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Reality Trumps Theory

Guest Article by David Bensema, former CIO and CMIO of Baptist Health Kentucky.

My leadership journey has allowed me to have multiple roles over the last 11 years. In each role, telemedicine loomed large: first as a nebulous future capability, then as a highly touted but thinly implemented (and somewhat clunky) leading-edge technology. Most recently, it has become a well-funded, and increasingly robust, must-have part of any accessibility strategy.

However, the benefits, in my mind, have always been theoretical and not fully realized.  Remote monitoring of high-risk patients is increasingly prevalent, but the financial return is difficult to prove, representing the “soft green dollars” one of my colleagues was fond of referencing.

Telehealth has had some notable successes. This is the larger umbrella within which telemedicine exists. It includes remote health training as well as public health and remote support of health providers in less developed areas, generally without a billing and reimbursement model. Telemedicine, however — the direct and concurrent provision of care to patients by remote care providers, with an expectation of reimbursement — has had more disappointments than fulfilled expectations.

Multiple telemedicine vendors have entered the market in recent years. They have done an excellent job of selling their solutions to employers with self-funded insurance plans, and to health systems venturing into population health (an enigma all its own, worthy of a future post). They go in offering increased accessibility and lowered overall cost of care for the identified groups.

Even I, in a very small way, fed the excitement. In fact, I presented on the potential of telemedicine in the retail clinic space at the 2012 American Telemedicine Association in San Jose, California. I discussed the opportunities for timely specialty consultations, particularly in cardiology. These would use the advanced practitioner in the retail clinic to perform maneuvers directed by the specialist, utilizing tools like the digital stethoscope to allow the specialist to directly hear and interpret findings.

That theoretical model of care met its enemy in simple reality. In the end, cardiologists just weren’t waiting to drop everything and jump on a video conference with the clinic. Plus, payers were not interested in incurring an additional charge for the same instance of care.

Despite all of the excitement, investment, and hype, telemedicine has consistently and disappointingly lagged behind the timelines laid out by visionaries. Adoption by patients has largely missed projections, with patients frequently citing the lengthy questionnaires and registration process prior to being able to access a care provider. I have repeatedly made this observation in meetings within my prior healthcare system, as well as in meetings over the past four years for the many organizations of which I am a member.

I came to the conclusion that telemedicine needed a “hook” in order to thrive: that marketing tool that captures the intended audience’s attention and compels them to stay with the message long enough to take it in and internalize it. This past week, I had the hook set in me.

I woke at 7 am to a text message from my niece, who is a time zone behind me. For her to send me a text at 6 am was an ominous sign.

I opened the message to find an embedded video of my great nephew and a text description of his previous night and current symptoms. My niece noted that he had coughed all night, was now breathing quickly and more shallowly, and her family physician was not scheduled to be in until noon that day.

This was all useful information.  The hook, however, was the video.

My 21-month old great nephew, a bruiser of a little boy with an ebullient personality, was tachypneic. He had a respiratory rate of 36 breaths per minute and limited belly movement, suggesting shallow inspirations. More ominous to my familiar and loving eye was the glassy-eyed, emotionless expression of a very fatigued, if not toxic, little boy. The only thing lacking was auscultation capability, so I could not hear his breath sounds, except to note that there were no audible wheezes on the video’s soundtrack.

With this limited but compelling information, I advised my niece that he needed to be seen quickly. I could not rule out pneumonia, and I was concerned that his tachypnea might be evidence of fatiguing and presage a further decline in his condition. In response, she presented to the pediatric track at the emergency department near her home. He was diagnosed with bronchiolitis and, thankfully, a normal oxygen saturation. He had a difficult ensuing 24 hours at home, but did so with a well-informed and prepared mommy, who was much relieved to know what was going on and had options for defined changes in condition.

Telemedicine. All it took was a worried mom and a little boy that I love in distress, and I was hooked.

So, how do we translate this into actionable and scalable changes in the current telemedicine model?  I have a couple of ideas, but look forward to the conversation to follow.

My ideas:

  • Eliminate the long, algorithmically-driven questionnaires. Do so in favor of the briefest panel of questions that are able to exclude critical illness with high sensitivity, directing those patients to other sources of care.
  • Allow the submission of a video with narrative, rather than the patient answering scripted questions and free text, to be securely submitted to expedite submission and provide more robust information.
  • Work diligently to engage care providers — with existing patient relationships — to participate in telemedicine for their patients.

To date, telemedicine has been a bit of a disappointment (at least for me). After getting a firsthand look at how valuable this tool really can be, though, I truly believe it deserves more attention and effort.

We can improve this model of medical care and create something that really works. We can do better!