Eyeworld

38 March 2018 EW NEWS & OPINION Insights by J.C. Noreika, MD, MBA Visiting a doctor, many Americans will choose convenience over cost and quality. Entrepreneurs are scrambling to see that they get it A merica's healthcare indus- try has overtaken manu- facturing and retail as the nation's largest employer. In 1924 Calvin Coolidge famously stated, "the chief business of the American people is business." An aggregate comprising 17.2% of GDP, one assumes that citizens perceive healthcare an irrefutable benefit. Clinicians know otherwise. Like Einstein's quest for the Unified Theory of the Universe, no government, politician, bureaucrat, or consortium of billionaires (more on this in another column) have yet discovered its Rosetta stone to unlock how cost, universal access, timeliness, and quality of care orchestrate into a harmonic compo- sition. Not that they don't try. Duffy et al. recommend a high tech method to promote access to quality care while lowering cost. 1 The authors contend that non-visit interactions are as old as Alexander Graham Bell but are "improvisa- tional." Physicians need to embrace a formal telehealth grid like that of Kaiser Permanente. Exploiting secure email and video, virtual visits comprise more than 50% of its more than 100 million annual patient encounters. Kaiser Permanente CEO Bernard Tyson claims that virtual visits have outnumbered office visits since 2016. There is much to recommend telehealth. As patients' demand for care increases, our country will be 90,000 physicians shy of need by 2025. Demonstration projects have preferred in-office evaluations. That number likely explodes when elder- ly patients with chronic diseases are surveyed. According to the Centers for Disease Control and Prevention, 86% of all healthcare spending is attributed to chronic diseases whose successful management requires both medical intervention and be- havioral-risk modification. There is a tendency to assign words more power than they possess. Technology's buzzwords— machine learning, artificial intel- ligence, blockchain, augmented reality, telemedicine—are imprecise terms. They are tools, means to an end. They should not be conflated with solutions to the global paradox of growing demand and inevitable cost control. Yet, I sense virtual visits have utility. When properly implement- ed, they can enhance efficiency and access. Virtual visits improve productivity by liberating time for the clinic's most expensive assets, physicians, to attend those things that matter most. Invariably, those things—cancer, dementia, major surgery, vision loss—require human connection, a compassionate face- to-face encounter that seamlessly weaves science with medicine's life-affirming art. EW References 1. Duffy S, et al. In-person health care as option B. N Engl J Med. 2018;378:104–106. 2. Resneck JS Jr., et al. Choice, transparency, coordination, and quality among direct-to- consumer telemedicine websites and apps treating skin disease. JAMA Dermatol. 2016;152:768–75. 3. Ashwood JS, et al. Direct-to-consumer telehealth may increase access to care but does not decrease spending. Health Affairs. March 2017. Editors' note: Dr. Noreika has practiced ophthalmology since 1981 and has been a member of ASCRS for more than 35 years. Join the discussion on this article and others on the EyeWorld blog at blog.eyeworld.org. Contact information Noreika: JCNMD@meditrends.net found that patients want simplicity and nimble efficiency; traditional ties to primary care providers no longer hold. When average emer- gency room visits cost an estimated $1,734, advocates tout the virtual visit's cost effectiveness. The Rand Corporation found that telehealth visits cost $79 compared to about $146 for an office visit. Doctors Without Borders employs telehealth to facilitate virtual collaboration on challenging cases among physicians in Niger, South Sudan, and other countries with 280 experts around the globe. Providence-St. Joseph Health System operates 33 clinics in four states. Clinical visits transpire via smartphone, tablet, and comput- er. For a monthly fee, the Cleveland and Mayo Clinics and others offer small hospitals doctor-to-doctor consultations. Although patients cannot be charged for the service, rural hospitals find it cheaper than recruiting their own specialists. Us- ing telemetry and enhanced video, world-class organizations a half continent away monitor small ICUs unable to provide 24/7 physician coverage. A 35% decrease in average length of stay and 30% fewer deaths have been documented. The virtual visit is not without drawbacks. It muddles boundaries of what constitutes medical prac- tice. Regulated by individual states, oversight of telemedicine lacks stan- dardization. To prescribe treatment, most states require physicians to be licensed within the state the patient resides. This will change. More than 200 bills addressing telemedicine have been introduced in 42 legis- latures. At the time of this writing, 17 states have formed a coalition to permit a physician licensed in a member state to obtain rapid licen- sure elsewhere. But other regulatory and legal headaches add cost to ini- tiatives whose reimbursement lags innovation's promise. In 2016 smartphones captured 81% of the mobile phone market. Embracing these immediate gratifi- cation marvels abetted by lightning fast browsers, patients' expectations have changed. Convenience is the norm. Users equate a trip to the doctor's office with a time-consum- ing imposition. Sometimes they are right; the quandary is knowing which conditions, e.g., viral ver- sus streptococcal pharyngitis, lend themselves to protocols that can be safely managed without actually seeing, touching, and swabbing the patient. Dermatology sits at ground zero of virtual visits. Children's Hospital of Philadelphia (CHOP) recently awarded a $500,000 contract to de- velop a system. iDoc24's First Derm has a patient take two pictures of their skin problem and answer a few brief questions. "Within 24 hours a board-certified onlime (sic) derma- tologist will reply with professional information about your condition." The cost to a credit card is $29. According to the Wall Street Journal, most of the dermatologists are in Eu- rope. Researchers posing as patients with skin problems found that of 16 telemedicine sites visited, fewer than one-third disclosed physician cre- dentials, 32% failed to discuss side effects of prescribed medications, and many misdiagnosed potentially serious conditions after failing to ask follow-up questions. 2 CHOP must aim higher. Another company called First Opinion markets itself as "the free way to talk to a doctor." The physi- cians are in India; if a prescription or test is required, a locally licensed physician joins the conversation for $39. First Opinion's Facebook pages are populated by millennials. They awarded it more than 6,200 "likes" and 4.6 stars. Are virtual visits cost effective? The most read article in Health Affairs in 2017 contended that telehealth increased access but did not decrease cost. 3 Costs rose because only 12% of telehealth visits replaced in-office visits. 88% of costumers represented new demand for services. For liability reasons, in-office follow-up and lab tests were often recommended. Industry disputes the results as outdated. HealthMine polled 500 tech savvy patients and found that 42% Dr. Telescreen will see you now J.C. Noreika, MD, MBA

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