Technology driving changes in the way appointments are made and how doctors “see” patients
By John Carruthers, assistant editor, March 03, 2014
The general public spends ever-greater amounts of time online, organizing and planning their lives. Shopping and banking have gone from errands to be run to trifles that can be completed in five minutes at a desk or on a phone screen. Medicine is also moving to the digital domain: Patients can take advantage of always-on connectivity to find a physician online, make an appointment, research information and treatments related to their conditions, and even get a consult from a specialist.
Online appointment scheduling
Technology has allowed many medical practices to embrace online tools to fill their schedules. A handful of companies offer online appointment scheduling (much like restaurants use OpenTable.com) for a small fee. This can reduce the workload of a front desk, but more importantly, it can help practices fill last-minute cancellations and retain that revenue. Oliver Kharraz, MD, COO and founder of ZocDoc.com, one of those appointment-booking services, said that what used to be unthinkable for doctors to consider – online scheduling – has rapidly become an accepted paradigm in an era of larger practice, more patient demand, and an increasingly expectant population.
“There’s been a gradual resetting of expectations on the side of the patient through the fact that the entire rest of their lives is now happening electronically,” said Dr. Kharraz, who noted that ZocDoc sees five million unique users each month. “You shop on Amazon, book your flight on Orbitz, find a contractor on Angie’s List, and the expectation is increasingly that you can interact with any service provider on the Internet. It’s not a stretch that they’ll want to do that with their doctor.” [pagebreak]
In an era of millions more patients being served by the same number of doctors, technological solutions will have to bridge much of the gap, Dr. Kharraz said. The average no-show and late cancellation rate for a typical physician is around 25 percent. ZocDoc puts those appointments back into the system, he said, allowing its providers to utilize more of their capacity, especially if the dermatologist or practice manager knows of a patient who needs or has expressed a desire for immediate care. These unclaimed cancellations, he said, act as a hidden supply of care.
The expansion of telemedicine
Telemedicine is another once-marginal use of technology that is achieving growing acceptance in practice among dermatologists. While still a long way from universal acceptance by payers in all states, telemedicine has made great strides from its first uses in the early 1990s. Medicaid programs in more than 40 states currently reimburse some sort of telemedicine service — mostly the traditional live interactive model, though there is a push for reimbursement for the more dermatology-friendly store-and-forward system. Part of that change, according to Karen Edison, MD, a current member of the Academy’s Telemedicine Task Force, is the elimination of doubt over a physician’s ability to glean accurate information from a teleconsult and recommend the correct course of treatment.
“Technologies have evolved and improved so much that there’s no longer any question about the quality of the digital images or the quality of the video conferencing in terms of our ability to see, make diagnoses, and recommend treatments,“ she said. “The broader health care community as well as the health policy community has, in the last three to five years, awakened to the promise of the technology in improving health and health care for our patients.” [pagebreak]
Dermatology has long been concerned with obtaining and storing patient images and information to track patient progress over the years. This, according to Karen Rheuban, MD, medical director of the University of Virginia’s office of telemedicine, makes dermatology the perfect partner to demonstrate the utility of telemedicine expansion.
“There’s a huge demand for dermatology services that has only been increasing. Dermatologists have long been involved with image acquisition as part of their practice. In our digital world, there is no reason that digital photography can’t be part of the record, part of health information exchange, and expanded through telemedicine,” Dr. Rheuban said. “Not only is it a tool that can be integrated into everyday care, but store-and-forward has the potential to maximize the efficiency in terms of workflow and case management. A dermatologist could look at appropriately acquired images to determine the need for triage.”
University of Virginia dermatologist Kenneth Greer, MD, first began using telemedicine to offer consults to prisoners in the Virginia state penal system. The difficulty and logistics of getting a specialist to see high-risk prisoners led to a pioneering live interactive model. In the near future, he said, dermatologists may be able to generate further revenue by performing store-and-forward consults at the end of the day. The model, he said, offers more flexibility and less dependence on support personnel to work.
“Once the payers catch up, you’ll probably have individuals who sit down after office hours and do store-and-forward consults for a fee,” Dr. Greer said. “There’s the potential for it to be a bigger part of dermatology than live interactive telemedicine, where I depend on lighting, more equipment, and the support personnel.” [pagebreak]
In late 2013, telemedicine received a much-needed boost from the Centers for Medicare and Medicaid Services (CMS) in the 2014 Medicare physician fee schedule. The new fee schedule expanded the geographic areas where telehealth services are covered by Medicare, from counties not defined as part of a metropolitan statistical area to a new standard defined by the Office of Rural Health Policy using a method called the Rural-Urban Commuting Area Code. This method, which is explained in greater detail at www.hrsa.gov/ruralhealth/policy/definition_of_rural.html, defines roughly 91 percent of the area of the U.S., containing around 20 percent of the population, as rural. The change, Dr. Rheuban said, was long overdue.
“With telemedicine, Medicare’s definition of a rural area’ where they would reimburse for E/M services was extremely challenging,” Dr. Rheuban said. “Under the definition that lasted through the end of 2013, the Grand Canyon was technically still in an urban’ area that didn’t fall under coverage.”
The timeline of dermatology’s widespread embrace of telemedicine among individual practitioners, according to Des Moines, Iowa dermatologist Timothy G. Abrahamson, MD, will largely depend on the speed of CMS and private payers, who have until recently failed to recognize the parallels between patients in underserved areas and patients in remote states where telemedicine is more widely reimbursed. For instance, Medicare has reimbursed for store-and-forward telemedicine in Alaska and Hawaii for decade, he said.
“My thought would be that the simplest way to move forward with telemedicine is to pursue the same payment structure that Alaska and Hawaii have gotten for the same services. If the argument is rural access, the Alaskan experience said that most patients were an hour and a half away from access,” Dr. Abrahamson said. “In Des Moines, I’ve regularly had patients come from two hours away. I’m not necessarily pushing for more, just the access to the established model of store-and-forward telemedicine as in Alaska and Hawaii.” [pagebreak]
Dr. Abrahamson began a pilot program in January 2014 that allows for live interactive teledermatology for inpatients at one of the five hospitals at which he sees patients in the Des Moines area. The key for dermatologists, he said, will be in pursuing reimbursement for store-and-forward, which was previously only reimbursed by CMS in limited areas of the country that CMS, under the older definitions of the term “rural,” found to be the most remote and underserved.
With much of the onus of record-keeping being placed on medical providers, he also argued that store-and-forward consults could offer much better case documentation.
“You would be able to keep photos, or even a video, in the patient record for a year or two with a system similar to what radiologists use, and you could go back and see the data a provider used for their decision process,” Dr. Abrahamson said. “There’s access to better data with store-and-forward, and there’s more data potentially storable from the consult. It can help justify a service or decision much better.”
Presently, Dr. Edison said, teledermatology serves a very important function for many providers, allowing for triage of existing patients. Teleconsults with previously seen patients, she said, allow some providers to achieve an optimum balance between new patients and follow-up patients. Those with routine or well-controlled skin conditions, she said, can be delayed or referred to another provider. But high-quality images that show an area of concern can serve to get a patient in the door more quickly and help ensure a better outcome.
Taking things a step further, some services offer patients direct access to a dermatologist without ever seeing any health care provider in person. According to Dr. Edison, of the more than 100,000 consumer-directed health apps in smartphone marketplaces, 26 relate directly to dermatology, and about a dozen claim to connect a user with dermatologists for photo consults. [pagebreak]
DermatologistOnCall, for instance, allows patients to create an account, capture their own images, and get an answer on the severity of their skin condition within three business days from a board-certified dermatologist, along with a treatment plan or an in-office appointment for more serious cases.
“I think that there’s a fee-for-service model around teledermatology from patients themselves that may become popular — they’ll pay for access, and for convenience,” Dr. Edison said. “I don’t think fee-for-service is going away overnight. Even when we more fully adapt to a new model, there may be pockets of it that exist, and this could be one of them. Patients are willing to pay for access.”
Despite the promise of a streamlined visit and additional payment source, Dr. Edison is quick to point out that patient-centered care works best when health care can be delivered locally, if not regionally. It doesn’t particularly help the patient, she said, if a dermatologist makes a good diagnosis but the patient has no access to the treatments, pharmaceuticals, or testing necessary.
Seeing providers begin to act in concert with the technological tools available, said University of Pennsylvania dermatologist Carrie Kovarik, MD, chair of the Academy’s Telemedicine Task Force, demonstrates possible future practices for much of the specialty.
“Technology has already allowed patients to not necessarily travel to the doctor’s office to receive care. Whether it’s looking up results from a patient portal, or being able to receive treatment via a primary care office and teleconsult, it’s brought everything closer together,” she said. “We have patients who come to our office for follow-ups that could be done at a distance. If the patient is doing well, they could save a lot of time and money doing follow-up care via these new means.” [pagebreak]
New tools for tomorrow
Whether dermatologists see a patient in person, for a teleconsult requested by another provider, or through direct-access teledermatology, they may soon turn to photo recognition software to track changes in their patients’ conditions. While currently in its early stages, photo recognition, integrated into a patient record with captured images, could possibly process serial photos of lesions and recognize changes in those lesions over time and alert the physician to suspicious growth. Properly captured images, working in concert with a software algorithm, could also accurately estimate body surface area to help dermatologists track a patient’s progress, according to Dr. Kovarik.
To best advocate for reimbursement and safeguard the quality of care, Dr. Rheuban said, new standards will need to be developed and continually evaluated. The need is urgent, she said, because the widespread embrace of technology that allows for virtual visits and software solutions that recognize changes from visit to visit seems inevitable.
“If we’re going to advance the field, we need to have as many practice guidelines and standards for the acquisition of images and the delivery of care as possible. I want to do this in a thoughtful, careful way, but I would like the societies to weigh in on what the guidelines are for the delivery of care in that specialty,” she said. “Just like the radiology world developed DICOM as their standards, the various specialties need to determine what standards are most appropriate. Dermatologists themselves need to set the appropriate standards and have the flexibility to adapt as technology evolves.”