EPtalk by Dr. Jayne 3/7/19

My sci-fi nerd flag was flying high when I heard that the Amazon, Berkshire Hathaway, and JPMorgan Chase venture will be called Haven. That was also the name of a planet featured in “Star Trek: The Next Generation” and one where the Enterprise crew was supposed to have some well-earned rest and relaxation. I’ve perused the website and appreciate the way they’ve spelled out their mission clearly and in a way that most people can understand. It looks like most of the open positions are in their Boston and New York offices. It will be interesting to see what kind of people gravitate there.

Researchers are seeking to use artificial intelligence to help design better vaccines against the influenza virus. Flu is a virus that mutates rapidly. Researchers from two pharmaceutical companies are taking biochemical data from samples of exposed patients and running them through an algorithm in an attempt to understand how an effective immune response forms. Other teams are using machine learning to predict the spread of influenza using training data sets from physician offices, hospitals, and social media. The Centers for Disease Control maps flu trends, but being able to truly forecast flu activity would be an asset. I hope they hurry up and get it right. I’ve avoided flu for most of my medical career, but it hit me this week and with a vengeance.

In Mr. H’s annual reader survey, there were some responses that indicated a desire to see more focus on less-traditional areas of healthcare IT, including telehealth. Since I’ve been doing some of my own explorations in the telehealth realm, I’ll share my observations and findings.

One of the first things I’m finding is that it’s important to understand what you mean when you start talking about telehealth. Is this provider-to-provider, institution-to-institution, or direct-to-consumer? The differences involved in the various approaches are vast.

In talking with physicians, there is good acceptance of the provider to provider offerings, which can help serve rural areas or places that don’t have the specialists needed to care for patients with certain conditions. This typically involves a patient coming in to see their provider, then joining with a subspecialist or other clinician via video call. The provider who is actually with the patient can assist with physical exam findings and vital signs. It doesn’t have to be a physician, but can also be a nurse or other trained member of the care team.

This approach can be huge as far as saving time and money for patients to travel to see subspecialists, understanding that some patients just wouldn’t go because of the burden. I’m seeing this more as academic medical centers partner with outlying organizations and it seems to really be taking flight in the pediatric subspecialist world.

There is also good acceptance of institution to institution telehealth, such as remote ICU monitoring or telestroke management services. This can allow specialists to weigh in on the care of patients at institutions that might not have the level of expertise needed to care for certain conditions. It can also just serve as an extra set of eyes for an already-skilled facility, making sure that nothing is missed in the care of critically ill patients. There are typically deep linkages between the organizations from both contractual and philosophical perspectives, so the level of trust is high.

Telehealth services that are delivered directly to the consumer have variable uptake. Some healthcare organizations have already built robust telehealth programs, allowing their providers to work directly with patients who may have challenges traveling to the office. Devices can be used to report patient-generated data in order to provide better care, such as daily weights for heart failure patients or blood glucose readings for diabetic patients.

Other organizations may be using telehealth strictly for acute visits, allowing physicians to extend their hours, access, and productivity without having staff in the office for an extended session. They may be using a telehealth platform within their EHR or licensing with one of the nationally-known telehealth companies to get this done.

Then there are the independent telehealth organizations that may contract with employers or payers, or may market directly to patients as consumers.

I think providers are skeptical of the independent telehealth organizations. There was recently a raging editorial from one of the leaders of the American Academy of Family Physicians on the topic. However, there’s no question that these services are filling a gap in services that aren’t being provided by brick and mortar clinics or traditional primary care practices. Although there are some direct-to-consumer organizations that seem fairly profit motivated, others have significant interest in measuring clinical quality and patient outcomes along with patient satisfaction and efficiency metrics, just like an in-person practice would. These organizations are doing work to explore how they can fill gaps in care while maintaining antibiotic stewardship and clinical quality. They’re also working to ensure that the loop is closed with reports to primary care physicians so that there is continuity of care.

The challenge for these organizations is the lack of data looking at telehealth care of various conditions. There simply isn’t a body of research (yet) that looks at the effectiveness of a telehealth history and examination vs. an in-person examination. We know that physicians have treated certain conditions over the phone for decades, yet there are challenges when it is a brand-new patient-physician relationship rather than an existing one. Smart organizations are gathering data on their outcomes and their approaches and using it to drive future care pathways.

I think we’re going to see a continued boom in telehealth including expansion into the primary care and chronic care space. There will also be plenty of room for specialized telehealth organizations to flourish. Patients are voting with their pocketbooks on convenience and access and I hope traditional organizations are making note.

The Epic campus has made it into Atlas Obscura,one of my favorite sites for internet time-wasting. I had heard about many of the features, but not the medieval drawbridge, which caught my attention. I’ve never been, but I hear it is something to behold.

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