One night last summer, when I was working as a medical student in an emergency room, a woman pulled me aside. Her left eye was pink and looked painfully irritated. She had been waiting for hours to get it checked but would have to leave soon to catch a train home. How much longer, she asked, before she could be seen?
A doctor was able to evaluate the patient before she dashed out the door, but her dilemma struck me. We buy groceries, trade stocks, and chat with friends across the globe without getting out of bed. Yet seeing a doctor remains a fantastically old-fashioned routine: minutes of medical attention can cost hours spent in transit or in a waiting room. When the price of losing that time gets too high, we might not even bother to be seen.
There's a potential solution to this problem: using technology to deliver health care remotely. That approach, known as telemedicine, involves locating available doctors over the Internet and connecting with them, at a moment's notice, using video chat. Telemedicine lets you see a doctor whenever and wherever you want, freeing you to choose a doctor based on merit rather than location. It can also improve the quality of medical care and reduce costs.
Telemedicine works especially well for urgent care, which deals with issues that need prompt attention but can be diagnosed and treated without an in-person exam—respiratory illnesses or urinary tract infections, for example. But it has many other possible uses. A study published last month in Health Affairs focussed on an off-hours telemedicine service in a chain of Massachusetts nursing homes. When residents got sick, an outside physician could use two-way video-conferencing equipment to see them instead of going to the facility in person or transferring patients to a hospital. Homes that used the service regularly sent a smaller portion of residents to the hospital than those that didn't. The cost savings for Medicare, which would have had to pay for those hospital visits, far exceeded the cost of the telemedicine service.
In 2010—around the time that the nursing-home study was being conducted—telemedicine seemed on the verge of a breakthrough. Milt Freudenheim wrote, in the Times, that telemedicine was "gaining traction as never before"; Bernard A. Harris, Jr., a venture capitalist, told him that Americans were arriving at "a gold rush of new investment in telemedicine."
But there was a problem: many health-care providers weren't on board. In the nursing-home study, for example, two of the facilities barely used their telemedicine services. Not surprisingly, their hospitalization rates were similar to those of facilities that didn't have telemedicine capabilities. "Simply making off-hours telemedicine coverage available does not guarantee that nursing homes will use the service," the study's authors wrote. In this instance, the staff had no incentive to learn a new system. Avoiding unnecessary hospitalizations didn't save them money—in fact, it cost them money. "As long as nursing homes pay for the service and Medicare realizes the savings that result, we suspect that the use of the service will be limited," the authors wrote.
In the wake of the Affordable Care Act, the outlook may be changing. Health-care providers are forming Accountable Care Organizations, large groups that win bonus payments from the government for meeting certain standards of quality and efficiency but lose money if their costs exceed target levels. Bundled payment schemes pay providers a fixed amount to manage a given medical condition, in contrast to the traditional model that reimbursed a la carte for each service. "In the past, we were paid for the process rather than the outcome," Thomas Nesbitt, the associate vice-chancellor for technology at the University of California Davis Health System, told me. Now, doctors have an added interest in improving their patients' health efficiently. That makes telemedicine newly attractive. "Physicians see that they can manage their chronic-disease patients on a regular basis and achieve better outcomes, and get financial rewards for that," Nesbitt said.
Policymakers are also warming to telemedicine. Medicare, which previously only paid for telemedicine in rural locations,
Interest and opportunity, of course, aren't enough. There is also the question of execution—how to schedule virtual patients, document encounters, and ensure that health-care providers get paid. To simplify logistics, the U.C. Davis Health System has a telemedicine clinic that provides technical, operational, and billing support. "The physicians just show up," Nesbitt said. But he acknowledged that, "eventually, if we want telemedicine to be more widespread, incorporating it into the normal workflow process is a barrier we will need to overcome."
Meanwhile, for-profit telemedicine companies, which compete with hospital systems for business, are gaining momentum. "Since the A.C.A., we're seeing a lot of interest in the area," Bob Kocher, a venture capitalist at the firm Venrock, told me. Kocher, who is also a physician and a former special assistant for health care in the White House, recently took part in Venrock's investment in a telemedicine company called Doctor on Demand, which launched in December of 2013. Startups like Doctor on Demand have the potential to offer what Clayton Christensen, a professor at Harvard Business School, calls "disruptive innovation"—innovation from smaller firms at the "bottom" of a market. Eventually, these firms can displace industry leaders.
In his book "The Innovator's Prescription," Christensen proposes that telemedicine can be disruptive if it is used to "extend care into areas of nonconsumption, where the alternative is no health care at all." If competing against nonconsumption is telemedicine's best bet, the people to woo are not payers, providers, or policymakers, but patients. That may be why Doctor on Demand is marketing its services directly to consumers. One of the company's founders is Jay McGraw, the son of Phil "Dr. Phil" McGraw and the creator and executive producer of "The Doctors," a daytime talk show about health and medicine. On his show, Dr. Phil recently demonstrated how the service might work. "If you wanted to see my throat…could I show it to you?" he asked a Doctor on Demand physician via video chat, aiming an iPhone camera at his open mouth. "What if you just need a prescription refill?…What about something like"—he feigned a cough—"Viagra?" The audience laughed and clapped.
As gimmicky as these tactics seem, Doctor on Demand may have tapped into a psychological truth: behavior change is as much about emotion as it is about reason. Simply recognizing the benefits of telemedicine isn't enough; patients must want to use it. "It's like going from buying clothes in the store to online," Pat Basu, the chief medical officer of Doctor on Demand, told me. "The user experience needs to be good, or they won't do it."
Perhaps the user experience will never be good enough to replace face-to-face medicine entirely. Skeptics say that there is no substitute for human touch. In his 2011 TED Talk, titled "A Doctor's Touch," Dr. Abraham Verghese warned against losing the physical exam, stating, "We're losing a ritual that I believe is transformative, transcendent, and is at the heart of the patient-physician relationship."
Then again, as care becomes more accessible, the patient-doctor relationship could change for the better. By turning occasional encounters into ongoing dialogues, telemedicine could enhance, rather than diminish, the human capacity for connection. "A lot of people think it's about the technology," Nesbitt said. "But it's really about a new model of care that the technology facilitates."
Rena Xu is a student at Harvard Medical School and Harvard Business School. She has written for the Web site of the Atlantic and for the New England Journal of Medicine.
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