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doi: 10.1097/01.HEARTI.0000390849.47312.6e
Features: Scanning The Horizon

New Healthcare Delivery Options Will Help Meet Challenges Of Healthcare Reform Law

Lewis, Darcy

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There's an old saying about not being able to fit 10 pounds of flour in a five-pound sack. The healthcare reform bill President Barack Obama signed into law - and the hundreds of regulations that government staffers are writing to implement it - promise to significantly change the practice of medicine, as millions of people who did not have or could not afford health insurance will be making routine appointments with primary care doctors, seeking consultations and second opinions with specialists and getting diagnostic testing without a proportional increase in the number of providers and facilities. Some facts and figures to consider:

▪ Approximately 32 million uninsured people will be covered by 2019. This includes 16 million who will enroll in Medicaid, the federal government's health insurance program for low-income Americans.

▪ In 2008, the U.S. Census Bureau projected that in 2010 there would be 12.3 million Americans aged 65–69 who are eligible to receive Medicare, and that there would be 16.8 million in the 60–64 age group - that is, next in line to receive 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 Medical Association, the current physician 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 specialties instead of primary care.

As a result of these challenges, the hunt is on to find new ways to reduce healthcare costs and increase efficiency as more patients enter an already strained system.

“There is a perfect storm brewing as the population ages and requires more care. Meanwhile, more patients will be entering a healthcare system where there aren't enough physicians to meet the needs of the patients we have already,” says Zeev Neuwirth, M.D., Chief of Clinical Effectiveness and Innovation at Harvard Vanguard Medical Associates in suburban Boston. “Finally, healthcare costs are a tremendous burden on our economy. We must make healthcare more efficient for the health of the country, the health of the economy - that is our imperative.”

Heathcare providers from solo practitioners to large medical centers are considering and trying out dozens of ideas and technologies to streamline the delivery of care without sacrificing quality. These initiatives range from multi-billion-dollar ideas, such as implementing electronic health records nationwide, to modest innovations, such as a cell-phone app that helps patients manage their health. Telemedicine, mobile medicine, shared medical appointments and E-mail consults are four that have the potential to be game-changers. “These technologies respond directly to consumers' preferences and permit doctors to focus on what they do best: provide safe, high quality care to their patients when they need it and where they need it,” says Catherine Dower, Associate Director of Research for the Center for the Health Professions at the University of California-San Francisco.

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Doctors are leading the charge for telemedicine - videoconferencing that lets physicians diagnose and treat patients remotely - to become more widely used throughout the medical system.

“The term generally refers to the ability to review real-time, high-quality video and the ability to zoom in and out as needed,” says Lee Schwamm, M.D., F.A.H.A., Director of TeleStroke and Acute Stroke Services at Massachusetts General Hospital in Boston. “It's an immersive experience that lets the physician feel as if [he or she is] really at the patient's bedside.”

The Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009, which provides federal incentives for healthcare providers to invest in health information technology, will spur wider adoption of telemedicine. “The HITECH Act includes a lot more federal money and support for telehealth,” says Dower. “People will finally have the money to test these innovative ideas and see what really works.”

Stroke telemedicine (or telestroke), has already gained rapid acceptance by doctors and patients alike, because it increases access to stroke specialists, especially in rural or other underserved areas. The U.S. averages only four neurologists per 100,000 people, and not all of them specialize in stroke. In areas where there aren't enough stroke specialists to go around, a telestroke evaluation is as effective as a bedside stroke evaluation to determine if a suspected acute stroke patient is a candidate for treatment with tPA, according to a 2009 scientific statement on telestroke issued by the American Heart Association/American Stroke Association. The clot-busting drug can reduce brain damage if administered within three hours of the onset of symptoms.

“Every hospital has a CT scanner, a lab and a pharmacy to provide tPA - and now telestroke provides the specialist expertise,” says Schwamm, who was the lead author of the AHA/ASA scientific statement. Harvard Medical School reinforced the AHA/ASA findings in a special report issued in September, “Stroke: Preventing and Treating ‘Brain Attack’”, which noted: “Telestroke programs are especially useful for helping physicians at smaller hospitals determine when to use clot-busting therapy. In these hospitals, telestroke may be the only way for a patient to receive potentially brain-preserving treatment in time.”

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As telestroke proves its value and more institutions are investing in the necessary video equipment, other medical specialties are getting in on the act. “Video consults from academic health systems to rural hospitals are growing significantly for both acute situations and managing chronic conditions like uncontrolled high blood pressure,” says Thomas Nesbitt, M.D., a senior administrator in the University of California-Davis Health System and Executive Director for Telehealth Services at the Center for Connected Health Policy in Sacramento, CA. “That's a better way to use the scarce resource, which is the specialist's time, and it keeps people from having to travel great distances.”

Take the 25-bed Grande Ronde Hospital in La Grande, OR, which obtains remote care from 11 different medical specialist teams in four states. One of their telemedicine offerings is a remote pacemaker clinic. “Our patients used to have to travel three-plus hours each way to Boise just to get their pacemakers checked, which takes all of 10 minutes,” says Doug Romer, R.N., Grande Ronde's Executive Director of Patient Care Services. “Needless to say, we have lots of happy patients now.”

And new technologies are being developed to expand what doctors can do without actually laying hands on a patient - for instance, a telemedicine stethoscope that can allow pediatric cardiologists, who are in short supply in many parts of the country, to hear the heart sounds and “see” a young patient visit via a teleconference.

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Mobile health, an emerging field within telemedicine, uses cell phones and smart phones that can take photographs or short videos to enable doctors to make diagnoses from wherever they happen to be, not just where the video equipment is located.

Javeed Siddiqui, M.D., Associate Medical Director at the Center for Health and Technology, University of California-Davis, had been doing regular telemedicine consults with a small hospital 90 miles away. But one night, he received a text at home from a colleague who was concerned about a newly admitted patient with a serious infection. After some discussion, Siddiqui asked his colleague to take a picture of the man's leg with his cell phone and E-mail it to him.

Using his cell phone, Siddiqui was able to magnify the image and determine that the patient had a strep infection that had progressed to life-threatening toxic shock syndrome. He ordered the most effective antibiotics, and the patient was wheeled into surgery just two hours later. “So much of medicine is getting the right information to the right person at the right time,” he says. “Because my colleague and I both had our cell phones, we were able to start the correct treatment without losing time and the patient walked out of the hospital just five days later.”

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As promising as telemedicine is, there is one thing it cannot do: increase the number of hours in the day that a doctor can see patients. But what if the doctor instead increases the number of patients he or she can see in a day - while also increasing the amount of time spent with each of them? Impossible, you say? Then you haven't heard of shared medical appointments that group several patients with the same medical condition.

In addition to the doctor, each shared appointment includes a nurse to take vital signs, a trained facilitator to guide discussions, a medical documenter who completes the doctor's notes in real time and a care coordinator outside the room who provides an after-visit summary with follow-up instructions.

“As a doctor, it's wonderful to walk into that room knowing that all the administrative tasks have been taken care of and all you have to do is focus on the patients,” says Neuwirth, whose medical group, Harvard Vanguard, is known as a national leader in shared visits. “Doctors love to talk, to teach, to listen - this allows the doctor to do all the things he or she does best.”

Neuwirth estimates that shared appointments can save a practitioner an hour or more each day because instead of repeating the same instructions on how to take blood pressure or when to check blood sugar to patients one by one, the doctor can educate several patients at the same time. Patients can also learn from each other, he adds. “Say you've got angina, but the person next to you has had it much longer. He or she can really offer you some wisdom, [and] tell you things you never even thought to ask.” (Just so you know: all patients must sign a confidentiality agreement before being allowed to participate in a shared appointment.)

Harvard Vanguard currently has 30 clinicians offering more than 50 shared appointments in a dozen specialties. “I have a waiting list of 20 doctors in the practice who want to do shared appointments and I get a couple calls every week from outside physician groups and medical centers that are interested in what we do,” Neuwirth says.

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Patient satisfaction with shared appointments at Harvard Vanguard has been very high, with more than 80 percent of first-time shared appointment patients returning for a second group visit.

One such satisfied patient is James Chamberlain of Drakut, MA, who attends quarterly shared appointments to help manage his diabetes. He also continues to have a private physical with his doctor each year. “I really enjoy the group appointments and I learn so many things I never thought of before,” he says. “You see how your numbers compare with others in the room and that really makes you think about your health and how you can improve it.”

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Another way to streamline communications between doctors and patients is E-mail, but while patients love it, doctors have been less than enthusiastic.

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 Children's Center in Baltimore, exchanges E-mails with his patients' parents only at their request. When the number of parents E-mailing him reached about 25 percent of his practice, he surveyed them and found they “very much want to use E-mail to communicate 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 [compensation] issue addressed in the health care reform law.”

Despite the promise and potential of healthcare reform, confusion will undoubtedly reign for years to come as healthcare innovations 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 innovations throughout the healthcare system,” says Schwamm. “If doctors would be allowed to figure out the best way to take care of patients while using resources efficiently, we would rise to that challenge in a heartbeat.”

So the spirit of Marcus Welby is alive and well, but the TV healer's real-life counterparts have to navigate a convoluted and complex healthcare system while also trying out new technologies that will eventually allow them to spend more time practicing medicine and less time on paperwork.

© 2010 American Heart Association, Inc.