Last week we examined how, in a typical practitioner’s day, he or she often needs to make adjustments in patients’ care to keep them on the path to getting –- or staying — healthy.
Usually a face-to-face physical exam isn’t necessary to make accurate changes to a patient’s care regiment. Instead, all discussions can be done via a form of telemedicine, such as a phone call, email, or video-conferencing. Unfortunately, it’s become standard that face-to-face time is required between patient and doctor, creating more hassle for the patient while not impacting the quality of the outcome.
I’d like to visit the case of a particular patient, Mrs. EE, and discuss how telemedicine allowed me to make small, ongoing adjustments to her medical regiment quickly and easily, and with very positive outcomes.
Mrs. EE is a 79-year-old homebound patient. She recently was discharged from the hospital after developing bilateral deep thigh vein thrombosis. At discharge she was started on Coumadin (warfarin) by mouth to be monitored and the dose adjusted to an INR standard of at least 2.5 before stopping the Lovenox injections, which were being given twice a day by a trained nurse assistant.
We arranged for a visiting nurses association to draw routine lab work to monitor the bleeding times and report response so we could adjust the Coumadin dose properly and decide when it was appropriate to stop the Lovenox. Over 10 days, the visiting nurse called me on my cell phone every 2 to 3 days, with the INR results. The Coumadin doses then were adjusted appropriately (and we’ve now arrived at the proper Coumadin dosing).
If I had any doubts about managing the anticoagulation therapy, I instantly could pull up one of many algorithms built into our EMR that are managed by our doctors. These algorithms would help me with a decision tree for Coumadin dosing change and frequency for getting the next blood test. I could gauge when the next INR was to be done and when to discontinue the Lovenox injections.
I now get monthly phone calls from the visiting nurse regarding Mrs. EE. Both she and the patient have my cell phone number. My fees during the first 2 weeks of starting the monitoring was less than $200.
The patient now pays me $25 a month to have me supervise her Coumadin dosing and to have my cell number on her speed dial. She much prefers this to the second option: organizing two people to get her into a wheelchair and moved into a car and finally wheeled into a doctor’s waiting room for the privilege of figuring out how to manage her Coumadin dosing.
These small tweaks are examples of discussions that I have least five times a day. Multiply this exercise at least five times a day for every doctor in the country. Imagine how much time and money –- real money -– is being wasted on people trekking to an office visit when something as simple as a phone call can provide the right care. The power of a doctor being paid to answer a phone means that patients are expecting their doctor to answer a phone and get paid to do so. But no doctor in his right mind will consistently do a micro-tweak if he’s not getting paid for it. Why would he?
Some patients will argue that their doctor will answer a phone and handle these micro tweaks for free, but believe me nothing is free, and sooner or later your doctor is going to force you into an unnecessary office visit, make you go through the hoops of hassle and delay for the single purpose of getting paid. Time is money — that’s what the bottom line is about.
Until next week, I remain yours in primary care,
Alan Dappen, M.D.