Monthly Archives: July 2015

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HealthSpot Kiosks Begin Retail Rollout

Carrie Ghose – Columbus Business First

HealthSpot telemedicine kiosks and Rite-Aid have announced the opening of 25 booths in stores in Akron, Canton, Cleveland, Dayton and Springfield.   Based on feedback from this initial rollout, a decision will be made on whether more stores will install booths.

HealthSpot’s booths use high-definition teleconferencing to connect patients with on-call physicians. The booths have an attendant who helps operate and sanitize the system. Incorporated within the booth are digitally connected instruments such as stethoscopes, blood pressure cuffs, and cameras.  The on-call physicians are from Cleveland Clinic, Kettering Health Network, and University Hospitals of Cleveland.

HealthSpot is a “natural extension” of the company’s offerings and provides an “alternative solution to accessing quality health care in a familiar, professional and convenient setting,” said a statement from Robert Thompson, Rite Aid executive vice president of pharmacy.

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Americans Wary of Telemedicine

– Eric Wicklund, mHealthNews

A new internet survey was recently performed by TechnologyAdvice. The study included 504 respondents and asked several telemedicine questions. Of those surveyed, approximately 75% would not trust a diagnosis made by telemedicine or give it less weight than an in-person meeting. Additionally, 56% said they would not be comfortable meeting a doctor for the first time by telemedicine. Only 7.5% said they would be comfortable using a healthcare kiosk in a retail setting.

“This is perhaps the largest issue that telemedicine vendors and healthcare providers will need to overcome,” say the lead author, Cameron Graham. The study goes on to comment that “”In order for telemedicine to make a meaningful impact on American healthcare, patients will need to not only become familiar with the concept, but also recognize the benefits it can offer over traditional appointments.”

Study was not all negative. 65% of respondents said they would use telemedicine after first meeting the doctor in person. Less than 30% had a strong opposition to the technology. The survey concluded, “If patients can be convinced that telemedicine provides an experience comparable to an actual visit – at least for preventative questions – there appears to only be a small amount of intrinsic opposition to virtual systems. Overcoming these concerns will be crucial for the long-term success of the industry.”

Modern Doctors’ House Calls: Skype Chat and Fast Diagnosis

Article quoted from The New York Times

TACOMA, Wash. — One night, when her face turned puffy and painful from what she thought was a sinus infection, Jessica DeVisser briefly considered going to an urgent care clinic, but then decided to try something “kind of sci-fi.”

She sat with her laptop on her living room couch, went online and requested a virtual consultation. She typed in her symptoms and credit card number, and within half an hour, a doctor appeared on her screen via Skype. He looked her over, asked some questions and agreed she had sinusitis. In minutes, Ms. DeVisser, a stay-at-home mother, had an antibiotics prescription called in to her pharmacy.

Using videoconferencing, a doctor in Des Moines, foreground, discusses a case with a nurse in a clinic in another city.Iowa Court Ruling Says Doctors Can Prescribe Abortion Drugs by VideoJUNE 19, 2015
In the Iowa system, a doctor consults by video with a patient at a clinic, then remotely opens a drawer with two abortion drugs.Videoconferencing Is Used to Administer Abortion DrugsJUNE 8, 2010
The same forces that have made instant messaging and video calls part of daily life for many Americans are now shaking up basic medical care. Health systems and insurers are rushing to offer video consultations for routine ailments, convinced they will save money and relieve pressure on overextended primary care systems in cities and rural areas alike. And more people like Ms. DeVisser, fluent in Skype and FaceTime and eager for cheaper, more convenient medical care, are trying them out.

Dr. Ben Green, a physician who helped develop the telemedicine program at Carena, a company that offers virtual visits. Credit Evan McGlinn for The New York Times
“I’m terrible about going to the doctor, just because of the time it takes,” Ms. DeVisser, 35, said. “This feels empowering: You just click a button and the doctor comes to you.”

But telemedicine is facing pushback from some more traditional corners of the medical world. Medicare, which often sets the precedent for other insurers, strictly limits reimbursement for telemedicine services out of concern that expanding coverage would increase, not reduce, costs. Some doctors assert that hands-on exams are more effective and warn that the potential for misdiagnoses via video is great.

Legislatures and medical boards in some states are listening carefully to such criticisms, and a few, led by Texas, are trying to slow the rapid growth of virtual medicine. But many more states are embracing the new world of virtual house calls, largely by updating rules to allow doctor-patient relationships to be established and medications to be prescribed via video. Health systems, facing stiff competition from urgent care centers, retail clinics and start-up companies that offer video consultations through apps for smartphones and tablets, are increasingly offering the service as well.

While telemedicine consultations have been around for decades, they have mostly connected specialists with patients in remote areas, who almost always had to visit a clinic or hospital for the videoconference. The difference now is that patients can be wherever they want and use their own smartphones or tablets for the visits, which are trending toward more basic care.

In Philadelphia, Jefferson University Hospitals now lets patients have video follow-up visits with internists, urologists, and ear, nose and throat specialists. Mount Sinai Health System in New York is starting to offer video visits for primary care patients. Mercy, a health system based in St. Louis, will soon open a $54 million virtual care center to house a number of telemedicine programs, including urgent and primary care video consultations for chronically ill and other high-risk patients who need frequent assessments and advice.

Advocates say virtual visits for basic care could reduce costs over the long term. It is cheaper to operate telemedicine services than brick-and-mortar offices, allowing companies to charge as little as $40 or $50 for consultations — less than for visits to emergency rooms, urgent care centers and doctors’ offices. They also say that by letting people talk to a doctor whenever they need to, from home or work, virtual visits make for more satisfied and potentially healthier patients than traditional appointments that are available only at certain times.

Hope Sickmeier, 51, a fourth-grade teacher in Ashland, Mo., used her Anthem insurance for a virtual urgent care visit one Saturday night, three days into a toothache that kept getting worse. A week earlier, she had gone to the emergency room with a migraine and owed a $200 co-payment.

This time she grabbed her iPad, downloaded the app for the visits and scanned a list of available doctors, choosing one with “a trustworthy face.”

When the doctor appeared on her screen, she told him her symptoms and, holding her iPad close to her face, showed him her painful tooth and the swelling in her jaw.

“I was in so much pain, I didn’t care that it was weird,” Ms. Sickmeier said. “He got right to the point, which was what I wanted. He prescribed antibiotics and called them into an all-night pharmacy about 20 minutes away.”

Washington State gave a victory to the industry in April when Gov. Jay Inslee, a Democrat, signed legislation requiring insurers to cover a range of telemedicine services if they already cover those services when provided in person. But the new law, which made Washington the 24th state to ensure reimbursement for some telemedicine services, does not cover virtual urgent care outside a medical facility.

Dr. Green’s desk at Carena. Advocates say virtual visits for basic care could reduce costs for patients and medical providers. Credit Evan McGlinn for The New York Times
Still, the law “opens the doors with a lot of our payers,” said Matt Levi, CHI Franciscan Health’s director of virtual health services. He added that some insurers, like Molina Healthcare of Washington, the state’s largest Medicaid plan, were starting to cover virtual urgent care, though the law does not require it.

“We are jumping in with both feet on this,” said Peter Adler, president of Molina Healthcare of Washington. “We think it’s the future, and it’s here now.”

Some large insurers are starting to pay, too. UnitedHealthcare, the nation’s largest insurer, announced in April that it would cover virtual visits for most of its 26 million commercial members by next year, citing the shortage of primary care doctors and the cost of less than $50 per virtual visit. Anthem will cover virtual urgent care visits for 16 million members in 11 states by the end of this year, and it expects the number to reach 20 million next year. Both insurers are relying on third-party telemedicine companies to provide the doctors and the technology platform for the service, just as most health systems do for now.

Even as virtual visits multiply, researchers say it is not clear whether they really save money or provide better outcomes.

“But I think it’s very plausible, and probably likely, that a lot of people who do a virtual visit would otherwise have stayed home,” Dr. Mehrotra said, pointing to research that suggests most people do not end up seeking care when they feel sick. “So it could increase health care spending over all.”

CHI Franciscan’s virtual urgent care program contracts with Carena, a private company in Seattle that employs 17 physicians and nurse practitioners to do virtual consultations in 11 states. Among CHI Franciscan’s patients, the most frequent users are women ages 25 to 55, and the most typical diagnoses are bladder infections, upper respiratory tract infections and pinkeye.

Users are prescribed medication about 40 percent of the time, said Beth Bacon, the company’s vice president for consumer affairs. Most visits take place on weekends or between 5 p.m. and 8 a.m., she said, when doctors’ offices are closed. Like other virtual urgent care programs, CHI Franciscan’s emphasizes that it is not for medical emergencies, advising customers on its website to “call 911 or proceed to the nearest emergency room” if they have chest pain, difficulty breathing or other potentially life-threatening symptoms.

Although Carena provides all the physicians for the program now, several CHI Franciscan doctors are training to become “virtualists.” Dr. Dan Diamond, a family practitioner at one of CHI Franciscan’s urgent care centers who recently trained to conduct virtual visits, said he enjoyed the less hurried pace.

“I don’t have people knocking on the door and saying, ‘Doc, we need you in another room,’ ” he said. “I’m able to focus on that one patient, without all the commotion that happens in an urgent care or an emergency room.”

Still, he added, “there are some times where we just can’t do it virtually and we need to lay hands on a patient.”

Ms. DeVisser turned out to be one of those cases. While happy with her virtual visit last summer, she ended up going to her primary care doctor a few weeks later because the antibiotics had not fully cleared up her sinus problems. He referred her to an ear, nose and throat specialist, who found through an examination that she had nasal polyps that needed to be removed.

“At least it mitigated the problem,” she said of her video consultation. “And it was much more comfortable than having to go sit with a bunch of other sick people in a waiting room.”

Testifying in Support of TeleStroke

Cardiovascular disease, including stroke, is one of the nation’s leading causes of death and disability. Prompt recognition, evaluation and treatment can lead to improved recovery outcomes and quality of life. TeleStroke has allowed hospitals without the necessary expertise to get quick patient care at any time and through different media sources such as smart phones, tablets and video conferencing software.

Looking for ways to expand this type of access to more patients, Massachusetts General Hospital (MGH) doctors have joined to support the FAST (Further Access to Stroke Telemedicine) Act, which was introduced by Senator Mark Kirk. This bill will “amend title XVIII of the Social security act to expand access of stroke and telehealth services under the Medicare program”. Among the experts involved, Lee Schwamm, MD, who is the vice chairman of the Department of Neurology and the director of TeleStroke and Acute stroke services in MGH, testified via teleconferencing before the U.S. Senate.

Director of the TeleStroke program at MGH, Juan Estrada, stated that the “lack of reimbursement is a major barrier to the development of TelesSroke programs” and that with these reimbursements hospitals are unable to participate in 24/7 stroke care will be able to engage a TeleStroke program as an affordable solution.
http://www.massgeneral.org/about/newsarticle.aspx?id=5363
Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation 2015;131:e29–322.

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Telemedicine in Chronic Kidney Disease

MedicalResearch.com Interview

MedicalResearch.com recently posted an interview with Dr. Judy Tan from Mount Sinai Hospital in New York. The topic of the interview was to discuss preliminary results of her groups’ study of a tele-nephrology service.

Dr. Tan comments that chronic kidney disease affects 26 million people in the United States. As in other specialties of medicine, many patients have difficulty with access to care. In order to meet the demand of the patients at the Hudson Valley Veterans Affairs Medical Center, her group developed an outpatient tele-nephrology service. The technology uses medical video conferencing equipment and customized medical instruments such as stethoscopes. Their hypothesis is that clinical outcomes would be comparable when care was delivered via the tele-nephrology service compared to in-person visits.

As an initial step, Dr. Tan’s group has enrolled patients in the tele-nephrology program. The preliminary data shows that in the patients followed for 1 year, estimated GFR was well preserved, systolic blood pressure was reduced, urine protein-creatinine ratio decreased, and the majority of patients were on ACE Inhibitors. As a next step, the Dr. Tan hopes to prove non-inferiority to a group of patients treated with conventional in-person care. If her hypothesis proves correct, she hopes to expand services further and address other types of kidney disease.

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Walgreens, Insurers Push Expansion of Virtual Doctor Visits

By Associated Press | June 10, 2015

Walgreens is expanding into the telemedicine market and expects to reach about half of the country by the end of 2015. The massive drugstore chain will give customers using a new smartphone app access to doctors who can then diagnose and treat minor ailments 24 hours a day.
The news comes as two major insurers, UnitedHealth Group and Anthem, are expanding their own telemedicine services. Their services will give primary care access to around 40 million subscribers. The growing use of smartphones and tablets appears to be fueling both the customer demand and the rapid expansion of telemedicine into care that the family doctor is unable to provide.

Walgreen’s Chief Medical Officer Dr. Harry Leider says that its doctors will be “careful in only using telemedicine for certain conditions that are amenable” and that they are “not treating heart attacks.” The doctors in the program are specifically trained to recognize when telemedicine patients need to be referred to in-person evaluations or emergency rooms and all patients will receive a record of the visit which can be forwarded to their primary care physician.
The American Telemedicine Association estimates that about 450,000 patients will see a primary care doctor via telemedicine for minor ailments and routine checkups and that about 15 million people who will have care delivered by telemedicine urgently or emergently. Doctors say telemedicine improves access to care especially in rural communities. As long as the care given is good and a record of the patient visit makes it back to that person’s regular doctor, safety won’t be compromised.

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Telemedicine guidelines to be crafted at AMA meeting

By Steven Ross Johnson | June 5, 2015
Establishing ethical guidelines for the blossoming telemedicine industry is one of the topics leaders of the nation’s largest physician organization will pick up during their annual policymaking session in Chicago this weekend.

The American Medical Association’s annual Meeting of the House of Delegates is scheduled for June 6-10. The gathering sets policies that affect a number of issues for the nation’s physician workforce.

Among the topics delegates will vote on is proposed new guidelines by the AMA’s Council on Ethical and Judicial Affairs aimed at addressing how doctors who conduct virtual visits either over the phone or via videoconferencing should ensure patient privacy and inform patients of the limitations of technology.

Other recommendations call for telemedicine practicing physicians to inform patients on follow-up care when needed and to coordinate with primary-care physicians even when follow-up care is not needed.

The guidance goes on to recommend that individual physicians and physicians groups stay updated with the latest developments in the telemedicine field, including technological innovations, and that they support efforts toward developing clinical standards that ensure care quality and safety.

“All physicians who participate in telehealth/telemedicine have an ethical responsibility to uphold fundamental fiduciary obligations by disclosing any financial or other interests the physician has in the telehealth/telemedicine application or service and taking steps to manage or eliminate conflicts of interests,” according to a CJEA meeting report on the resolution. “Whenever they provide health information, including health content for websites or mobile health applications, physicians must first ensure that the information they provide or that is attributed to them is objective and accurate.”

The AMA’s focus on telehealth comes at a time of fast growth for the industry as insurers and patients look to address the rising health costs and higher demand for services. Estimates have valued the telemedicine market at nearly $15 billion, with projections that it will continue to grow in the coming years.

The rapid growth has raised questions among some providers about the safety and quality of care provided with telemedicine. That’s led to a backlash in some circles. Such was the case in April, when the Texas Medical Board voted in favor of limiting telemedicine practice in the state, requiring physicians to have an in-person visit with a patient before allowing them to conduct exams through telecommunication technologies, unless the patient is in a medical setting at the time of the initial telemedicine visit.

Other items slated to be voted on at this year’s meeting include a resolution that would call for stricter policies that limit non-medical exemption for vaccinations in light of the rise in vaccine preventable diseases such as the large, multistate outbreak of measles that began at Disneyland last December.

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AHA Issues Recommendation for Stent Retrievers.

Associated Press – June 29th, 2015

The American Heart Association has given their strongest possible recommendation in support of new stent retriever devices. These tiny mesh cages are used to treat large strokes and can aid doctors in restoring proper blood flow to effected parts of the brain. They work by trapping and removing blood clots from clogged arteries thereby reducing the risk of permanent brain damage.

The is the first time in decades that a new stroke treatment has been recommended by the group and follows the publication of several major studies that found the devices significantly cut the risk of death and disability in certain stroke patients.

“It is pretty exciting,” said the head of the guidelines panel, Dr. William J. Powers, neurology chief at the University of North Carolina at Chapel Hill.

Before stent retriever devices, the best treatment was a clot-dissolving medicine called tPA. TPA remains the first choice in treating strokes and the new device will be used in addition to this medication. The drug must be given within 4½ hours after symptoms start and unfortunately, most people don’t seek help in time.

The new guidelines say patients now can be treated with a stent retriever if it can be done within six hours of the start of symptoms, they have a severe stroke caused by a clot in a large artery, and have brain imaging showing that at least half of the brain on the side of the stroke is not permanently damaged. However, only major stroke centers have the staff and expertise to do the technically difficult procedure.

Antibiotics prescription practice patterns with telemedicine

A new study published in the May edition of JAMA Internal Medicine performed by the RAND Corporation demonstrated that antibiotic prescribing rates for acute respiratory infections were similar between direct-to-consumer telemedicine and direct interaction in physician offices.

The California Public Employees Retirement System has offered Teladoc as a benefit since 2012. The authors of the study enrolled patients 18-64 over a 19 month period who were seen 1 or more times for the diagnosis of acute respiratory illness. They then compared antibiotic prescribing rates for Teladoc and physicians’ offices. A total of 65,824 patients were enrolled (1725 Teladoc and 64,099 physicians’ offices).

What they found was that in both adjusted and unadjusted analysis, the fraction of acute respiratory illness visits at which an antibiotic was prescribed was similar and not statistically significant (58% for Teladoc vs 55% for physicians’ offices, p = .07). The most common antibiotics prescribed were similar, however, the adjusted “broad –spectrum antibiotic” prescribing rate (defined as macrolides and fluoroquinolones) was higher for Teladoc (86% for Teladoc vs 56% at physicians’ offices, p < .01). This study comes as questions have been raised regarding the quality of care delivered by telemedicine when compared to traditional face-to-face office visits. Although the rates of prescribing were similar, researchers say the higher use of broad-spectrum antibiotics is concerning due to the higher drug costs and contribution to antibiotic resistance. The authors suggest consideration should be made for telemedicine quality improvement initiatives to physicians and direct to patient education to influence demand for unnecessary antibiotics. Uscher-Pines, Lori PhD, MSc; et al. JAMA Internal Medicine. May 26, 2015.

Telemedicine for China

Emma Peters, Yahoo! Finance –

The Chinese healthcare system has many issues it is trying to overcome. Most of them have at their root a general mistrust of the Chinese people for the government, its institutions, and even its healthcare providers. As an example, patients commute to major urban centers, which are already suffering from overcrowding, due to a lack of trust in the care at local clinics. There is a belief by some, including Florian Then a partner at McKinsey and Company, that telemedicine can help relieve some of these issues.
Market intelligence from IDC reports that there are 847 million mobile phones in China in 2015 and about 83% of Chinese internet users access the web via mobile phone. The hope would be to use this existing infrastructure to augment resources such as providing urban doctor support to rural physicians via telemedicine and offering intensive online education to patients on chronic disease topics.
It is estimated by the research firm IHS that the Chinese government spent around $13 million on telemedicine in 2013 but this number may need to be larger. One of the biggest hurdles, however, seems to be physician participation and lack of an incentive to partner with the government in this initiative. According to a report compiled by Benjamin Niu, an analyst at IHS, “China’s next several steps in telemedicine could lay the foundation for the sort of innovation the country has built a reputation for: creating something entirely new out of necessity and the systemic failure of the established way things are being done today.”