Trust, Healthcare, and Technology

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A Failed “Trust Fall”

When you are dealing with potential life and death situations in healthcare, trust is incredibly important.  As a patient, trusting your provider is, in my opinion, THE most important element of a doctor-patient relationship.  You have to feel that your doctor is watching out for your health foremost over any consideration of financial gain, hospital influence, or outside interference.  That trust and that relationship is the very essence of quality healthcare.  That trust is earned and once lost, almost impossible to regain.

As technology encroaches more and more into healthcare, how important is that trust?  Can you gain trust in a healthcare provider you have never met before using a remote solution like telemedicine?  When you use a remote connection to treat a urinary tract infection (UTI), would you rather see YOUR provider or will any provider do?  At what point is YOUR doctor critical?  When is a transactional healthcare relationship ok and when do you need someone you really trust?

A Transactional Health System

Are we building more of a transactional health system?  By transactional I mean, I have a straight forward problem and I need an action performed by a provider. I need a retail healthcare transaction. If I need a flu shot, I can go to my primary provider, that clinic’s nurse practitioner, my local drug store, a free clinic, or even the health department.  I don’t need an assessment by a trusted professional, I just need the shot I get every fall to prevent the flu.  I don’t really care where I get it, I just want it to be quick, convenient, and cheap.  That is a healthcare transaction.  The quality of the interaction is much less important than the cost and convenience.

Chronic care of a medical condition is less transactional.  The quality of the transaction matters.  A patient with known coronary heart disease has several conditions that can contribute to their longterm condition.  The ability to pick up sometimes very subtle clues is important in longterm health of that patient.  Quality care of that kind of patient is based on the identification of symptoms that allows early detection of problems, treatment of related diseases to lower the future risk or a heart attack like diabetes, hypertension, and hyperlipidemia, and assessment (and prevention) of lifestyle factors like smoking, obesity and a sedentary lifestyle.  The best clinics have a team approach that involves physicians, nurse practitioners, nurses, dieticians, and even psychologists and exercise physiologists.  This is not a transactional relationship.  You are forming a chronic care relationship with a team to prevent recurrence of a potentially life-threatening situation like a heart attack.  Waiting on the patient to initiate a transaction is not sufficient care in that situation.

Technology and The Healthcare System

The real question for me is can we build a healthcare system that is both transactional as far as cost and convenience are concerned, and still provides quality, trustworthy relationships for serious chronic health problems?  I don’t need to come into a provider’s office and wait an hour to see a nurse for a flu shot anymore.  We have figured out a mechanism to prevent that.  There are many aspects of chronic care medicine that can also be improved by making it more transactional.  If I keep up with my weight, HR, blood pressure, and glucose readings at home using quality instruments that are just as accurate as those found in a doctor’s office, do I need to come in and let the office do those same measurements in a situation that is far from my normal?  The technology exists (and payment models already exist) for the patient to transmit their basic health data like weight, blood pressure, heart rate, glucose readings, sleep data, exercise data, and even EKG data to the provider securely without a visit to the office.  The technology even exists to allow limited examinations using high-definition video and Bluetooth connected otoscopes and stethoscopes that can rival a limited exam in a provider’s office.  Can that technology get cheaper and more ubiquitous to allow a consumer of healthcare, access to the devices to allow performance of a limited exam?  Yes, it can.  It probably will.  Do you trust that system and does it break down that critical element of trust with an in-person provider?

So, with the ability to evaluate health data and perform a limited exam remotely, can we create a quality, chronic care system that is transactional when we want and need it to be?  I think we are starting that process with Housecall Telemedicine.  We are connecting trusted providers with their patients. We are connecting the patient’s collected healthcare data to their providers and presenting it in a way that makes it easy to review and analyze.  We are allowing patients to stay at home or at their office for a limited provider visit rather than spend half a day waiting in a doctor’s office.  We are making an inconvenient, cumbersome, process of a provider visit more transactional.

Who Do You Trust?

There are levels of trust in answering a patient’s healthcare question.  That patient can ask a relative or a friend the question.  They can ask “Doctor Google” the question.  They can ask a nurse the question, or they can ask their doctor the question.  Whose answer do you trust for your health especially with a serious health question?  Does the perceived seriousness of the question matter?  Where is that nexus between trust and convenience located when it comes to healthcare answers?   Can technology bridge that gap or does it get in the way?  Those are the questions we have to answer as our healthcare system changes in the 21st century.

Data and Telemedicine: MACRA, MIPS, and Your Data

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MACRA, The Medicare Access, and CHIP Reauthorization Act of 2015 changed the way that Medicare rewards clinicians for value over volume.  It supports multiple quality programs under the new Merit-Based Incentive Payments System (MIPS)
and gives bonus payments for participation in eligible alternative payment models (APMs).  In general, it moves payment from a fee-for-service payment model to a value-based system that encourages quality and more efficient/effective patient care.  This system also is tailor-made for the incorporation of telemedicine into a value-based payment system.  Each year, we move closer to a value-based system and away from a fee for service system.  How can you dip your toe in the water of a value-based system to try it out? The Center for Medicare/Medicaid Services (CMS) gave us the answer as of January 2018.

Medicine doctor working with modern tablet computer and virtual

CPT code 99091:  Remote Patient Monitoring allows patient-collected physiologic health data that is digitally stored and/or transmitted by the patient to be securely sent to the provider.  This involves patient-collected heart rate, blood pressure, weight, glucose readings, CPAP usage, EKG readings, and pulse oximetry readings to be shared directly with the provider for monthly review.  This must be transmitted using a HIPAA-compliant, secure system like Housecall Telemedicine and cannot be transmitted by insecure mechanisms like email or text. It pays an average of $59 per patient per month nationally. Not only has remote patient monitoring been shown to improve outcomes and access to care, it also has been shown to improve cost-effectiveness and reduce hospital readmission rates.  This study from 2015 showed in COPD and CHF patients that 30-day readmission rates were reduced 50% and showed a 13-19% reduction in 180-day readmission rates. This finding was made even more impressive given that the study population consisted of underserved patients and included many who had no insurance.  Indeed there are numerous studies that show telemedicine, remote patient monitoring, and transitional care programs along with care management programs can drastically reduce 30-day readmission rates by as much as 50%.

Remote Patient Monitoring can also be used with Chronic Care Management (CCM) services (CPT codes 99490 and 99487).  These codes were introduced in 2015 to compensate providers for the routine care of complex chronic conditions that providers have delivered for years without compensation.  CCM Patients must have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, and chronic conditions that place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline.  This includes (but is not limited to) conditions such as Alzheimer’s disease and related dementia, Arthritis (osteoarthritis and rheumatoid), Asthma, Atrial fibrillation, Autism spectrum disorders, Cancer, Cardiovascular Disease, Chronic Obstructive Pulmonary Disease, Depression, Diabetes,  Hypertension and infectious diseases such as HIV/AIDS.   CCM requires at least a visit in-person yearly that can be billed separately.  It also requires a formal care plan for each individual patient that is reviewed and revised as needed.  CMS even loosened its prior restriction on telemedicine to allow Chronic Care Management Care Planning to be done directly with the patient by a care manager via an unrestricted telemedicine conference (CPT G0506) as of January 1, 2018.

Chronic Care Management for “non-complex” cases (CPT 99490) pays an average of $49 monthly nationally.

Chronic Care Management for “complex” cases (CPT 99487) pays an average of $86 monthly.

Chronic Care Management Care Planning (CPT G0506) pays an average of $59 monthly and can be done via telemedicine between a care coordinator and the patient.

Remote Patient Monitoring (CPT 99091) pays an average of $59 monthly.

A complex patient enrolled in both CCM and RPM generates an average revenue of $204 per patient per month or $2448 per patient per year to a practice.  This is in addition to in-person visits with the provider that are charged separately.

Reimbursement Update on Remote Patient Monitoring, and Chronic Care Management Codes for 2018

CMS Fact Sheet on Chronic Care Management Services

Frequently Asked Questions About Chronic Care Management

Housecall Telemedicine is a data platform that allows you to connect patient data to a direct telemedicine visit.  From the very beginning of the company, the idea of connecting patient-collected personalized data to a provider has been “THE IDEA” behind the company.  That idea was fairly out there in 2014.  Now in 2018, it is becoming mainstream.  Now that the CMS has come around with recent CPT codes that support the data connection between patient and provider, the expansion of telemedicine has clearly begun.  Good ideas from the CHRONIC ACT that were recently incorporated into law with the latest budget act passed in February 2018,  make the use of telemedicine in Medicare patients even easier.  These new rules expand the use of telemedicine in end-stage renal patients, and for tele-stroke.  It also greatly expands the use of telemedicine for use in Medicare Advantage plans and ACOs.  The use of the Next Generation ACO telehealth waiver allows ACOs to waive the geographic restriction for telemedicine use in Medicare and allows the patient to be anywhere to make a telemedicine connection to a provider.  The use of telemedicine for Chronic Care Management care planning in an unrestricted fashion continues to expand the use of telemedicine and provides improved access to care for our patients and that care is more consistently delivered.  It seems like CMS finally Cares Enough To Care and has finally begun to really answer the question Why Telemedicine?

 

Care Enough To Care

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Screen Shot 2018-03-12 at 4.57.03 PM“I can teach you medicine, but I cannot teach you to care” was a frequent saying from a mentor during my residency training.  Empathy, the ability to understand and share the feelings of another, is perhaps the most critical component in a doctor.  It is also one that is sometimes missing today in many healthcare workers.   I would venture that a lack of empathy is not just less in healthcare, but in our society in general.  Do you care enough to care?

Could a greater miracle take place than for us to look through each other’s eyes for an instant?

– Henry David Thoreau

Empathy is not just a good thing in abstraction but it translates to better business and better patient outcomes.  In a study of orthopedic patients, 65% of patient satisfaction was attributed to empathy,  the largest factor found in the study.  Satisfaction was not significantly affected by wait time for an appointment, wait time in the office, time with the surgeon, resident/fellow involvement, whether or not patients were seeking a second opinion, health literacy, or treatment choice.  Empathy was far more important.  The study showed that physician empathy was the best opportunity to improve the patient experience.  Research has shown empathy and compassion to be associated with better adherence to medications, decreased malpractice cases, fewer mistakes, in addition to increased patient satisfaction.  This translates to better overall patient outcomes, fewer hospital readmissions and an improved bottom line for hospitals.

This video is from the Cleveland Clinic from a few years ago but it makes a very important point.  If you could stand in someone else’s shoes; hear what they hear; see what they see; feel what they feel; Would you treat them differently?

56% of physicians said they lacked the time to be empathic, and 29% reported burn-out as the primary reason for their difficulty in being empathic.  One criticism of telemedicine is the lack of an in-person personal connection to the patient.  But empathy is a skill that can be utilized even through a remote connection.  Telemedicine allows the provider to time-shift a patient encounter to a time and setting of their choosing.  It changes their practice in a way that the provider has more time to show that they care.

Check out the new Housecall version and sign up today!   It is available on desktop computer, iOS, and Android platforms  Ask us about how we can help your bottom line while delivering state of the art healthcare for your patients.

Responsibility

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Healthcare Security“Do the right thing even when no one is watching.”  That was always one of my father’s axioms.  It is a philosophy of being responsible and accountable to your own personal standard and having a standard that is independent of the setting.  “The right thing” is something you know in your heart.

In business, “the right thing” is sometimes confused with “the right thing for our business” or “the right thing for our profits”.  It is easy to cut the corner in business to make things more profitable.  It is easy to focus on a short-term gain more than a long-term relationship.  It becomes easy in business to not hold your company’s standard up to your own.  It’s “just business” for many companies…

In telemedicine, we have a responsibility to get certain things exactly right every time.  Security is critical! We are entrusted with safeguarding your personal information and your electronic health data.  It is a responsibility that is not only vital to our company but a sacred responsibility to our customers.  We have our servers hosted on the most secure cloud servers in the world at Armor (http://www.armor.com). This is a company that goes the extra mile to provide top-notch security for your data.  They are responsible for the infrastructure of our servers, while we are responsible for the data put into those servers.  Our team at iHeartDoc is up to date on the latest threats and phishing/social engineering schemes that are a daily threat to data security.  Your electronic protected health information (ePHI) is safe in our HIPAA compliant, HITRUST certified servers.  Our security team undergoes regular audits and remediation analysis to ensure the most secure environment possible for your data.  Your data security is our responsibility.

As a physician, I often tell patients that the most important aspect of a doctor-patient relationship is trust.  If you can’t trust your doctor, you need to find another doctor.  The same goes with any company providing telemedicine or keeping your health data.  If you can’t trust that company to “do the right thing even when no one is watching”, you need to find another company you can trust.

Why Telemedicine?

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TelemedicineMy daughter is a senior in high school.  She is busy completing her college applications and the most common question is “Why (insert school name here)?  It is a classic question that puts the prospective student on the spot.  Do you know enough about your prospective school to say what specifically appeals to you?  Do you know enough about yourself, to know what is important about a prospective school?  I think that question is a basic question that must be answered for any important decision.  Why??  It certainly applies to a paradigm change like telemedicine.

Why would you use telemedicine as a patient?  That question is pretty easy for most patients to answer.  Do you like the experience at your doctor’s office?  Is the parking easy?  Is the wait reasonable?  Do you get a valuable exchange for the time, energy, money and general hassle that going to a doctor entails?  Was it worth it?  Would you prefer to meet with your doctor from the comfort of your home or your office?  If you have chronic medical conditions, how much time have you spent waiting on a short provider visit, how much money have you spent, how much time off work or away from your friends and family have you lost waiting for a few minutes from your healthcare provider?  Telemedicine provides a solution for many patients.  You can send your data about your health from your app, smartwatch or mobile device.  You can connect to your provider from the comfort of your home or office.  You can forget about the hassle of parking and finding your way around a hospital or medical office.  You can skip the hours spent waiting.  You can connect on your terms as a patient.  It can’t replace an in-person visit but it can certainly supplement that visit for many patients.  Telemedicine makes a lot of sense for patients.

For a provider, the question of “Why Telemedicine?” is harder.  Doctors and nurses are creatures of habit.  They don’t easily change habits that have served them well for years.  Changing a paradigm of care is certainly a big thing to ask of a healthcare provider.  Most are as busy as they can stand.  They don’t have enough hours in the day to do the work they are asked to do now.  Why would they want to learn to work in a different way?  The answer is found in almost every survey of healthcare providers today:  Doctors and nurses are not happy with the way healthcare is delivered today.  Their job satisfaction is at an all-time low.  They are asked to see more patients, spend less time with each patient, and get paid less for each visit each year.  The paperwork and EMR time is increased and the time “being a doctor” is less and less.  The answer for most is to work harder.  That just leads to longer hours and less job satisfaction.  I would propose that the real answer is to work smarter and more effectively.  One of the most valuable (and least valued in my opinion) aspects of today’s healthcare system is the concept of physician time.  The goal should be to maximize the most expert care by a physician for the treatment of the sickest patients and to allow routine preventive care that moved outside the hospital years ago, to move outside the doctor’s office today.  Telemedicine makes sense for chronic and preventative care.  It can be performed by nurses, nurse practitioners, and physician assistants as well as physicians.  It can time shift appointments to a time that works for both the patient and the provider.  The sickest patients still need to come in for an in-person appointment but the chronic, preventative care that is reviewing data from lab work, and tests, counseling about lifestyle modification, and asking questions searching for the early symptoms of disease, can all be done over a high definition mobile connection.  Telemedicine frees up the provider’s schedule to see those patients that require an examination while allowing quality care to be performed remotely by several members of the care team.  Much of that remote care is currently provided over the phone, is unreimbursed, and still carries a malpractice risk.  Telemedicine allows a higher level of care for those visits and a much more personal connection and a higher level of satisfaction for both patient and provider.

Why Telemedicine?  It is moving healthcare into the 21st century using advanced mobile technology to supplement the patient-provider connection, not replace it.  We will look back one day and wonder how we worked in healthcare the way we currently work.

How Housecall Began…

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Housecall Beginning

Housecall started the summer that my two daughters were away at the Kansas City Ballet Intensive.  Ballet Feet  It was an idea that a doctor-dad had, as he viewed his two daughter’s ailing feet from 400 miles away.  Ballerinas, for all their grace and precision, have notoriously terrible feet.  They stuff them into pointe shoes and then try to balance on their toes for several hours a day.  Young ballerinas learn to deal with the myriad ailments that come with dancing for hours at a time.  That summer intensive was my two daughter’s first experience in dancing at a pre-professional level.  Their feet were not used to the punishing schedule.  So, they turned to their dad, a Cardiologist.  I was giving them advice about foot care (not exactly my specialty) after viewing the various bumps, bruises, blisters, and sores that many hours of ballet had wrought.  I found that FaceTime actually worked pretty darn well to get an up close, high definition view of a blistered toe or a swollen foot.  A mobile phone could easily share a detailed view of what hurt.  I thought about all the times I had a patient who had called in and gone into a detailed description of some bruise or swollen area.  The call invariably resulted in telling them to “just come in and let me look at it.” 

I researched FaceTime and Skype and discovered that neither were secure enough for a medical use.  They could fairly easily be hacked.  I looked around at the video conferencing apps and products that had been around for a decade or more to connect businesses remotely to their home office.  I found that they too were not secure enough for medical use and that most companies that had tried to create a telemedicine product out of their video conferencing app had found that a medical appointment was a little different than a discussion of the latest product release.  Several large communication companies had tried and failed at finding the right way to do telemedicine.  I began to think that this was an idea whose time had come and I was in a unique position to do something different. 

I also had spent years looking at lists of heart rates and blood pressures from patients.  They came into my office with legal pads filled with their home readings over days, weeks and sometimes months.  Many patients with hypertension have fairly good BP readings at home but very high readings in our offices.  The dreaded “white coat hypertension” was reliant on accurate patient-derived data from home, but dismissed data derived by a trained medical professional in the office.  I had noticed the trend of patient health tracking via Jawbone’s Up band, Fitbit, and the at the time soon to come Apple Watch.  I saw that trend as transformative.  The patient would collect their own health data and be able to share it with whomever they wanted.  I wanted to give the patient the ability to be the collector (and owner) of their own health data but to put that data in a format that would make sense for a doctor reviewing it in a telemedicine conference.  Adding that data information to a remote telemedicine visit would allow a doctor to actually treat a patient just like they did in the office.  That formative idea was Housecall. 

A Comparison of Telemedicine and the Electrical Grid: Changing an old mechanism to a new one.

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http://www.telhealthandmedtoday.com/telemedicine-the-microgrid-and-ai/

A couple of important quotes from this article:

“Like electric utility companies, the current healthcare delivery model is based on a centuries-old concept of bricks-and-mortar—the hospital or clinic. New clinics and hospitals require investments of large amounts of capital; with measures of operational efficiency—economic return on that capital—based on bed occupancy. Yet, recent studies reveal that for many illnesses, diagnosis,6 monitoring7and prevention8,9 significantly increase health levels and decrease the cost of overall healthcare delivery.”

 

“As the poet Goethe wrote, “Art is long, life short, judgment difficult”. The implementation of telemedicine—and the realization of its many benefits—will take time and will not be easy. There are issues of vested interests (who collects the revenue), training and licensure, regulatory and legal systems, inertia of a stable system.”

Housecall can add telemedicine to your organization affordably and reach directly to the patient, import patient collected data, and connect primary providers with specialists during their visit with the patient.

Give Housecall a try today!

https://itunes.apple.com/us/app/housecall-telemedicine-your/id677557566?mt=8