By Robert Pearl, MD | Forbes.com | October 13, 2016
Hype in healthcare technology abounds. Pursuit of the next Shiny New Thing is relentless, while powerful tools that already exist are relegated to the status of an afterthought. All too often, the technology that is promoted is based on whether an entrepreneur or established technology company can generate large profits, as opposed to leading to major improvements for patients. Maybe one day wearables, Watson, robotics and single-drop laboratory testing will fulfill their promise, but not so far.
In contrast to the technologies unlikely to make a major difference, there are multiple readily available, relatively inexpensive technologies that have the power to radically improve the way healthcare services are delivered. Unfortunately, these opportunities rarely get the level of attention they deserve.
In this and my next two columns, I’ll focus on three healthcare technologies that are already achieving remarkable outcomes and changing the lives of tens of thousands of patients. In all three cases, the requisite tools are already available to most doctors in the U.S. or relatively inexpensive to purchase. None of these are theoretical or pilot projects. All come from one of the Permanente Medical Groups, the Permanente half of Kaiser Permanente, and all have been implemented successfully, some for several years. Neither I nor our organization have a financial interest in any of them, and the only benefits we receive are the favorable outcomes they provide for the millions of patients we care for across the United States.
Seeing Is Believing, Even From Afar
Video can connect physicians with their patients and one another. It allows doctors to see patients thousands of miles away, and to bring clinical experts into another physician’s office to consult on a complex clinical problem. The technology liberates doctors and patients from the constraints of distance and time. Unfortunately, across the country today, only 2% of doctors offer patients video visits. That’s because physicians have problems getting payment from insurance companies for their time, and also because the healthcare industry seldom encourages technology that generates relatively low-profit margins. Neither should stand in the way of better patient care.
I believe video has the power to revolutionize medical practice as we know it, but only if and when physicians integrate with colleagues from multiple specialties and are reimbursed based on the value they create rather than on the volume of billable services delivered. Otherwise, the opportunity to use this valuable technology will be largely wasted.
The Video Advantage In Action
Let me take you on a tour of Permanente Medical Groups across the country. These five stops will give you an overview of what’s possible today.
Telephone the advice center in Washington, D.C., when your daughter has a high fever, and you will be asked if you would like to be connected through video with an emergency physician working there. Where you’re located, whether at home just a few blocks away or thousands of miles away, makes no difference. The doctor accesses your child’s medical record remotely and asks you a few questions. Then he tells you to press a button on your phone to securely connect you with him through video. He asks you to take him to your daughter and let him have a look. This is the old-fashioned house call via modern technology. If your daughter is lying still in bed with her neck held stiff, he immediately tells you to call 911 and notifies the nearest emergency department that you will be arriving with a presumptive diagnosis of meningitis. But if she is riding her bike around the living room, he recommends everyone go to sleep and schedules a visit for the morning.
Travel to Santa Rosa, California, and talk with a urologist who happens to be an internationally recognized expert on kidney cancer. If you’re diagnosed with this cancer and referred to him, he too will offer a video visit. About two-thirds of patients referred to him prefer to drive or fly there to see him, but one-third choose to have all pre-operative work completed locally with only a video consultation before surgery. As the specialist explains, kidney cancer can’t be felt, and the diagnosis is based on radiological findings. If the patient decides on a video rather than in-person visit, the surgeon schedules the consultation for the next day, assuming all the necessary X-rays have been completed locally. During the video meeting, he shows the patient all the scans that were done, the anatomy of the urological system and the details of the procedure. The experience is at least as educational and informative as an in-office visit. As a result, in most cases—and based on patient preference—the physician first meets the patient in person on the day of surgery.
Drive south to Walnut Creek, California, and the neurologist is at home waiting for a text or call on his phone. Meanwhile, in an emergency department 100 miles away, a patient comes through the door with symptoms that suggest a stroke. Immediately the patient and the stroke specialist are connected by video. Sometimes the diagnosis remains uncertain and a brain scan is needed. But more often than not, the neurologist can diagnose the issue and instruct the ED doctor to immediately begin “clot-busting” medication. The result most often is treatment for what physicians call “door-to-needle time,” in less than 30 minutes, half the time required in surrounding hospitals. That half-hour difference saves lives and preserves brain function.
Head east to the Sacramento Valley and meet with a group of physicians managing the most complex patients, those with numerous hospital admissions each year, and they will tout the advantages of going into the patient’s home. It’s one thing to instruct people with heart failure to lower their salt intake, but it’s quite another to tour their kitchens and spot the potato chips and pretzels that explain their recurrent readmissions. It’s also one thing to talk about exercising to regain strength and another to watch people go through their daily routines.
Indeed, stop into any of our medical offices and observe the departmental meetings. You’ll hear surgeons excited about the tremendous opportunities available through video to inspect a wound for brief moments several times a week rather than only once in person. You’ll hear rheumatologists talk about achieving better clinical outcomes through frequent video evaluations for arthritis patients with no inconvenience or extra cost to patients.
Watch, too, as patients who live at a distance connect through video to receive behavioral health services and counseling, or pregnant mothers participate in a program to get off of or avoid alcohol and drugs. See the tens of thousands of patients every month on both the west and the east coasts obtaining immediate care, courtesy of video, for chronic and acute problems, from their personal physicians at lower expense. This will leave you without any doubt that the future of this technology is now.
Why Video Is So Powerful For Patient Care
Much of medical practice, often estimated to be 70%, is based on a combination of the information the patient provides through his or her history, and the overall assessment the physician makes simply by seeing the person. The subsequent physical exam enables the doctor to narrow the range of possible diagnoses, and the laboratory and radiological studies provide the specificity needed for treatment.
For example, if a patient describes progressive difficulty breathing and a high fever, and the physician can observe him expending intense effort with each breath, the doctor can be relatively confident in diagnosing an infection, most likely pneumonia. The stethoscope and X-ray clarify the location and confirm the diagnosis, and the sputum culture identifies the particular organism. Similarly, seeing how a rash is distributed across the skin, looking at a post-operative wound and watching a child with asthma breathe enable an experienced clinician to assess the problem, offer advice and, in many cases, begin treatment.
Patients who require in-person visits are grateful for the care they receive. However, on our patient satisfaction surveys, people report being as much as 10% more satisfied when doctors can use video to recommend therapy and address their problems.
What often is missed in calculations of the benefits of technology is the total cost of medical care. Video provides substantial savings by eliminating the need for patients to miss work or school, or to drive long distances through traffic for care. And parking alone in some cities today can cost as much as treatment itself. Traditional medical practice undervalues the patient’s time and underestimates inconvenience. But in a patient- and consumer-centered care delivery model, the opportunities for broad use of video become immense and worth, potentially, billions of dollars in total savings.
With the right structure in place, video provides more than convenience. It also offers a powerful opportunity to transfer expertise across long distances, and to bring specialization and expertise to patients immediately. But before that can happen, physicians must agree to link their practices with their colleagues’ and be willing to be reimbursed through a different system than the traditional fee-for-service. The federal government is encouraging greater integration through new legislation. The combination of MACRA (Medical Access and CHIP Reauthorization Act of 2015) and Medicare Advantage will accelerate the pace of change.
Personalized Medical Care
People often assume that technology and personalized medicine conflict with each other, but the opposite is the case. When physicians connect with patients they know through computers or mobile devices, the care they provide—compared to an office visit—is faster, more convenient, higher in quality and lower in cost.
In clinical practice, people often prefer a pill to treat or manage a condition to the hard work of diet, exercise and lifestyle changes. So it is likely to be with technology. Doctors are more likely to embrace a high-priced, highly promoted medical device than make the delivery system changes needed to reap the value from video. Going forward, the easy part will be obtaining the devices and connecting doctors with patients and other physicians. The hard part will be restructuring how healthcare is delivered and changing the payment systems to capture the clinical and economic value created.
The time has come for the 98% of physicians who don’t offer video to step forward and at least dip a toe in the water. When they do, they’ll most likely decide to take the plunge
This article appeared on Dr. Pearl’s column on Forbes.com.