Doctoring From a Distance | Healthcare of Tomorrow

When Sonya Shakir’s 12-year-old son Charles developed a raging earache just before bedtime last winter, she decided to bypass the emergency room and head to a community center on Cleveland’s East Side. Within 15 minutes of arriving, Charles was lying in a high-tech pod equipped with a wireless stethoscope, blood pressure cuff, thermometer and other medical instruments, watching his mother chat by video with a doctor in a hospital several miles away.

“So you’re not feeling well today? What’s wrong?” asked the pediatrician at University Hospitals Rainbow Babies and Children’s Hospital, from a screen in the kiosk. A clinical assistant gently pressed the tip of a video-equipped otoscope into Charles’ ear, projecting images of the canal and eardrum on a second screen. “See that redness and swelling?” the doctor asked, pointing out the telltale signs of an ear infection. With a few taps on his keyboard, he sent a prescription for an antibiotic to a pharmacy for the family to pick up on the way home.

“It was like something from out of ‘The Jetsons,’  ” says Shakir, referring to the futuristic cartoon show popular years ago. Her two younger children “ran around to the back of the kiosk looking for the doctor,” she says. “They couldn’t figure out where he was.”

Thanks to rapid advances in health care technology, medical expertise is increasingly being beamed to the patient from elsewhere. Telehealth kiosks are cropping up across the country, and the pace will accelerate as pharmacy chains like Walgreens, Rite Aid and CVS begin testing them in a handful of cities. Thousands of Americans have already mastered the art of the video chat with a virtual doctor, by laptop, iPads or cellphone, to discuss a new symptom or medication adjustment. “We’re on the cusp of huge changes,” says Jonathan Linkous, chief executive officer of the American Telemedicine Association, a nonprofit trade group of health care providers, hospital executives and telemedicine vendors. “Consumers have stepped up and said this is what they want.”

More than convenience, telemedicine offers hospitals and physicians entering an era of population health management new ways to take better care of their communities. In Shakir’s neighborhood, for example, there were no walk-in urgent care centers besides hospital emergency rooms, which is why Rainbow chose that location for one of its first test sites. “Our goal was to improve the quality of outpatient care for children, increase their access to pediatricians, and decrease unnecessary emergency visits,” says Andrew Hertz, medical director of the Rainbow Care Connection, the pediatric accountable care organization for UH.

“I looked into a machine, and it took a few photos, and that was it,” says diabetes patient Sheila McKine, 60, of Philadelphia, who recently underwent an eye screening by remote experts at the city’s Wills Eye Hospital while at a dialysis appointment at her local clinic. Wills has recently expanded its public health programs by deploying mobile vans equipped with ophthalmology cameras to screen for glaucoma and damage to the retina caused by diabetes. “We’ve taken them to doctor’s offices, pharmacies, community centers and churches,” says Julia Haller, ophthalmologist-in-chief at Wills. In McKine’s case, the photos detected a cataract, which she has since had removed.

Dr. L. Jay Katz, glaucoma surgeon and Chief of Wills Eye Hospital’s glaucoma service, evaluates images of a patient’s eyes through telemedicine.(Will Figg for USN&WR)

Specialists at major medical centers, in fields from oncology and cardiology to neurology, now can be called upon to “see” patients who live hundreds of miles away. Ophthalmologists at Wills, among the top in their field, help diagnose hundreds of complicated eye conditions each month from digital photos and medical records sent by doctors from across the country. Nationwide, about 125,000 ER patients each year receive rapid virtual evaluations of symptoms such as facial paralysis and numbness on one side by remote stroke specialists. As a result, many receive vital clotbuster drugs early enough to reverse permanent damage. 

At the Levine Cancer Institute in Charlotte, North Carolina, oncologists provide access to state-of-the-art cancer treatments and clinical trials to patients elsewhere, thanks to a telemedicine network that links all hospitals and medical offices within the Carolinas HealthCare System. Oncologists in the 25 participating hospitals across the region “attend” joint tumor board meetings each week to discuss individual cases and develop treatment plans. “Genetic counselors have remote video sessions to discuss breast cancer gene mutations with a patient,” says Derek Raghavan, president of the Levine Cancer Institute. “A palliative care doctor in one location can meet remotely with doctors and patients in another to help ease chronic pain.”

(For now, doctors aren’t legally allowed to practice telemedicine beyond the state where they’re licensed. Congress has changed the law to allow active-duty soldiers to get care from military doctors across state lines and could soon allow veterans the same leeway. State medical boards are also working on plans to set up compacts that would recognize medical licenses among various states that join the compact. “We don’t consider this a fix but a step in the right direction,” Linkous says.)

Telemedicine is even becoming routine as a way to keep a closer eye on the intensive care unit. Some community or rural hospitals don’t have critical care physicians and nurses at night – or at all. About 11 percent of patients in ICUs nationwide are now cared for by specialists working in monitoring centers connected to the hospitals by wireless technology.

A Harvard Medical School study published this year found that hospitals using a tele-ICU have been able to lower death rates by preventing infections and other complications. At the University of Massachusetts Memorial Medical Center in Worcester, for example, the ICU mortality rate dropped from 10.7 percent in 2005 to 8.6 percent in 2007 after an off-site team of critical care nurses and ICU specialists began monitoring patients in two of the hospital’s locations. The team watched for electronic alerts, for response to in-room alarms, and for whether patients were getting care at the bedside that adhered to best-practice guidelines.

The latest telemedicine frontier is mental health. From military veterans struggling with post-traumatic stress disorder to children with psychiatric issues, technology is now linking people who otherwise would not have access to services to psychologists and psychiatrists who can really make a difference. A recent study published in JAMA Psychiatry showed that outcomes improve dramatically when soldiers are offered therapy via videoconferencing by a trained specialist. Researchers randomly assigned 265 veterans with PTSD to either have remote cognitive processing therapy (which involves, say, challenging their beliefs that they could have done something differently to save their buddies) or their usual care, typically involving mood-lifting medication. Those who had an average of 12 sessions of telemedicine CPT saw a six-point drop in their PTSD scores, compared to two points for the other vets.

“It’s been very personal, and he really helps me,” says Calvin Goforth, 32, an Iraq veteran from Mena, Arkansas, who is receiving CPT via video for decade-long flashbacks, lingering guilt, and other PTSD symptoms that resulted from 87 combat missions and the loss of four close friends. Goforth’s psychologist practices at the VA Hospital in North Little Rock, a three-hour drive away.

At Carolinas HealthCare, thousands of patients in nearly two dozen primary care medical practices now can consult mental health specialists over a video link. “We plan to expand this into all 200 of our primary care centers in the next five years,” says John Santopietro, chief clinical officer for behavioral health.

Such services are transforming the care available to children at 70 rural school districts in Georgia. Jennifer Jilcott’s two boys, who live in the town of Nashville, have had their earaches, stomachaches, and sore throats checked out by the school nurse in concert with a virtual pediatrician, who examines images and data transmitted from a wireless otoscope, stethoscope and penlight. Also from the nurse’s office, Jilcott and her 14-year-old son, who has autism, speak monthly to a psychiatrist at the Marcus Autism Center in Atlanta to discuss medications for his anxiety symptoms and strategies to help him stay on task when doing his chores and homework.

The state’s Medicaid program and other managed care companies recently began reimbursing providers for these programs, which have “cut health care costs by keeping sick kids out of the emergency room,” says Paula Guy, CEO of the nonprofit Global Partnership for TeleHealth, the Georgia arm of which runs the school program.

Generally, however, reimbursement policies have been a barrier to more widespread implementation of telehealth services. A 2014 survey of 57 hospital and health care executives conducted by the law firm Foley & Lardner found that while 90 percent had started adding services, about 40 percent were not always getting paid by insurers or were collecting considerably less than for in-person care. 

That may change rapidly, however, as managed care moves from paying a fee for every service to paying lump sums per patient or per medical condition, with the idea being to profit by keeping patients healthy and the number of admissions and tests and procedures down. By 2018, Medicare plans to tie half of its payments to the quality or value of care provided, rather than the quantity of the tests and treatments. This year Medicare established specific billing codes that allow providers to get paid for “remote patient monitoring” for chronic conditions like diabetes and heart failure and for annual wellness visits and psychotherapy.

For simple matters, insurers are beginning to give a green light. United Healthcare announced earlier this year that it will offer the Doctor on Demand service to its subscribers, and other insurers could soon follow suit. With this service or the many other virtual doctor websites like it, consumers consult with a general practitioner via a secure video link; such visits could result in a diagnosis of and treatment for, say, strep throat, pinkeye or a urinary tract infection. “About 6 percent of our virtual visits need to be resolved with an actual doctor visit,” with a handoff to a patient’s own local doctor, says Adam Jackson, CEO and co-founder of Doctor on Demand. “Our virtual doctors also follow up with the patients within a few days after the initial visit, especially if a medication has been prescribed.” 

What’s the outlook for surgery at a distance? A decade and a half after the first remote operation, in which two doctors in New York manipulated a laparoscope using high-speed fiber optics and surgical robots to remove the gallbladder of a woman in France, that revolution has yet to get underway. One big barrier: the computer connections needed to ensure that instructions sent from the surgeon to the robot can be received instantaneously and with no risk of tampering. “We already have robotic surgery that is done remotely,” says Thomas Lendvay, associate professor of pediatric urology at the University of Washington and co-director of Seattle Children’s Hospital Robotic Surgery Center. “But the surgeon is in the other room, not hundreds of miles away.”

Lendvay and his colleagues at 11 sites throughout the world are now testing a tele-operation system to learn more about how robotic tools can be used to perform rapidly and flawlessly. Others are working to overcome delays in transmitting directions to the surgical robot and are developing cybersecurity systems. Within the next five to seven years, Lendvay predicts, telesurgery, too, will become more common.
Excerpted from U.S. News’ “Best Hospitals 2016,” the definitive consumer guidebook to U.S. hospitals. Order your copy now.