My 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.
Housecall started the summer that my two daughters were away at the Kansas City Ballet Intensive. 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.
I pity the fool that does not bother to ask the question…
You must sign up as a provider and notify your patients of your availability to see them via Housecall. The patient can then make appointments with you through the scheduling portion of the app. A provider can also manage appointments through the web scheduling portal at http://www.iHeartDoc.com/Housecall. This web portal does not contain the video conferencing portion of the app, just the scheduling portion. It allows for your medical staff to help manage Housecall appointments much like any appointment is handled in your office.
- How do I bill for my services?
Housecall is covered by a growing list of private insurers but you must check with your local carrier as coverage varies widely from state to state. It is not currently covered through Medicare. Medicaid coverage varies from state to state as well. In situations where coverage is not provided you can bill the patient directly provided you notify them before providing the service. For Medicare patients you must have a signed Advance Beneficiary Notice prior to providing services to bill the patient directly for non-Medicare covered services. Credit card and insurance data is available through the app if the patient has filled out that data in their profile. No billing is done through the app. You must bill the insurance or credit card as you usually do.
- How do I document the visit? Is there an EMR in the app?
No EMR or documentation is done through the app. You use your existing EMR or dictate a note to document the visit just as you would during an in-office visit. The ability to archive the videoconference is not currently available but will be available in an upcoming version. The wellness and health data from Jawbone or Withings can be screen captured and printed if necessary.
- What health and wellness services are currently supported?
Withings is supported as well as Jawbone. Withings makes wireless scales as well as wired and wireless BP cuffs. Their Pulse activity monitor is not currently supported but we plan to support it in the future. Jawbone’s UP band is currently supported and provides exercise data, sleep data, and dietary data in graphic form. Any app on the patient’s iPhone can be captured via a screen shot and sent to the provider for review. This gives some support within the app for a wide variety of health uses and connected apps.
- What is the cost of the app for a provider?
The app services are free for the first 30 days for a patient or provider after initial app purchase. At 30 days, a provider must purchase addition time on the app to continue their use. Current cost is $9.99 per month via an in-app purchase. Discounts are available for longer range purchases up to a year of app time for $99.99 per year. Patient use is free.
- How do most providers use the app?
Most providers use the app in the same manner as a regular office appointment. The visit can be scheduled on an iPad or iPhone that can be used to conference with the patient privately in their office or an exam room. The provider can make notes in the EMR or chart during the visit. At the conclusion of the visit a nurse can arrange follow up visits via the app prior to the conclusion of the teleconference. Many providers have used the app for short visits after previous procedures or testing. It can also be used for rapid follow up of ill patients recently hospitalized to prevent readmission to the hospital.
- What kind of connection is required to use the app?
The app is capable of working on a cellular connection alone but the video quality can suffer from a noticeable lag with a poor non-4G signal. It does perform well on a reliable 4G cellular connection. For optimal quality, a good WiFi signal is preferable.