Several people I know who have retired to Florida in recent years still return to the New York area a couple of times a year just to see their doctors. In the majority of cases, these are simply routine follow-ups. But in the era of expanding healthcare technology, smartphones, and tablets, this all seems pretty inefficient, not to mention expensive. Why not just reach out to your practitioner remotely? That’s been the promise of telemedicine for several decades. Now institutions like the Cleveland Clinic are moving it from trial into practice. At the recent Techonomy Health Conference in New York, we had the opportunity to sit down with Dr. Brian Donley, Chief of Staff of the Cleveland Clinic, to speak about their telemedicine program.
The Cleveland Clinic has several initiatives to broaden access to its care team, including an app which will let someone immediately access medical advice without having to travel to an urgent care facility. Dr. Donley sees it as a way of broadening access,
A great problem is access, and so the access to care is a challenge for all healthcare in America and so part of the focus in telehealth is how can we allow better access to care for people that need it and instead of the traditional driving into the hospital, parking your car, spending that time, how can we meet patients where they are. And so with telehealth we’re doing a big effort, on telehealth, for patients but also for providers. What I mean by that is we do what we call express care online and so instead of going to an emergency room or an urgent care we have an app that you can download, anywhere in the world, wherever you are, you get on the app and you can be connected to a Cleveland Clinic provider who can take care of that urgent care promptly. It saves a patient driving in to an urgent care, and many places maybe there is no access to an urgent care, and helps solve that problem as an urgent care would do it. The other important thing I think about telehealth in addition to the patient, which is important, is it allows improved care of patients in the hospital.
Price for the service is generally $49 or less per visit. Donley feels that a strong telemedicine or telehealth system can also help inside the institution.
When you’re an integrated health system or you’re a health system that might not have all the resources of tertiary care, you can actually do a telehealth consultation. if you lived in a small town in Iowa, let’s say, or any small town in America, right in your small town might not be the specialist who could handle your problem, and your doctor in your small town has you as a patient and wants to know, hey, what’re the options for this patient, we’ll actually do telehealth visits for provider to provider. It also helps with access because dermatology certainly is a place where there’s tremendous need for more dermatologists. And so we will actually have our dermatologists with advanced practice providers available on what we call, tele-dermatology to provide consultations within our system to other physicians in the Cleveland Clinic, so that they can get a quick answer of does that patient need to see a dermatologist or not, is there a quick easy answer to their questions to save that whole trip to the dermatologist.
Donley feels that telehealth can be of great benefit to a 50 plus population that’s on the move and wants to be able to take their medical providers with them. He says a big component is the ability to access electronic medical records (EMR’s),
At the Cleveland Clinic we also have a patient population from around the country and in many aspects from around the world that will access our care. A couple things we’ve done is no matter where you are, the Cleveland clinic, we have operations in Florida, in Las Vegas, in Toronto, in Abu Dhabi, and certainly throughout Northeast Ohio but we have one electronic medical record that everyone has full access to on every one of our sites so it’s an integrated health record (medical record). So it helps with that problem and it’s a drive that healthcare systems need to move towards. The other important aspect with that is just as we previously talked about, is telehealth. I’ll tell you a specific example of what we’ve done with telehealth is in our diabetes clinic. You know patients will need to be periodically checked for their diabetes, check their levels, and have a 15-20 minute check up and interaction. Many of our patients in the winter in Cleveland Ohio, you know it’s not the most beautiful spot temperature wise in the winter, they go to Arizona or Florida and so we actually connect with them through telehealth and will do their 15-20 minute checkup so they can continue with the same integrated health system, the same continuity of care which always leads to better care.
One of the issues facing telemedicine is how to make use of all the gadgets that we already own or are available that can gather specific pieces of information such as blood glucose, blood pressure, heart and respiration rates and the like. While many end users are able to gather that data, integrating that with telemedicine systems is still proving to be challenging. Donley says it’s going to take payers as well as providers to make that happen,
There’s the payer and there’s industry, all working to try to provide more affordable care at a better quality. And actually which, they are together, so better quality care is always more affordable care. I think that we need to partner better as an industry, as a provider, as a payer in order to handle that issue . I think that the amount of data that is out there right now, ends up being an overwhelming amount of data, just for the provider, and so the question is how can we use artificial intelligence, deep learning, or machine learning to help us sift through that data so that the appropriate data comes to the appropriate person In real time to then make the appropriate action to improve that person’s condition. How we will make care better quality and more affordable is by prevention. So this data, if we get the right data, and the actionable data, then that’s really the key is how we move forward and I think better partnerships are going to be essential.
He points out that the increasing ubiquity of accessible electronic health records through patient portals such as MyChart can also help improve the delivery of care
What we’ve done is all of our patients, transplant, anyone, you can direct message to your care team. An important aspect is that care has to be delivered by a team. Not by an individual. And that’s a cultural change for the patient and a cultural change for the provider but its essential back to that better access, better affordability, better quality.
Donley notes that the Cleveland Clinic has already developed a technology system for stroke victims that’s already saving lives and improving outcomes.
We developed an ambulance that we put a CAT scanner on the ambulance, so we put a mobile CAT scanner, and we call it our mobile stroke unit. In addition to the CAT scanner on the ambulance, we also have all the Telemedicine technology to transmit images of the Cat scan and of the patient back to our main campus. We worked with several communities in northeast Ohio with their EMS triage system, so when a call comes in that someone needs EMS, we’ll call the triage operator, if they ask them several questions and if it could potentially be a stroke, they specifically will send out the stroke ambulance, the ambulance will go out and assess the patient. If there’s concern for stroke, the patient gets a CAT scan on their driveway. Those images are then sent to our neurologists at main campus who sit there waiting for them. They read them, they determine if this is the kind of stroke that could benefit from the clot-busting drug, TPA. That drug is then administered on the way to the hospital. It then reverses the effects of the stroke. We’ve had some remarkable stories of individuals that were having a stroke, that would have had lifelong disability from a stroke, but because they got the drug early enough the whole treatment comes down to how fast you get that drug. So because they got that drug we’ve actually had patients come to the hospital and go home the next day.
There are still a host of issues impeding the broader adoption of telemedicine across the country. One is the fact that each of the fifty states has different licensing procedures for doctors. How does that impact medicine across state borders? Still another issue is payment. Who is going to reimburse doctors for a visit that’s conducted by iPhone instead of in a traditional office? And how does the use of telemedicine impact the workflow within the institution? Do you need to add staff, or will you reduce the number of in-office face-to-face visits? Donley admits there are still a lot of moving parts.
There are some barriers that are in the way of allowing it to move faster, move towards telehealth but those are barriers that can be overcome…….and one of the barriers is how they’re paid for and so that’s certainly where regulations can be helpful.The other concern about it is taking licensure for physicians is by your state so a barrier is that in telehealth, you take care of patients all over the country and so the barrier is that you’d need to be licensed in every state. So these are two big concerns. Two big things that we need to work through as a country with regulations and policy can be helpful in that way. I’ll tell you what’s helpful though, is the model in shifting payment to value compared to volume. And part of that is taking risk for your payment. Either downside risk or upside risk which means you provide better quality care, you actually can be financially rewarded for that. Moving farther down the scale of risk is actually capitated care. So like Medicare advantage is capitated, so you’re paid so much per member per month to take care of that patient, and the nice thing about that, and there’s pluses and minuses to different models, but the nice aspects of that is that you’re paid a fixed amount of money, it removes the whole concern of getting paid for every visit, every telehealth visit, every time the person comes in because you’re paid a set amount of money. That helps really move the telemedicine forward.