February 2nd, 2010 by Bryan Vartabedian, M.D. in Better Health Network, News, Opinion
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If you told me last year that web-base psychotherapy would gain traction I wouldn’t have believed you. That was before I met Mark Goldenson, CEO of Breakthrough, a silicon valley based web startup that matches patient and therapist through a secure online portal. Breakthrough clients can review a therapist’s qualifications and fees, view sample video, and initiate therapy by video or phone.
In a 2.0 world marked by clouds, hives and democratized healthcare, Breakthrough is cultivating one-on-one relationships through improved access to mental health services. Everyone should be talking about this. Read more »
*This blog post was originally published at 33 Charts*
December 30th, 2009 by AlanDappenMD in Primary Care Wednesdays
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A Case Report: Even a Doctor Needs to Talk to His Doctor
I love the following battery of questions I hear from doctors and patients alike regarding telemedicine: “Don’t you think it might be dangerous to answer a patient’s medical questions by phone or email?” and “Shouldn’t you handle all issues in the office with a face-to-face visits like most other primary care physicians (PCPs)?” and then “Isn’t medical care by phone or email impersonal, shoddy, and second rate?
I however argue that everyone with these assumptions is wrong, Wrong, WRONG!
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September 30th, 2009 by AlanDappenMD in Primary Care Wednesdays
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A Keynote Address To The American Telemedicine Association September 25, 2009
The following is a summary of Alan Dappen, MD, keynote address at the mid-year meeting of the American Telemedicine Association (ATA). His keynote, billed as “Private Practice And Telemedicine: A Success Story” discusses how Dr. Dappen’s practice, DocTalker Family Medicine, which is a fee-for-service practice that deploys telemedicine for over 50% of its patients needs, has enjoyed growth and has received numerous awards and media attention. You can check out Dr. Dappen’s full address on the site.
On to the highlights of Dr. Dappen’s talk:
“This is my third visit to an American Telemedicine Association (ATA) event. I’ve been a proud member for seven years. Two years ago I presented the fundamentals my medical practice DocTalker, where the doctor is chief cook and bottle washer.
“Our practice mirrors the recommendations outlined by the Institutes of Medicine’s book
Crossing the Quality Chasm and those purporting the ‘medical home’ model. Read more »
June 10th, 2009 by AlanDappenMD in Primary Care Wednesdays
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Eight years ago, the Institutes of Medicine published a paper entitled Crossing the Quality Chasm: A New Health System for the 21st Century, which envisioned the future medical practices. Many of the concepts discussed were adopted and endorsed in years to come by the American Academy of Family Practice, The American College of Physicians, the American Medical Association, among others.
The five major innovations of care outlined by this study include:
1. A communication-centered practice model,
2. Information management,
3. Technology replacing office staff,
4. Reduced pricing and transparency in billing, and
5. Removing external conflicts of interest between doctors/providers and patients.
Complete adoption of these innovative concepts can cut at least 30% of primary care costs while significantly improving patients’ quality of care, and further reduce overall health care costs by offering immediate and highly accessible care that avoids emergency room visits, enhances wellness, manages chronic illness and diagnoses disease early. These cost savings and quality improvements are enabled by utilization of advanced communications and information technology that replace much of office overhead and staff, and encourage patients to seek the most cost-effective and convenient care possible. Many medical practices have adopted some of the recommendations, yet less than 1% have transitioned to complete and consistent adoption because they frankly have few financial incentives to do so.
These innovations are the cornerstones of retooling our broken healthcare system, and in turn can pave the way to “fixing” many of the issues plaguing this system. The five cornerstones provide for what so many Americans are clamoring for yet are unable to find: continuous access to a medical provider team thus enhancing patient access, control, and convenience of care; increasing the quality and speed of treatment; reducing the cost of care; creating transparency in pricing; and removing external parties that create conflicts of interest between doctor and patient and often interfere with providing quality and speed of care to patients.
I’ve built my own primary care practice on these five concepts, and while all can significantly lower costs while vastly improving the patient experience, I’d like to take a look at the concept I find to play a pivotal role: a communication-centered practice model.
A Communication-Centered Practice Model
Twenty-first century, day-to-day-primary care starts with the primary care provider being the first in line to answer a patient’s phone call or email. During this call or email, the provider reviews a patient’s history, and bearing in mind that the provider already knows has a professional relationship with the patient, then can make appropriate decisions. At least 55% of the time, the patient’s situation does not require an office visit, however instead involves going straight to the pharmacy for medications, going to labs for tests, getting an x-ray, or recommending a referral. In this model of practice, the doctor spends at least half the time of the time answering phones and emails, thereby providing immediate access and convenience to the patient.
If either the clinician or the patient believes there is a need for an office visit, the visit is arranged immediately. Patients can talk to their medical expert or an on-call member of the medical team 24/7. This instantaneous access can result in patients having most of their day-to-day issues addressed within 10 minutes of reaching the practitioner, and can expect care from their personal provider from home, work or anywhere in the U.S.
As mentioned above, over 50% of medical issues can be addressed by telemedicine, specifically by phone or email, as long as a patient-doctor relationship exists. This results in people being healthier and on the road to recovery much faster, thus not taking time off from work. Office hours are flexible and can be arranged day or night and any day of the week including weekends.
The importance, barriers to adoption, and the unexamined assumptions as to why 97% of all medical care currently occurs in a medical office and nowhere else has been reviewed in several of our prior postings:
Are Face-to-Face Office Visits Really Required to Provide the Highest Quality Care?
In Defense of Remote Access Medical Visits
The Commonplace Tool That Can Revolutionize Health Care
Telemedicine Care: A Malpractice Risk? Au Contraire …
Telemedicine Checks In On Chronic Health Care Problems
In the future, I plan on taking a look at the additional four cornerstones that need to have traction if the Obama administration hopes to restore vitality to the primary care system.
Until next time, I remain yours in primary care,
Alan Dappen, MD
May 13th, 2009 by AlanDappenMD in Primary Care Wednesdays
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“OK,” I can hear you say, “Enough about telemedicine. So what if you can prevent two-thirds of office visits by using the phones, or that it’s convenient for the patient and can start them on the road to recovery faster, or that it costs much less money than conducting an office visit, or that malpractice companies have accepted this delivery model.
I can see that you still side with the other non-believers in telemedicine, citing, “Telemedicine is no way to build relationship with patients. Problems abound with telemedicine: It’s too impersonal, patients could easily not be telling you the truth because you lose the “body language and facial expressions,” and it certainly can’t be useful for chronic illness. Maybe it’s good for the simple problems, but this has no place with complex or chronic medical care.”
I do, of course, have some rebuttals for you …
Let’s start with impersonal. In today’s world, we let our friends and family communicate with us constantly through phones and email, and I’ve yet to see how this has destroyed the intimacy of our relationships. So why do Americans anxiously wait up to four days for a doctor’s appointment to get their problem or question resolved and waste at least four hours of a day to get to the office simply to wait for an unpredictable time for a predictable 10-15 minutes of the doctor’s time when so many issues can be resolved remotely by phone? Furthermore, try convincing someone with a urinary tract infection (UTI) or that needs a prescription refill that their long wait, suffering, and run through the primary care funnel were “good for the relationship.” In fact, nothing is more personal that a doctor saying to their patients, “Here is my direct phone number, please call me anytime you need help.” Viewing telemedicine from this perspective determines that the “impersonal” concern is a ruse to protect doctor’s privacy at the expense of their patients.
What about the patient who is not truthful? Does a face-to-face visit make this less likely? In 30 years of work, several patients I know have not always been honest. Many of these people were attractively dressed, well educated and for awhile, fooled me badly. I saw them all face to face too. To this day, I have no idea what to look for when someone is trying to pull the wool over my eyes.
If people are going to hide the truth, they can do it in person just as well as over the phone. When a doctor becomes suspicious about a patient’s truthfulness through a pattern of calls and behaviors, then a scheduled office visit may help. However, forcing office visits based on a blanket rule of thumb of not trusting your patients means there is something fundamentally wrong with the doctor-patient relationship.
Lastly is the idea that chronic disease management isn’t appropriate through phones and email. Really? Let’s say you had diabetes, or hypertension, or high cholesterol, or cancer, or depression, just to name a few. With one of these conditions, you will be in contact with your health professional a lot more than you are now. Not only is your life more complicated, but the doctor wants you to consume 10% of your life waiting to see him in person because it’s good for him. Instead, many of these visits can be conducted easily anytime through phone calls and email.
Here are some examples:
#1. A phone call: “Mr. Doe this is Dr Dappen. I see a calendar reminder that you’re due for labs to check your cholesterol and to make sure the statin drug we put you on is not causing problems. I’ve faxed the order to the lab that is located close to you home, so stop by anytime in the next week and they’ll draw the blood. I should have the results in 24 hours after your visit to the lab, and we can review the report over the phone at that time and decide if we need to make any change.”
#2. An email from a patient: “Dr. Dappen, I’ve been worrying about my blood pressure readings. Over the past 3 weeks, they’ve been running consistently higher. Not sure why and until recently the home readings were doing great. Attached is the spread sheet of readings. Look forward to your input.”
In fact, examples abound of how chronic disease management conducted via phones and email is more efficient, reduces costs, and improves outcomes; I’d invite any Doubting Thomas to visit the American Telemedicine Association for further inquiry. An entire telemedicine industry is gearing up to manage chronic illnesses and most of the time it has nothing to do with patients visiting doctors’ offices.
When all is said and analyzed, the conclusion is really simple as to why the use of telemedicine is not more prevalent: no one wants to pay a doctor the market value for the time it takes to answer a phone and expedite an acute problem or manage a chronic health care problem. No money means no mission. This means no phones, no email. Don’t think about it. See you in the office. Why ruin 2400 years of tradition?
