Kvedar: Telemedicine may be 'EHR v2.0'
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“It’s almost like EHR v 2.0, or moving care out of the EHR and into the patient environment, making it more continuous, more just-in-time,” and telemedicine makes this possible, he said.
“I’ve been at this since 1995, when it really was a crazy thing,” Kvedar said. “I was inspired by the idea that we might be able to extract value out of healthcare interaction if we were able to separate the provider and the patient.”
One way of doing that is extending providers across distance to provide care to the patient when patient needs it. A big part of this is a focus on self-care, showing patients how their lifestyle affects their illness. In other words, “getting people to care for the one they care about the most—themselves,” he said.
There is a need to extend providers and engage patients.“The juggernaut of demand continues, but we’re not keeping up with the [physician and nurse] supply,” Kvedar said. “We can’t train enough people, even if we could economically justify it. When the unit of product is a person meeting another person, and one of those is in short supply, we have to change the way we do it.”
“The ideal components of any solution are access, efficiency and quality. We have to think about doing all three,” Kvedar continued. He cited the center's tele-ICU, which puts a group of intensivists in one location, allowing them to service multiple ICUs using existing patient technology and instrumentation, and getting data from the bedside to the provider via the internet.
Video communication at the bedside has been shown to add significant value by leveraging a specialist intensivist group of providers across a much larger group of patients. This is possible because ICU events are high impact, but usually low-frequency events, he said.
The center’s tele-stroke program, now a network of 20 to 30 facilities in Massachusetts, New Hampshire and Rhode Island, enables smaller organizations to “rent a stroke neurologist,” said Kvedar. Attending specialsits all have videoconferencing at home so they’re available at a moment’s notice, and can make assessments of patient as if they were onsite.
“The story is about video communication directly with patients. It’s a fun thing when you hang around technology for years, you can watch various things come from vision to reality,” he said. The evolution of $60,000 video/telephone systems to today’s high-resolution smartphones makes it easier for both patients and providers to conduct virtual visits.
Payment and billing ramifications might be evolving as well, said Kvedar: Payment is getting figured out, but it’s an ongoing theme. “There are ways to look globally at economics around this. One is, as we prepare for a world where we’re paid for outcomes and quality, it will be up to us to interact with patients in whatever way we think will add the most value. That could be via email, or via skype, it doesn't have to be in the office,” he said.
In some instances, third-party payors will pay for video visits, although it's not enough to sustain a practice, Kvedar added.
Smartphones and video aside, telemedicine applications in place today rely on remote monitoring devices and follow-up calls. Connected cardiac care, for example, is designed to solve the problem of readmissions by identifying patients who are at risk for readmission and giving them a weight scale, a blood pressure cuff and a table-top device that takes those data and sends them to a database. “If they don’t [report] vital signs, we call them and ask why not," he said. "Early on, they know they’re being held accountable.”
For hypertension, the center's blood pressure program encourages patients to measure their blood pressure three times per week. Patients can view their blood pressure measurements online; clinicians can intervene at the earliest sign of trouble.
Likewise, Diabetes Connect enables patients to measure, record and manage their blood sugar levels—depending on how engaged the are. "Caring enough to upload” is a good sign, Kvedar said.
For clinicians, quality is probably the first obstacle for telemedicine, along with reimbursement and workflow. For patients, the obstacles are ease of use, provider endorsement and incentives. “We’re not ready to pay people to be healthy as a society,” Kvedar added.