine, if properly designed, can provide world-class expertise irrespective of geography. 

Patient education material is electronically provided for many conditions, along with the ability to provide specific instructions for the patient, a work excuse if needed, and referrals for mental health and specialists, if appropriate.

Telemedicine Offers an Honest Glimpse Into Social Barriers

My experience with telemedicine has provided me with direct experience to the social determinants of health. The amount of morbid obesity in the patient-reported height and weight data seems much higher than what I experience in my private practice. And the lack of access to dental health is much greater than I ever imagined. Nearly every day, I have consults from patients with toothaches, cracked teeth or gum swelling who have not seen a dentist in years due to lack of ability to pay for a visit or due to no appointment availability for weeks out. 

Many patients tell me directly they are calling because they need a refill on a chronic medication and cannot afford the copay required for an office visit. My experience is consistent with findings Oliver Wyman published earlier this year:

  • At least 1 in 3 Americans didn’t see the dentist last year.
  • An estimated 42% of Americans don’t have dental insurance.
  • Health plan members diagnosed with dental and gum conditions are 25% more likely to suffer from heart disease, twice as likely to visit the emergency room or hospital, and spend on average two times more annually on overall health care costs.

The imperative for health plans to integrate dental services into their benefits structure in newly designed models of care is corroborated by my telemedicine experience, which offers glimpses to a more effective digitally accessible service delivery.

Avoiding the Vending-Machine Mentality

The concern some critics have regarding telemedicine as inappropriately over-prescribing antibiotics is valid in some cases. There is enormous pressure from patients to get an antibiotics prescription from a telemedicine consult for what are more likely than not viral upper respiratory infections. The evaluation and assessment process remains a crucial component of the experience. 

There is often a vending-machine mentality that has to be called out and corrected. They are not calling telemedicine consults to “order a medicine,” but to get a consult with a physician for a medical concern.

The telemedicine company has monthly patient satisfaction survey feedback and quality reports. My telemedicine antibiotic prescribing rate for all upper respiratory infections is around 15%, far lower than what is known to be primary care office-based prescribing rates in national studies. 

As the telemedicine industry continues to mature, there will be opportunity to provide increasingly sophisticated solutions to the health care delivery system, including improvement in patient education, chronic disease management and augmentation of primary care services as the shortage of traditional primary care continues to grow. 

Evidence-based protocols may allow extension of some services to include advanced practice providers into telemedicine practices. Nonfacility-based mental health services can provide solutions for that shortage. For patients with rare diseases, local expertise is often not available.

Telemedicine, if properly designed, can provide world-class expertise irrespective of geography. 

This piece first appeared on Oliver Wyman Health.

Grace Terrell

President and CEO of Envision Genomics

Dr. Grace Terrell is the president and CEO of Envision Genomics, chair-elect of American Medical Group Association and vice-chair of the Department of Health & Human Services’ Physician-focused Payment Model Technical Advisory Committee (PTAC)

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