Telemedicine, or seeing your doctor over the internet, promises to cure part of the problem, but is not without its drawbacks.
Always Investigating this week broke down the numbers on a growing doctor shortage statewide. As we started digging into solutions to the doctor shortage, one of the big ideas that keeps coming up is telemedicine.
It’s a way to help one doctor see many more patients than he or she might be able to in the office. While it holds a lot of promise, there are many steps before consumers, doctors, even policies are set up to make telemedicine all it can be.
For more and more patients, when they hear “the doctor will see you now,” it might be on a phone in the palm of their hand
“Telemedicine has been described as the future of medicine for decades,” explained Dr. Matt Koenig, a neurologist based at The Queen’s Medical Center but serving patients at facilities through Hawaii via telehealth modules. “It’s really actually the present of medicine.”
Whether it’s urgent care assessments, or emergency stroke intervention from Queen’s-based physicians like Dr. Koenig, providing care and consultation by network, camera and screen is helping Hawaii’s strained doctor workforce reach more patients.
Neurologists at Queen’s serve a total of nine hospitals on a stroke telehealth system.
“They actually activate the hospital before the patient arrives,” Koenig said, “The hospital pages us and we log on to the camera. When it works well, we actually see the patient roll into the door and we are able to start examining them immediately.”
Always Investigating asked, how can they diagnose to the same level of detail that somebody by the bedside would?
“You can do a lot more than you might think by telemedicine,” Koenig said, “especially for stroke, because some of the signs that we see of stroke relate to being weak or having problems with coordination.”
Patients of large insurers and networks such as Kaiser and HMSA have access to telemedicine. HMSA pioneered care over the air in Hawaii and even nationwide over a decade ago as major telehealth vendor American Well’s first client. HMSA says maybe it was a little ahead of its time back then.
“More and more,” said HMSA Dr. Mark Mugiishi, “as millennials are patients and millennials are doctors, the concept of using technology to fulfill all of your consumer needs, whether it’s shopping or medicine or whatever is just more and more acceptable and is actually more natural.”
That’s music to the ears of big telemedicine supporters like Lorrin Kim, the state Department of Health’s chief of planning and policy.
“If I could wish for one thing,” Kim said, “it would be an entire population of folks who would walk into their doctor and say, ‘Doctor, why can’t I see you on my iPhone?’ and create that patient demand.”
That’s easier said than done. Some patients just want face-to-face visits. Physicians have to grapple with costs, privacy and security issues, and their own preferences for bedside care.
“About 15 percent of providers have reported they have had a telehealth experience,” Kim said. “Now that needs to be 75, 85, 100 percent, close to that.”
Doctors have to be credentialed everywhere they give care, so as telemedicine makes them ever-present, it doesn’t necessarily get easier for the physician.
“It’s a mountain of paperwork,” Koenig said. “We have to fill out a 50-page credentials packet, provide supporting documents that are redundant. This paperwork is very similar for each of those hospitals.”
“There are some things the state and individual hospitals could do to change their laws and policies to make it easier through rules about how hospitals are able to share credentials,” Kim said. “Some administrative burdens have been lessened. A law enacted a few months ago is an attempt to streamline the paperwork for licensure for doctors from out of state in particular. Tax incentives, medical enterprise zones, and strong reimbursement parity laws help.”
There are concerns about cost from all sides – doctors, insurers and patients. Hawaii doctors by state law now have to be paid the same for a telehealth call as an in-office visit; sometimes mainland doctors will do it for less.
Always Investigating asked, how does an insurer like HMSA keep equity and parity in rate when there are doctors who may be crossing state lines by internet?
“That’s a complicated question,” Mugiishi said, “because the model that we pay for our online care is we do have doctors in other places on the mainland. We have separate contracts. The ones on the island are seeing their own patients and we pay them a claim like we do when someone seems them at the same rate as if they saw them in the office. Affordability is a really big issue, we need to look at all the different ways.”
Doctors crossing virtual borders happens in the other direction too with Hawaii doctors serving patients outside of the islands.
“When it’s nighttime here, it’s early morning in Minnesota,” Kim explained of a neighbor-island doctor he knows. “She is able to do some early morning consultations for patients there, supplementing her income.”
Another telemedicine shortfall: It can’t be used for everything yet.
“Certainly the military has pioneered robotic surgery, for example, remote robotic surgery, that is reality,” Koenig said. “It’s not common practice at this point other than the field of battle, but it’s not science fiction anymore.”
Experts say wearable diagnostics, trackable data, even virtual doctors who diagnose you by a scan and an algorithm are all part of the future of telemedicine.
“Wearables, robots, artificial intelligence, big data, all of those things are going to come together and work,” Mugiishi said, “and the reason it’s going to work is because the young people as they age in, that’s what they’re going to expect, what they’re going to want.”
The state is working on a statewide plan for telemedicine due by the end of this year. A telehealth council will be convening working groups for all the stakeholders, meant to shrink the hurdles and drawbacks of telemedicine and help doctors see more patients.