Virtual Patient Visits

Solo practitioner and general surgeon David Faber enjoys practicing medicine in rural Bedford, Pa., a small town in the southern part of the state.

The only downside is that when patients need more than he can give them - for example, highly specialized colorectal surgery - he often has to refer them to see specialists in Pittsburgh, a two- to three-hour drive, depending on traffic.

But thanks to a new telemedicine partnership between Faber and University of Pittsburgh Medical Center (UPMC) colorectal surgeon Andrew Watson, patients with certain colorectal health conditions requiring surgery don't necessarily have to make the Pittsburgh pilgrimage more than once. Watson and Faber's partnership allows Faber to send his patients just 10 minutes up the road to the town's hospital, UPMC Bedford Memorial, to experience a virtual visit with Watson via a high-tech connection.

Though the idea of a virtual visit sounds as simple as a video Internet call, Watson can do more than just see and converse with the patient on the other end, who is joined by an attending nurse from Faber's practice. During the visit Watson uses a series of plugged-in medical tools, including a digital stethoscope and webcam, allowing him to see the patient's ears, mouth, and throat. He also instructs the attending nurse to do a physical examination of the patient. So when the patient finally has to go to Pittsburgh, he can go straight into surgery with Watson.

"He's more specialized and works in a tertiary care center with all of the necessary resources to handle more complicated cases I can't here," says Faber. "I've been a solo surgeon since 2002, and in a rural community, I sometimes feel like I am performing without a backup."

The relationship between Faber and Watson that allows for virtual visits offers numerous benefits to both physicians and to Faber's patients. This relationship also represents the cutting edge of medicine, a field that is getting more notice in the day and age of shared-savings plans, high-tech doctoring, and outcomes-oriented care.

Before you let yourself escape into virtual reality, it's best to prime yourself with as much information as possible.

The growth of virtual visits

Though virtual visits aren't a new idea, they offer loads of benefits. They help rural physicians like Faber offer their patients top-notch services with less hassle. They also help moonlighting or retired physicians make a little extra money by connecting with patients in off hours to answer medical questions, says Doug Smith, a practicing physician who is the chief medical officer of Consult A Doctor, a telemedicine technology and services provider.

For an entity like Consult A Doctor, physicians who work with the company (after being screened thoroughly) are compensated per telemedicine consultation.

Over the last two years virtual visits have emerged as a viable method of delivering healthcare recognized by multiple payers, including Medicare. In January, HHS announced it is working on a rule that would allow hospitals to more easily credential and provide privileges for physicians and other practitioners who provide telemedicine services. Meanwhile, the American Recovery and Reinvestment Act has funded the development and build out of broadband technology and networks in rural areas.

Roy Schoenberg, CEO of American Well Systems, a provider of telehealth services, says the federal and private insurance push toward accountable care organization-like models and the cost savings they promise is a big catalyst for virtual visits.

"Physicians want to be close to patients for whom they take financial responsibilities," he says. "If you can take healthcare and bring it to where the patient is, you can significantly lower costs."

For physicians, Schoenberg adds, virtual visits also save money because they can be done anywhere with an Internet connection, meaning you don't have to turn on the lights, heat, etc. at the practice for a short period of time. Furthermore, telehealth allows providers to convert unpaid interactions into structured, documented, and fee-based online visits and/or clinical messages.

This is especially true, he adds, for patients who are able to participate in virtual visits from their home. By monitoring patients in their home, the goal is to try and reduce costly follow-up visits or possibly hospitalization if chronic illnesses are not closely watched and addressed.

In a virtual visit scenario, a nurse, upon seeing that a COPD patient is doing worse, may use video monitors to connect over a virtual network with physicians, and Bluetooth devices that measure the patient's blood-sugar and oxygen levels to transmit that information wirelessly. The physician could then assess whether the patient needs to be taken directly to the emergency room or can wait a few days for a less-urgent, in-person visit.

It's a scenario that has become more possible because technology is continuously evolving: Internet video today offers a higher-resolution image to physicians and patients than it did even one year ago.

Still, there are some obstacles to adoption. While reimbursement for telehealth services is broadening, Medicare still only reimburses for telehealth in rural areas, says Gary Capistrant, senior director of public policy for American Telemedicine Association, a healthcare technology lobbyist group. And while a dozen states have laws requiring private insurers cover telemedicine, the majority do not.

"Payers, as payers usually are, are a little slow to adopt," says Capistrant. "Some payers don't distinguish between telehealth and other services, and others get into rigid payment procedures."

Inside a virtual visit

Because even tech-savvy patients may be reticent to "visiting" with a physician over an Internet connection instead of in person, the first step to a virtual visit is patient education. During that initial visit, Faber answers questions and walks them through the process of being on camera. Next, he makes an appointment at the local hospital where video equipment is set up in an exam room. A designated practice nurse makes the 15-minute trip and assists with the visit once Watson appears on the video monitor. Faber's nurse does everything that requires a physical examination, right in front of the camera as Watson instructs.

"There are limitations," says Watson. "I can't palpate their abdomen."

Another downside is that Faber's practice initially loses money with every visit, as he has to dispatch one of his own salaried nurses to the hospital to serve as the patient liaison.

Still, providing the extra service at cost to his practice reaps plenty of gains. For starters, his patients are grateful, and he believes he is more likely to retain those patients and attract new ones by offering this service. "All of the patients are incredibly satisfied with it," says Faber, adding that without telemedicine, he would "completely" cut himself out of their care. By working with Watson, he gets referrals back to his office for post-op care and local procedures. He said he hopes to connect even more of his patients with out-of-town specialists on a virtual platform, so he can reap even more referrals.

Though Faber would love to have the technology to do this in his own office, so he could enjoy more of the financial benefits of the visit, the cost of equipment used in the hospital for the virtual visit is still too prohibitive for a solo practitioner. Faber said the video equipment that connects his patients to Watson costs about $25,000.

Prepping for a virtual experience

Perhaps you're wondering if a physician could facilitate a similar virtual visit for less money, for example, by using a simple, free Internet video service such as Skype.

The answer depends on what that physician wants to do.

The expensive video equipment used by Faber and Watson allows for medical tools (such as a stethoscope) to be plugged into a system, and readings to be translated over a connection. That option is not yet possible with all free public Internet services, nor are secure connections to meet HIPAA security standards.

As with unsecured e-mail, not all public video-Internet channels offer the same level of security as a private network, Schoenberg warns.

However, Capistrant says most physician practices can get by this by making sure their patients sign a waiver acknowledging the security risk of using an open network.

"It's common for doctors to have a standard consent form that says, 'I understand that this may not be 100 percent secure,'" he says.

As an alternative to free, public video-Internet programs, a number of telehealth providers are offering virtual systems that allow patients to connect with physicians over a secure, private, portal-like connection where a patient and a physician log into a protected network.

Schoenberg also notes that there are several elements to a "meaningful" physician-patient online encounter, including discussions of patient records, eligibility claims, and prescriptions - just as if the patient was in the office. Without these elements, he says, commercial payers and Medicare/Medicaid will not consider the video interaction "sufficient for reimbursement."

Nevertheless, there are limitations to what a physician can do over a video network without medical equipment or a nurse to help with a physical.

"If you're doing tele-mental health, whatever gives you decent audio and video is sufficient," says Capistrant. "You would need a high-definition monitor, however, if you're doing tele-dermatology."

And if you're doing a visit that requires more than a basic connection, it's difficult to do that with patients in the comfort of their own homes if they don't have higher-end equipment.

"The ability to see the patient when the patient is at home requires significantly less overhead," says Schoenberg, adding that in order for telehealth to be successful, it needs to "rely on what is naturally occurring in their house."

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

This article originally appeared in the May 2012 issue of Physicians Practice.