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Curbside Consult with Dr. Jayne 3/11/13

March 11, 2013 Dr. Jayne 2 Comments

Lt. Dan’s inclusion of “Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit” in this morning’s headlines caught my eye. According to the summary, “given a choice between virtual access to care and human contact, three quarters of consumers find access to care more important than physical human contact with their care provider and are comfortable with the use of technology for the clinician interaction.”

I’m not opposed to virtual visits – in fact I’d love to do them for certain patients or for certain conditions. In my market, however, clinicians contracted with the majority of commercial payers are not able to bill for these visits, and patient willingness to pay out of pocket is extremely low. Several of my colleagues have attempted to bill patients for after-hours telephone visits and the practice has been the subject of scorn, not only in the physicians’ lounge, but also with the local medical society.

A true virtual visit is more than a phone call. It’s a scheduled time to talk about the patient’s issues, review medications, review home vital signs, blood sugar readings, diet logs, and other patient data points. Based on a careful history and these elements, changes to the regimen can be made and behavioral interventions can be supported. The history elements, data, care plan, and goals still need to be documented in the patient chart, however, and that takes time. Unless you’re operating under a capitated model where you’re being compensated for these services through a per-member/per-month payment, you can’t perform these services without some sort of compensation.

Virtual visits also generate real liability. They can allow for physicians to care for greater numbers of patients which can increase risk if there is not close adherence to protocols and guidelines or if patients are not well known to the clinician. This makes the need for appropriate scheduling and documentation even more important. Virtual visits aren’t something physicians should be expected to cram onto their schedules in lieu of overbooks to the office schedule.

I do find Cisco’s findings somewhat contrary to my experience in solo practice. When I employed a nurse practitioner to care for my patients as my informatics duties grew, there was a lot of resistance to the team-based approach by some of my elderly patients, who grew up in an era where seeing the doctor was something special and had a unique value outside of the actual medical care. Some patients chose to wait weeks to see me rather than accept same-day appointments with someone other than “my doctor.”

This attitude is somewhat borne out in a later statement in the piece where it was noted that “consumers will overlook cost, convenience, and travel, to be treated at a perceived leading healthcare provider to gain access to trusted care and expertise.” I’m not saying I was a leading healthcare provider (in fact, when I was first in solo practice, I was a fresh grad with a bit too much idealism) but I was a good listener and genuinely cared for my patients. I’m not sure that level of empathy can be easily translated to the virtual experience. I had the privilege of truly getting to know my patients, who also felt they were able to know me.

We exchanged more than symptoms and diagnoses. We also swapped recipes and baked goods, stories of our small community, handicrafts, and more than our share of heartache. I had the distinct privilege of being able to function as an “old school country doctor” in the middle of the suburbs. This was mainly because the opening of my practice solved an access problem, but also gave patients a place they could think of as their medical home, whether it was a designated Patient Centered Medical Home or Center of Excellence or any other buzzword of the day.

I miss having continuity patients and I think about some of my favorite patients often. Every once in a while I will run into one while working in the emergency department and that is a rare treat. Although virtual visits may be cheaper (if they are ever reimbursed where I live) and more expedient, I don’t think they’re going to be as good for building that level of “trusted care” that patients expect when they’re faced with a life-threatening condition. What do you think about virtual visits? E-mail me.


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Currently there are "2 comments" on this Article:

  1. I saw an interesting presentation from Dr. William Thornbury and a demo of his solution for virtual vists (mevisit.com) last week at HIMSS. My impression is that virtual visits can be effective if:
    1. They are integrated into a physician’s practice and act as a complement to face-to-face visits
    2. They use best-practice based templates to gather information from the patient.
    3. They shift communication from primarily synchronous (i.e face-to-face, phone, Skype) to aschynchronous (i.e. messaging based)

    Based on over 1,000 virtual visits in 2 years, Dr. Thornbury found a 15% increase in practice capacity and 15% decrease in per-capita costs. The shift from synchronous to asynchronous communication accounts for the increase in productivity – the patient provides most of the information via structured interrogation which the physician reads. Reading is faster that talking and there is no “politeness time”. The average time for a virtual visit is less than three minutes

    In terms of compensation, 8 state medicaids are looking into funding for virtual visits. Dr. Thornbury has a simple solution for patients with private insurance – he charges patients directly at a rate that is less than the co-pay. The convenience factor turns this into a win-win for the patient and provider.

    Asked about liability, Dr. Thornbury responded that his insurer was pleased with the level of documentation that his solution provided – an improvement over the sketchiness of some physician encounter notes.

    Like anything else, the devil is in the details. Using simple telephone or skype will not provide many efficiencies. Plain email would also be relatively inefficient. The virtual visit needs to be well scripted using evidence-based templates.

    I recommend that you have a look at the demo and white papers on mevisit.com.


    Kurtis Bishop
    Managing Director, eHealth
    PwC Canada

  2. Virtual visits are a welcome option to patients and I would think clinicians as well. It sure would be nice to schedule a virtual appointment with my primary physician when I need a Z-Pac or amoxicillan when I feel my annual sinus infection coming on, instead of having to make an office visit. Technology, baby; bring it on!

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