Friday, June 24, 2011

Physician Communication: The Next Generation

Imagine using skype to contact your physician for a consult… stick with me….

In the midst of this rapidly progressing technologic era, our delivery of medical services is being transformed by Health Information Technology (HIT), Electronic Medical Records (EMR), and advanced telecommunications. In meeting criteria for “Meaningful Use”, physicians are driven to use these technologies to empower patients with communication through electronic medical records. A primary goal is to allow patients to obtain electronic copies of their medical records and share their health information securely over the Internet with their families. An overarching goal is to increase patient accessibility and communication with a physician to bolster continuity of care.

Communication. It all comes down to communication. This accessibility for patients to immediately communicate their worries of symptom or illness to a physician. The opportunity for physicians to instantaneously respond. As we embrace these technological opportunities of communication, physicians are open to new modalities for health care delivery – office visits can be supplemented not only by telephone calls, but now email, Skype, gchat, or any other imaginable resource or emerging technology.

Under the current Medicare payment system, a physician can only be paid for seeing a patient in the office. On my clinical rotations, I have witnessed an increasing number of physicians who respond to patient emails through secure health care portals. These emails promptly and conveniently enable a physician to address patient concerns. In the event that an email is not satisfactory to do so, the physician simply asks the patient to schedule an office visit. Our physicians should be reimbursed for this time.

CPT Codes exist for non-face-to-face services, including telephone calls, but these codes are not included in payment models through Medicare. Further, there is currently no established method of payment for any advanced telecommunications counseling or physician interaction.

Online physicians counseling has been increasing in the past five years – charging around 25$ for a five minute consultation – WITH the ability to provide personal prescription. These sort of interactions may be able to address simple patient questions, but really may go a long way towards harming the bond of the patient-physician relationship. Interactive care simply cannot be coordinated within the confines of a five minute video-chat.

However, I believe that there is an ever-increasing potential for the integration of these video-chats, and other counsel through advanced telecommunication, as a compliment to the traditional office visit. Imagine the typical family physician that holds normal office hours for patients throughout the day. Suppose that from, say, 1-2pm each day that physician also chose to hold online “office-hours” for any of the patients within his practice. During this time, patients could address basic questions, initiate follow-up issues, or discuss health maintenance. Just think of the wonders of diabetic counseling!!! A family doctor would have the accessibility to voice chat with a difficult or non-adherent patient once each week for five minutes, with appropriate reimbursement for time spent.

Nothing can truly supplant the face-to-face relationship between a doctor and patient. That bond and the value of that interaction can not be underestimated. Nor do I believe that proper diagnosis or treatment can be duplicated across a platform like gchat. However, with ever-rising patient needs and increasing accessibility issues, physician time is increasingly valuable. Patients too may struggle in regularly scheduling and attending office visits. Ultimately, utilizing these technologies would be cost-saving, efficient, could reduce preventable hospital admissions, expedite the identification of acute care instances and decrease time to treatment. For those patients that choose to embrace this modality, this could improve quality and patient satisfaction.

Look out - your family doctor may be armed with a Dick Tracy watch for consultation soon. Calling Dr. Smith……Calling Dr. Smith…..

Monday, June 13, 2011

Home Visits - are they things of the past?

One day in the middle of my third year of medical school, I was walking home from clinic when I met the Assistant Dean for Academic Affairs of my school, a general internist, walking down my street. We struck up a conversation and, when I asked her what she was doing on my street, she mentioned that she was doing a home visit for one of her patients.

"Home visit?" I responded in surprise. "You mean doctors still do those?"

"Yes, for a few of my patients who are home-bound."

Even though less than 100 years ago most doctors only did home visits, I had thought that today the home visit was a phenomenon restricted to only rural areas. The reasons?
  • Doctors just don't have the time nowadays.
  • Doctors can't afford to do it financially!
Little had I thought that I'd see my Assistant Dean, an incredibly busy administrator and clinician, doing home visits.

Right now, a year later, I'm doing a geriatrics rotation. During my geriatrics rotation, I spend a couple of days in clinic, a couple of days at nursing homes and rehab centers and the majority of my days doing home visits. Our school's geriatrics department is structured such that all patients who are home-bound are seen in their home environment.

Last Tuesday, my first day doing home visits, I started the day questioning the value of home visits. It was over 90 F outside and humid and, as we trekked up a hill to my preceptor's first patient, she warned me that most of her patients didn't believe in or couldn't afford air conditioning. But as soon as our first visit began, my position started to change even though sweat was pouring down my face and arms. I learned that Ms. H was falling all the time because she had numerous rugs in her apartment. I talked with Mr. E's building manager about the numerous times Mr. E had flooded his apartment and how he was at risk for eviction. Despite Ms. M's assertions that she took her meds regularly, I learned that she didn't because months worth of meds were sitting on her kitchen counter.

And not only were we clinicians learning more about our patients, the patients were also much more comfortable in their home environment. Especially for elderly patients many of whom are hearing or sight impaired, navigating a hospital or clinic's reflective floors, fluorescent lights and white walls can be frightening.

So, can we, as future family doctors, incorporate home visits into our future practices? One half day a week for our patients who need it? I would challenge each of us to leave the comfort zone of our offices and clinics and enter into the homes and communities of our patients. It is there that we can best serve them!