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Thursday, June 12, 2014

Telehealth and the absurdity of "place"

I have become very active in the delivery of health care via remote tools. This is one arena where the VA system is leapfrogging the civilian health care sector. The VA does not worry whether a telehealth encounter is billable. If it deliver the service faster at lower cost, so be it.

Our attempts to apply similar principles outside of the VA have been more challenging and shed light on a legacy model of care which is fixated on a host of details where are essentially divorced from actually adding value to patients. In order to fully appreciate just how off target these concerns are, it is helpful to simply step back and ask the questions:

1. What do we as physicians (and other health care workers) actually do which enhances our patient's lives?
2. What information do we need in order to succeed in these specific endeavors?
3. When communicating with patients and assisting them in making decisions, what approaches are optimal?
4. What role do direct, face to face encounters have in facilitating these activities which are central to delivery of services and adding value to our patients?

The last question is really the key one since the current payment system hold on to an uncompromising link between payment to the practitioner and some sort of real time and direct link to the patient. No face to face real time encounter, no payment. It prompts me to ask the obvious question, why? Is there overwhelming data that demonstrates that such an encounter is essential to the collection and processing of information critical for the diagnostic encounter or to the communication and shared decision making in a time frame most conducive to optimal care. I think not.

From my perspective, the hurried nature of the current models is awful. We force people to wait in "waiting rooms", waiting for their paltry 15 minutes of doctor time. The incentives are to try to do everything you can because any work done outside the confines of this frantic quarter of an hour does not count for billable work. Furthermore, it is all driven my how we are paid.

Current approved (billable) methods of telehealth drive to recapitulate the dysfunctional office encounters in the virtual world. We must stop thinking about telehealth in the terms and instead think about what we want to accomplish, what information do we need, how best to communicate, and which of those functions outlined above can be done remotely. The answer is basically all of them and they can be done better, as long as we stop trying to reconstitute the current model at a distance.

This perspective creates a whole new series of challenges relating to licensure. At this point in time, I still practice office based medicine. Patients come to me, where I practice in a state where I hold a license. However, some of these patients come from neighboring states. In addition, there are times where I may call them in follow up or communicate with them in some way. I may use a secure patient portal or my cell phone. I have no idea where they might be at the time and after they answer, I still have no idea where they are. I might be out of state when I answer and they might out of state or out of the country.

Does that mean I am in violation of state licensing laws, if I make diagnostic or therapeutic decisions and I happen not be be in the state where I am licensed at the time I am making these decisions? Similarly, if the patient who I am caring for is in another state when they are reading my instructions, is that a violation? Should they be required to come back into the state where I am licensed to read my instructions?

As the exchange of information and the delivery of care becomes less visit based and moves to a more continuous and remote data collection model, what is the meaning of the term "place" when discussing where care is delivered? Will we be required to put GPS devices on both our patients and ourselves and refuse to render care if either patient or provider is outside the licensed domain? Unless we freeze the current dysfunctional model in place, we are going to have to rethink state based licenses and the idea that care is delivered in one place.

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