Patients Demand Mobile Healthcare

 Like many physicians, Oxnard, Calif.-based solo OB/GYN Adrienne Lara used to spend up to two hours per day answering phone calls and calling patients back - without pay.

"Two hours, at my going rate, is going to be at least $1,200," says Lara.

But thanks to mobile e-visit technology - which allows patients to visit remotely with Lara through a secure e-mail platform that she accesses via an app on her smartphone - she's finally getting paid for some of that time.

"We're starting to see a need for higher productivity, seeing more patients for less money," says Lara, who uses the DoctorBase e-visit application, where patients can, for $20 per session, connect with Lara about everything from a skin lesion to UTI treatments. All of these things can be done without an in-person visit to Lara, or without playing phone tag.

Of course, there are limitations: About 30 percent of the time, patients will need to make an appointment for a visit so Lara can make an in-person assessment. And a few issues are still best handled with a phone call.

Still, the fact that 200 patients use the app to connect with Lara for an e-visit is testament to the growth of a new kind of consumer: The Mobile Patient.

Thanks to new health IT tools and services that cater to the mobile patient, practices can not only improve patient satisfaction and outcomes by helping patients outside of the office, but also see a big boost to their bottom line.

The age of the mobile patient

Today's patients are tethered to their smartphones and media tablets, and a growing number are using them for healthcare purposes.

One in three smartphone owners have used their phone to look for health information, according to a 2012 report by the Pew Research Center's Internet & American Life Project. That's twice as many as were doing so only two years ago.

The reason: Web-enabled phones have become more ubiquitous and powerful. One in five smartphone owners have at least one health app on their phone, according to Ruder Finn's 2012 mHealth Report, which also found more than 40,000 mobile health apps are available for smartphones and tablets as of October 2012. Analysts predict a significant growth in the global mHealth market over the next several years, expecting that it will reach $10.2 billion by 2018, up from $1.3 billion in 2012.

Today, patients can wake up to health alerts reminding them to take their blood pressure or blood sugar, log data into a personal health record or patient portal, use home-monitoring devices to send readings to physicians, participate in e-visits or video-based chats with their doctors, send high-resolution images, and even pay medical bills online.

While not every single patient is using technology like this, in a few years, more patients will be.

"We see technologies that promote patient engagement as being a win-win proposition," says Stephen Snyder, president of MTBC, which recently unveiled a mobile health app that allows physicians to connect with their patients. "Patients become more accustomed to self-service in healthcare, [so] adopting these technologies will be critical for small practices to stay competitive and avoid attrition to competitors who have fully embraced [them]."

As patients are mobilizing and health IT is flourishing, pressure on providers to reduce costs and see ever-more patients is fostering the development of technologies designed to make medical practice more efficient.

As Roy Schoenberg, president and CEO of American Well, a telehealth network and services provider, sees it, the model of healthcare delivery is undergoing a shift.

"For hundreds of years, you had to go to where healthcare was to get treated," says Schoenberg. "For the first time we have the ability to reverse the paradigm and say, 'We're going to bring healthcare to the person.'"

Mobile e-visits

Patient portals help practices do everything from answer questions from patients to manage payments and share lab work.

But the way patients want to use portals is shifting. For them, portals are becoming less about administration and more about communication. Last year, patients were delighted to schedule an appointment or view their lab results online. Now they want to talk to their doctor. They want e-visits.

There is no consensus yet on whether practices should charge for that.

Many physicians say all portal applications should be offered to patients freely, as the portal is a value-add for a practice that wants to improve patient engagement. In addition to saving practice staff time (fewer phone calls), portal adoption is also crucial for practices trying to meet the government's requirements for meaningfully using an EHR.

But some say that the physician-patient communication that many portals enable should be thought of differently from the portal's administrative functions. Allowing patients to see their lab results online is one thing, goes this thinking, but direct communication with their doctor about those results should be charged for as a visit, even when that communication happens online rather than in person, because it is a visit.

Most insurers won't pay for such communication, however, so physicians are left to charge patients for this service directly if they want to be compensated for their time.

Mobile e-visits essentially extract the messaging function of the traditional portal and place it onto a mobile platform; communication is facilitated by an app that resides on the devices physicians and patients carry everywhere already. Therefore, says Lara, because patients are more connected to her, they see the value proposition, and want to pay for interaction.

"This is a way of giving me some value for my work," she says. "It's a win-win situation. I'm getting paid for my time, which I think is valuable, and they're getting access to me. And it makes me stand out from other physicians."

There are other advantages to mobile e-visits, too. Lara says the whole issue of coverage is moot because patients pay a direct fee of $20 for an e-visit whether or not they have insurance, and the revenue is split between her and the mobile e-visit vendor.

*For more on how mobile e-visits work, listen to our podcast at http://bit.ly/evisit_mobile.

Mobile e-visits also hold promise for physicians who want to reduce the cost of patient care and expand their services.

A two-year e-visit pilot study conducted between a rural family physician, William C. Thornbury, and the University of Kentucky yielded some promising results. The project evaluated 471 patients ages 16 to 89 who paid $32 per visit to use a mobile e-visit application for minor medical problems. Twenty-six percent of patients reused the application within a few months of their first use, and 97 percent of patients said they were fully satisfied with the service.

The practice reported a decrease in per-capita costs of care by 15 percent and an increase in clinic capacity of 15 percent.

Thornbury has since turned the mobile e-visit application into Me-Visit, a company whose goal is to make "the concept of a house call by smartphone a reality." He says his experience in running an over-crowded, rural primary-care office and not being able to efficiently care for his patients inspired the technology.

"Three or four years ago, we would get two to five patients a day that we couldn't see," says Thornbury. "So I said, 'I'm not just going to kick the can down the road anymore. I'm going to do something about it.'"

Home monitoring tools

High-speed wireless connectivity has transformed home monitoring technology. Only a few years ago, devices such as home blood-pressure monitors only allowed patients to record information, which would usually be stored for later delivery to the practice. Today's devices transmit data to care providers in real time over Wi-Fi or cellular networks, often using smartphone apps that connect with monitoring equipment to measure everything from blood pressure to heart rate to oxygen saturation in the blood.

In fact, some apps can record data on their own, without requiring a dedicated monitoring device, explains John Holland, a senior vice president at telehealth technology provider AMC Health. For example, phone-based spirometry apps that interface with practices' EHR systems are available now, Holland says.

The reason such tools are not being used as often by physicians and patients? A lack of knowledge about them.

"Not enough people on the consumer side or the provider side are aware of these technologies being used right now," says physician David Lee Scher, a healthcare consultant who himself uses an AliveCor electrocardiogram that connects to his iPhone, and has been involved with the remote monitoring industry since 2000. "When I tell people about them at dinners and gatherings, it seems like Star Trek stuff. And when I show them the electrocardiogram on my cell phone, they really are amazed."

However, there is growing evidence that the market is shifting, and that a greater number of patients will adopt these tools in coming years.

Indeed, the Ruder Finn mHealth Report from October 2012 indicates a small but growing interest in mHealth telemonitoring. A third of respondents said one of the most useful apps for healthcare professionals would be monitoring devices that can alert caregivers, doctors, and nurses if a patient has a health emergency.

The market for telemonitoring has expanded beyond the home-health industry to primary-care and specialist physicians, thanks to an industry-wide push for collaboration and cost savings, according Holland. The growth of accountable care organizations have contributed to that push, he says.

While tools like these can't replace all physician visits, they can replace some physician visits, potentially saving money and time for the physician as well as keeping patients out of the ER.

To illustrate how home-monitoring technology has changed, Holland offers the example of a new patient starting on antihypertensive meds because his blood pressure levels were moderately elevated during his past two office visits.

"You don't know whether those office readings are 'white-coat hypertension' or true hypertension, so the first thing you might want to do is give them a home monitor and have them use it for a week, and take a look at the results to see if they need medication," says Holland. "Without a home monitor, you would start them on meds, and then have them come in again in two weeks to a month to check their blood pressure in the office again. … And you would have them keep coming back in, as you check their pressure, and this could take [several] visits. Instead, a physician can prescribe two weeks' worth of a medication and look at the home blood pressure readings to see if the drug is working. Medication can be adjusted by phone, without the repeated office visits. For many physicians, reimbursement for an office visit simply to check blood pressure is hardly worth the effort."

A new look at video

Perhaps the most prominent example of telehealth's promise to empower the mobile patient is video visits, because they allow patients to truly see their doctor, and vice versa.

"A video visit usually is about 10 minutes or less, and it can be done at home," says Schoenberg. "If you count all the overhead of seeing a patient in the office, you would end up finding that when you reach a certain volume, telehealth is actually making you more money than maintaining a practice."

Perhaps as a sign of the times, the pharmacy chain Rite Aid announced in March the expansion of its telehealth service, NowClinic Online Care, to 67 locations in Baltimore, Boston, Detroit, Philadelphia, and Pittsburgh. Customers can have private, one-on-one secure video consultations with physicians starting at $45 for 10 minutes.

While patients may also opt for instant-message "chat" conversations or phone conversations, it's the video option that Holland says is going to become huge. "There's a certain discomfort - on both sides, physician and patient - with anonymous visits," says Holland.

Additionally, Holland says there are some issues physicians need to consider with video, such as making sure a channel that connects patients and physicians is secure and that the videoconference is HIPAA compliant. But for the most part, the technology holds promise.

"[A physician] can see, 'Are they making eye contact with you? How's their speech?'" says Holland. "When you think about the time spent or difficulty spent in the office, the efficiencies are enormous."

In Summary

Providing mobile patients with access to care wherever they are is becoming critical to practices. Here's how patients and technology are evolving:

• Today, at least one in three cell phone owners use their phone to look for health information.

• The way patients want to use patient portals is shifting to more communicative functions, such as e-visits.

• Home-monitoring devices can now connect to smartphones; there are also smartphone apps that replace traditional monitoring devices.

• Video visits offer face-to-face interaction with physicians, which can make them more appealing than e-visits or phone calls.

Marisa Torrieri is an associate editor at Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the June 2013 issue of Physicians Practice.