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    New healthcare delivery_options_will_help_meet.4 New healthcare delivery_options_will_help_meet.4 Document Transcript

    • S CAN N I N G TH E H O R I Z O NMARCUS WELBYMEETS THE 21STCENTURYInnovative Healthcare Delivery Options Will Help Meet The Challenges Of TheHealthcare Reform LawBY DARCY LEWIST here’s an old saying about not being able to fit 10 As a result of these challenges, the hunt is on to find new ways pounds of flour in a five-pound sack. The healthcare to reduce healthcare costs and increase efficiency as more patients reform bill President Barack Obama signed into law — enter an already strained system. and the hundreds of regulations that government staff- “There is a perfect storm brewing as the population ages anders are writing to implement it — promise to significantly change requires more care. Meanwhile, more patients will be entering athe practice of medicine, as millions of people who did not have healthcare system where there aren’t enough physicians to meetor could not afford health insurance will be making routine ap- the needs of the patients we have already,” says Zeev Neuwirth,pointments with primary care doctors, seeking consultations and M.D., Chief of Clinical Effectiveness and Innovation at Harvardsecond opinions with specialists and getting diagnostic testing Vanguard Medical Associates in suburban Boston. “Finally, health-without a proportional increase in the number of providers and fa- care costs are a tremendous burden on our economy. We mustcilities. Some facts and figures to consider: make healthcare more efficient for the health of the country, the  Approximately 32 million uninsured people will be covered health of the economy — that is our imperative.” by 2019. This includes 16 million who will enroll in Medicaid, Heathcare providers from solo practitioners to large medi- the federal government’s health insurance program for low- cal centers are considering and trying out dozens of ideas and income Americans. technologies to streamline the delivery of care without sacrificing  In 2008, the U.S. Census Bureau projected that in 2010 quality. These initiatives range from multi-billion-dollar ideas, such there would be 12.3 million Americans aged 65-69 who are as implementing electronic health records nationwide, to modest eligible to receive Medicare, and that there would be 16.8 mil- innovations, such as a cell-phone app that helps patients man- lion in the 60-64 age group — that is , next in line to receive age their health. Telemedicine, mobile medicine, shared medical health benefits from the federal government’s insurance for older Americans. That’s a 25 percent increase in just five years.  According to the American Medi- cal Association, the current phy- sician shortage will swell to as many as 159,000 physicians by 2025. Already, 22 states and 15 medical specialties have reported not having enough practitioners to meet patient demand. Given the current system of health care finance, better pay tends to draw new physicians — who start their careers saddled with hundreds of thousands of dollars in medical school loans — to lucrative spe- cialties instead of primary care.16 H EART I N S I G HT • N OVE M B E R 2010
    • When a colleague at a hospital 90 miles away sent this photo of a patient’s leg to Dr. Javeed Siddiqui’s cell phone, he was able todiagnose a life-threatening infection.appointments and E-mail consults are four that have the poten- says Lee Schwamm, M.D., F.A.H.A., Director of TeleStroke andtial to be game-changers. “These technologies respond directly to Acute Stroke Services at Massachusetts General Hospital in Bos-consumers’ preferences and permit doctors to focus on what they ton. “It’s an immersive experience that lets the physician feel as ifdo best: provide safe, high quality care to their patients when they [he or she is] really at the patient’s bedside.”need it and where they need it,” says Catherine Dower, Associate The Health Information Technology for Economic and ClinicalDirector of Research for the Center for the Health Professions at Health Act (HITECH Act) of 2009, which provides federal incen-the University of California-San Francisco. tives for healthcare providers to invest in health information tech- nology, will spur wider adoption of telemedicine. “The HITECH ActA DOC AT YOUR BEDSIDE WITHOUT BEING IN THE includes a lot more federal money and support for telehealth,” saysROOM Dower. “People will finally have the money to test these innovativeDoctors are leading the charge for telemedicine — videoconfer- ideas and see what really works.”encing that lets physicians diagnose and treat patients remotely Stroke telemedicine (or telestroke), has already gained rapid— to become more widely used throughout the medical system. acceptance by doctors and patients alike, because it increases ac- “The term generally refers to the ability to review real-time, cess to stroke specialists, especially in rural or other underservedhigh-quality video and the ability to zoom in and out as needed,” areas. The U.S. averages only four neurologists per 100,000 peo- H EART I N S I G HT • N OVE M B E R 2010 17
    • ple, and not all of them specialize in stroke. In areas where there tors can do without actually laying hands on a patient — for instance,aren’t enough stroke specialists to go around, a telestroke evalu- a telemedicine stethoscope that can allow pediatric cardiologists,ation is as effective as a bedside stroke evaluation to determine if who are in short supply in many parts of the country, to hear thea suspected acute stroke patient is a candidate for treatment with heart sounds and “see” a young patient visit via a teleconference.tPA, according to a 2009 scientific statement on telestroke issuedby the American Heart Association/American Stroke Association. DIAGNOSING ON THE GOThe clot-busting drug can reduce brain damage if administered Mobile health, an emerging field within telemedicine, uses cellwithin three hours of the onset of symptoms. phones and smart phones that can take photographs or short vid- “Every hospital has a CT scanner, a lab and a pharmacy to pro- eos to enable doctors to make diagnoses from wherever they hap-vide tPA — and now telestroke provides the specialist expertise,” pen to be, not just where the video equipment is located.says Schwamm, who was the lead author of the AHA/ASA scien- Javeed Siddiqui, M.D., Associate Medical Director at the Center fortific statement. Harvard Medical School reinforced the AHA/ASA Health and Technology, University of California-Davis, had been doingfindings in a special report issued in September, “Stroke: Prevent- regular telemedicine consults with a small hospital 90 miles away. Buting and Treating ‘Brain Attack’”, which noted: “Telestroke programs one night, he received a text at home from a colleague who was con-are especially useful for helping physicians at smaller hospitals cerned about a newly admitted patient with a serious infection. Afterdetermine when to use clot-busting therapy. In these hospitals, some discussion, Siddiqui asked his colleague to take a picture of thetelestroke may be the only way for a patient to receive potentially man’s leg with his cell phone and E-mail it to him.brain-preserving treatment in time.” Using his cell phone, Siddiqui was able to magnify the image As telestroke proves its value and more institutions are invest- and determine that the patient had a strep infection that had pro-ing in the necessary video equipment, other medical specialties gressed to life-threatening toxic shock syndrome. He ordered theare getting in on the act. “Video consults from academic health most effective antibiotics, and the patient was wheeled into sur-systems to rural hospitals are growing significantly for both acute gery just two hours later. “So much of medicine is getting the rightsituations and managing chronic conditions like uncontrolled high information to the right person at the right time,” he says. “Becauseblood pressure,” says Thomas Nesbitt, M.D., a senior administrator my colleague and I both had our cell phones, we were able to startin the University of California-Davis Health System and Execu- the correct treatment without losing time and the patient walkedtive Director for Telehealth Services at the Center for Connected out of the hospital just five days later.”Health Policy in Sacramento, CA. “That’s a better way to use thescarce resource, which is the specialist’s time, and it keeps people SHARING IS CARINGfrom having to travel great distances.” As promising as telemedicine is, there is one thing it cannot do: Take the 25-bed Grande Ronde Hospital in La Grande, OR, increase the number of hours in the day that a doctor can seewhich obtains remote care from 11 different medical special- patients. But what if the doctor instead increases the number ofist teams in four states. One of their telemedicine offerings is patients he or she can see in a day — while also increasing thea remote pacemaker clinic. “Our patients used to have to travel amount of time spent with each of them? Impossible, you say?three-plus hours each way to Boise just to get their pacemak- Then you haven’t heard of shared medical appointments thaters checked, which takes all of 10 minutes,” says Doug Romer, group several patients with the same medical condition.R.N., Grande Ronde’s Executive Director of Patient Care Services. In addition to the doctor, each shared appointment includes a“Needless to say, we have lots of happy patients now.” nurse to take vital signs, a trained facilitator to guide discussions, a And new technologies are being developed to expand what doc- medical documenter who completes the doctor’s notes in real time18 H EART I N S I G HT • N OVE M B E R 2010
    • S CAN N I N G TH E H O R I Z O Nand a care coordinator outside the room who provides an after- Patient satisfaction with shared appointments at Harvard Van-visit summary with follow-up instructions. guard has been very high, with more than 80 percent of first-time “As a doctor, it’s wonderful to walk into that room knowing that shared appointment patients returning for a second group visit.all the administrative tasks have been taken care of and all you One such satisfied patient is James Chamberlain of Drakut,have to do is focus on the patients,” says Neuwirth, whose medical MA, who attends quarterly shared appointments to help managegroup, Harvard Vanguard, is known as a national leader in shared his diabetes. He also continues to have a private physical with hisvisits. “Doctors love to talk, to teach, to listen — this allows the doc- doctor each year. “I really enjoy the group appointments and I learntor to do all the things he or she does best.” so many things I never thought of before,” he says. “You see how Neuwirth estimates that shared appointments can save a prac- your numbers compare with others in the room and that reallytitioner an hour or more each day because instead of repeating the makes you think about your health and how you can improve it.”same instructions on how to take blood pressure or when to checkblood sugar to patients one by one, the doctor can educate several E-CONSULTS CONNECT DOCTORS AND PATIENTSpatients at the same time. Patients can also learn from each other, Another way to streamline communications between doctors andhe adds. “Say you’ve got angina, but the person next to you has patients is E-mail, but while patients love it, doctors have been lesshad it much longer. He or she can really offer you some wisdom, than enthusiastic.[and] tell you things you never even thought to ask.” (Just so you Take Judy Balacz of Mount Prospect, IL, who likes E-mailing her doctor because “I feel like I’m taking up less of her time than I would with a phone call for something that’s not urgent. I can send an E-mail at my convenience and she can answer at hers.” Cheryl Alkon of Natick, MA, also likes E-mailing her doctors, but her obstetrician told her she prefers phone calls because “she can’t always respond to an E-mail quickly and is afraid she will miss something important.” Other doctors are also concerned about protecting patient privacy, being swamped by patient E-mails or insurance companies in some states not reimbursing them for E- consults (CA is a notable exception; insurers are not allowed to deny claims for E-consults if an in-office visit would have been covered). Michael Crocetti, M.D., a pediatrician at Johns Hopkins Chil- dren’s Center in Baltimore, exchanges E-mails with his patients’ parents only at their request. When the number of parents E-mail- ing him reached about 25 percent of his practice, he surveyed them and found they “very much want to use E-mail to communi- cate with their providers, think it would strengthen the relationship and see it as a necessary next step in healthcare because it’s so convenient for them.” Crocetti says that while hospitals may set policies on E-mail communication between doctors and patients, practitioners often make their own personal decision whether to do so. “We have to figure out how to embrace this because it’s what patients want,” he says. “But we also have to figure out a way to get the [compensa- tion] issue addressed in the health care reform law.” Despite the promise and potential of healthcare reform, confu- sion will undoubtedly reign for years to come as healthcare in- novations are developed and adopted by doctors, patients – and perhaps most important, insurers. “Right now, it’s largely regulatory and financial barriers that keep us from making all kinds of in- novations throughout the healthcare system,” says Schwamm. “Ifknow: all patients must sign a confidentiality agreement before doctors would be allowed to figure out the best way to take carebeing allowed to participate in a shared appointment.) of patients while using resources efficiently, we would rise to that Harvard Vanguard currently has 30 clinicians offering more challenge in a heartbeat.”than 50 shared appointments in a dozen specialties. “I have a So the spirit of Marcus Welby is alive and well, but the TV heal-waiting list of 20 doctors in the practice who want to do shared er’s real-life counterparts have to navigate a convoluted and com-appointments and I get a couple calls every week from outside plex healthcare system while also trying out new technologies thatphysician groups and medical centers that are interested in what will eventually allow them to spend more time practicing medicinewe do,” Neuwirth says. and less time on paperwork. HI H EART I N S I G HT • N OVE M B E R 2010 19