telemedicine

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Virtual Check-Ups: The Doctor Will See Your Online Responses Now

(Medisoft via Compfight/Flickr)

(Medisoft via Compfight/Flickr)

Veronica Thomas
CommonHealth Intern

Like many patients with chronic conditions, Lesley Watts used to come in to the doctor’s office for a check-up on her digestive disorder every 12 months. This not only meant time spent in traffic and scouring for a parking spot, but also the brain fog and stress of answering her doctor’s questions on the spot.

But a year ago, when it was time for her visit, she instead  received an email reminder to pull up an online form that asked her everything her doctor needed to know about her symptoms. From the comfort of her recliner, Watts carefully answered the questions, among them: “Overall, how have your reflux symptoms been since your last office visit?” “How much have your symptoms affected your work, social, and/or home life?”

When she was satisfied with her responses, she clicked “submit.” The next day, she received instructions from her doctor about how to manage her symptoms better. Visit complete. And patient satisfied.

“It asked me questions that I had never been asked before, and as a consequence, I learned about symptoms I had not recognized,” she remembers. “I believe I received better care because I was able to take my time and provide more accurate answers.”

“We believe that it can actually increase your engagement with the system because you’re thinking about your condition outside of the physician’s office.”

– Dr. Ronald Dixon

Virtual care and tele-medicine are hot health topics, replete with weighty promises of revolutionizing healthcare. But they often refer to realtime video-chatting or texting with a clinician—whether it’s your personal provider or a random doctor overseas.

The Massachusetts General Hospital service that Lesley Watts participated in aims to conduct virtual visits without the realtime interaction.

Instead, patients complete an online questionnaire for their specific conditions, and send it to their personal doctor—whom they already know and trust—for review and response. For the past two years, primary care clinicians at an MGH Beacon Hill practice have been using over 30 different forms to follow up with some of their adult patients.

According to Dr. Amy Fogelman, a physician at the Beacon Hill practice, the clinical questionnaires are especially useful for chronic conditions that need management over time, like obesity and hypertension. In fact, the obesity questionnaire has proven more effective at helping patients lose weight than any other method she’s tried, she says. Continue reading

Tele-Coach: How An Eating Therapist Learned To Love Skype

By Jean Fain
Guest contributor

“How’d you do with your eating since last we met?” I recently asked members of my group on food issues.

“I’m really struggling,” said Heidi, a 27-year-old entrepreneur from Boston. “When I get overly full, that self-critical voice takes over. All I can think is ‘Screw it! I’ll start fresh tomorrow.’ I don’t know how not to let my eating spiral into overeating.”

Author Jean Fain while Skyping (courtesy).

Author Jean Fain while Skyping (courtesy).

Lydia, a 45 year-old minister from Akron, jumped in: “Instead of believing that self-critical voice, I’ve been telling myself: ‘That’s not what I believe.'”

“Did you hear that?” I asked Heidi. “Next time you start thinking ‘Screw it,’ you might try ‘That’s not what I believe’ or another of Lydia’s inspired responses.”

Heidi and Lydia (not their real names) are talking face to face, but not in person. Thanks to recent telecommunications advances, the 650 miles between the two are no barrier to participating in my eight-week group on using self-compassion for eating issues. Nor is a six-hour time difference. Last week, one participant Skyped in from her Lisbon hotel room.

Yes, I’ve jumped on the telemedicine bandwagon. I’m just discovering what hospitals, home health agencies and other major health organizations have been touting as the most cost-effective alternative to traditional face-to-face medicine since castor oil.

Clients with food and body image issues generally feel a lot less self-conscious attending a group remotely than up close and personal.

I knew about the telemedicine or “telehealth” trend, using technology to remotely deliver health-care services and information. But I’d never seriously considered joining the high-tech trendsetters. For decades, I’ve been happily providing individual and group therapy the old-fashioned way, and there are major legal questions about virtual psychotherapy, particularly across state lines.

According to Marlene M. Maheu, Ph.D., Executive Director of the Telemental Health Institute, “It’s the wild west. Clinicians are making up their own rules and disregarding those they agreed to follow when they got their licenses, and the consumers are at risk. They really don’t know who’s the right person to go to.”

Then, three things converged:

• Sixty-five members of The Center for Mindful Eating from around the world enthusiastically participated in my teleconference on The Self-Compassion Diet.
• My clients started complaining about sitting in traffic during the interminable reconstruction of Route 2 in Concord, Mass.
• One client couldn’t say enough about her Skype sessions with Los Angeles nutritionist and mindful eating author, Evelyn Tribole.

So I asked myself: “Why not Skype with clients?” Well, because telemedicine has real downsides. Besides the fuzzy legal regulations, I had at least three other concerns: Continue reading

Doc Punished For Treating Patients Via Skype: What To Make Of It?

(Wikimedia Commons)

(Wikimedia Commons)

Last week, the Oklahoman news Website NewsOK.com reported that Dr. Thomas Trow, a doctor living in “far Eastern” Oklahoma (read: towns few and far-between), had been disciplined for treating patients over Skype for mental health issues.

He was accused of prescribing them medications without ever having physically met with them; his response was that his nurse traveled to satellite clinics to meet the patients and present them via Skype. Also, NewsOK reported, “He stated that he did not think he had to see patients in person since they were psychiatric patients.”

According to the complaint against him, one patient overdosed three times in six months, NewsOK reports. “The patient known as R.C. died while under Trow’s care — as did two other patients during the same time — but investigators said Thursday that those deaths were not attributable to Trow.” The penalty:  “Trow was placed on probation for two years and ordered to complete a course on prescribing practices,” NewsOK says.

Telemedicine run amok? Or a reasonable rural strategy that went awry? We asked Dr. Joseph C. Kvedar, founder and director of the Center for Connected Health at Partners HealthCare, to comment.

Dr. Joseph C. Kvedar
Guest contributor

The medical board of the state of Oklahoma recently sanctioned a physician for using Skype to conduct patient visits. A number of other factors add color to the board’s action, including that the physician was prescribing controlled substances as a result of these visits and that one of his patients died. This situation brings up several challenges of telehealth — that is, using technology to care for patients when doctor and patient are not face-to-face.

• Legal/regulatory: On the legal side, physicians are bound by medical regulations set by each state. It appears that the use of Skype is not permitted for patient care in Oklahoma.

• Privacy/security:  Skype says its technology is encrypted, which means that you should not be able to eavesdrop on a Skype call. That would seem to protect patient privacy. At Partners HealthCare, we ask patients to sign consent before participating in a ‘virtual video’ visit. Because this is a new way of providing care, we feel it’s best to inform our patients of the very small risk that their video-based call could be intercepted. I don’t know if the Oklahoma physician was using informed consent or not.

But the most interesting aspects of this case involve the question of quality of care. Can a Skype call substitute for an in-person visit? Under what circumstances?

Video virtual visits are a new mode of care delivery. Whenever anything new comes up in medicine, it is subject to rigorous analysis before entering mainstream care. That same rigor applies to video virtual visits. Although some studies suggest virtual visits can be useful, the evidence is not yet overwhelming. I can’t say with 100% certainty how virtual visits will best be used, but based on several pilot programs under way at Partners, I have a hunch or two.

We have believed for some time that this technology should be limited to follow up visits, where the patient and physician already have a well-established relationship. Continue reading

Do You Really Need A Doctor F2F?


Dr. Joseph Kvedar wants to talk about Emotional Automation, and I second the motion.

He’s a telemedicine expert and director of the Center for Connected Health at Partners. I’m a regular person who would be thrilled if I could just Skype any checkup that requires no laying-on of hands. But I seem to be atypical. As Dr. Kvedar contemplates why the health care system is so slow to adopt alternatives to costly face-to-face doctor-patient office visits, he writes in a new blog post:

I now think that the primary roadblock is a psychological one. Providers, and to a lesser extent consumers, intuitively believe that quality care means meeting one’s doctor face to face. The main reason for this belief, by both parties, is that a trusting, caring relationship with a provider is thought of as a cornerstone of effective care. While it it undoubtedly true that trust is critical for an effective relationship and that effective relationships with providers lead to improved care (the likely best explanation for the placebo effect), I want to call into question the assertion that these relationships have to be human-to-human or face-to-face.

In fact, he writes, his center’s work has shown that alternatives can be highly effective:

In our own [Congestive Heart Failure] telemonitoring program at Partners Healthcare, we have cared for more than 3,000 patients with CHF using in-home monitoring of weight, blood pressure, heart rate and oximetry. Using this approach, we have seen readmissions drop by 44% and we are able to care for a daily census of 250 patients with 3-4 nurses. Considering that those same nurses, in a certified homecare agency model, would be caring for 4-6 patients daily, the impact of telemonitoring on extending the reach of providers to larger populations of patients becomes evident.

Ah, the academic-style understatement. Yes, the impact of telemonitoring “becomes evident” — as a potentially huge saver of labor and money. He points to another example of a “computerized relational agent” — a virtual nurse who speaks to hospital patients from a bedside screen for discharge planning. Patients “preferred the agent to a health care provider, because she did not talk down to them, was not in a hurry and allowed them to ask the same question multiple times.”
He concludes with a call to action:

Lets call this phenomenon Emotional Automation. Lets start a dialogue about it. Is it far fetched to think that we could parse provider work flow into those actions that truly require a real-time interaction with a provider and delegate others to technology? Can we set up systems that are extensions of our providers that will allow patients to feel cared for by their doctor but be interacting with a piece of software or a robot? How many examples can you come up with? What are the pros and cons of this approach?

Readers, what do you think?

Take Two Aspirin And Skype Me In The Morning

How many of your medical appointments could be done just as easily by video-conference?

Radio Boston talks with Dr. Ronald Dixon of Massachusetts General Hospital, who argues that something like 60 percent of visits could be done on-line. Also weighing in is Dr. Amy Ship, an internist at Beth Israel Deaconess Medical Center.

My vote: Heck, yes, in many cases. Anything that avoids the endlessly spiraling garages in the Longwood Medical-Industrial Complex is a good thing.