Three Approaches to Virtual Office Visits

Improving access to care is one of the primary mandates of the Affordable Care Act. Given that goal, many health systems are stepping up efforts to offer convenient, fast and lower-cost alternatives to the traditional in-person office visit.

One strategy they are adopting is video visits. Patients can use their computers or their smartphones to consult with their primary or specialist physicians. How this strategy works varies, of course, based on the organizational structure, reach, reimbursement systems and market in which each system operates. In fact, two recent stories — one in last Sunday's New York Times and a segment on Monday night's "PBS NewsHour" — both address the growth and diverse approaches being used by hospitals and health plans.

I spoke with clinicians at three hospital systems to learn about their unique approaches to this growing trend.

Care Anytime, Anywhere

At Stanford Health Care, the commitment to offer care anytime, anywhere, has been the primary incentive behind the development of an integrated "bricks to clicks" continuum of care.

For the patient, such a continuum supports a lifelong relationship with a trusted institution. Stanford has developed an app and a soon-to-be-released Web portal, says Pravene Nath, M.D., chief information officer at Stanford Health Care.

Patients have the option of choosing a video visit over other means of accessing care. Nath tells me there has been a solid uptake by the 18- to 40-year-olds. Specific conditions such as dermatology also lend themselves well to a video interaction. Satisfaction rates are high, he says, given the convenience and time savings for patients, as well as the potential cost savings for employers.

As the program continues to grow, Nath says Stanford Health Care plans to offer online coaching, wellness services and monitoring services to meet the needs of its patients.

A Need to Reach Rural Patients

Dignity Health's telemedicine initiative was born out of need, says James Roxburgh, R.N., M.P.A., director of Dignity Health Telemedicine Network. Rather than looking for the latest "cool technology," he says Dignity identified the needs and services that would most appropriately fit patient care requirements.

DHTN spans major cities with tertiary care centers and includes small rural communities, offering the same resources and tools to all the hospitals in the system. Established in 2008 with a goal to provide timely access to high-quality specialized health care services that are not readily available, DHTN is one of the country's largest acute care networks — it has 39 sites that include three skilled nursing facilities.

Patient response to these offerings has been positive, according to Roxburgh, particularly when response times can sometimes be faster than an in-person specialist consult.

Another important aspect of this program, says Roxburgh, is that the program helps to alleviate the challenges faced by the dearth of specialists in rural areas. The network offers learning opportunities to small community hospitals, as clinicians, particularly the nursing and ancillary staff, are able to gain experience by interacting with the telemedicine specialists. Nurses at the partner sites say they love telemedicine: Not only do they learn from the physicians, but they care for patients they wouldn't normally see, and learn from experience.

Reducing Wait Times

When wait times were lengthening in Kaiser Permanente's mid-Atlantic region (which covers Virginia, Washington, D.C., and Maryland), Dennis Truong, M.D., a former military physician, came up with the idea to offer visits via video. He had frequently consulted with colleagues around the world during his tenure in the military via Skype and thought it could improve access as well as the patient experience.

In 2013, the health plan started a pilot program that offers members the option (when they phone into the call center) to use their computers or smartphones from home or go to a nearby Kaiser clinical decision unit for a video visit assisted by a nurse or medical assistant.

A key factor in the success of this program is that the physicians, while they're speaking with a patient, have access to the patient's electronic health record on a second screen, says Truong. Physicians can make follow-up appointments or order tests instantaneously.

The average user of the video visit is a 44-year-old female, which is likely due to the convenience factor. For now, there is no co-pay for a video visit, but that may change, says Truong. 

Improving Care Quality

At Kaiser Permanente Northern California, a few video visit programs have shown promise in helping to improve health outcomes, according to a June 2015 article in Health Affairs by Robert Pearl, M.D., CEO and executive director of the Permanente Medical Group. The Early Start Program, targeted to pregnant substance abusers, offered the convenience of video visits. Participation in the program has shown a drop in pre-term births and is now being studied further, says Pearl. Another program enables college students who are using the acne medicine Accutane, and who often have difficulty making in-person office visits because of their academic schedules, to be regularly monitored for their psychological response to the medication, which has been known to cause depression and suicidal ideation. 

Standing Out from the Crowd

Health care has been slower in its uptake of Internet and mobile technologies, and understandably so, given the challenges of patient privacy, provider resistance, reimbursement inconsistencies, the need to re-educate patients and providers on new ways of interacting with each other and, of course, the considerable setup costs.

However, the opportunities to differentiate oneself in the marketplace are vast: bringing health care to the patients at their convenience and at lower cost; avoiding unnecessary hospital visits; offering home monitoring to avert preventable readmissions; and so forth. In fact, KPNC's Pearl projects that by 2016, the number of virtual visits, whether through email, phone or video, will surpass all in-person visits. All these opportunities are motivating organizations such as Stanford Health Care, Dignity Health and Kaiser Permanente to adopt video visits and other emerging tools for patient care.

On July 7, my congressman, Mike Thompson, introduced H.R. 2948, the Medicare Telehealth Parity Act of 2015. Passage of this bipartisan legislation would expand coverage of telehealth services under Medicare by putting them on the path toward parity with in-person health care visits. Of course, these bills take time; but in my opinion, things are moving in the right direction.  

Sita Ananth, M.H.A.,is a Napa, Calif.-based consultant and writer specializing in complementary medicine and wellness. She is also a regular contributor to H&HN Daily.