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Using Telemedicine to Reduce Wait Times for Veterans

By Richard J. Boxer, MD
May 10, 2016
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Although it’s not a replacement for all face-to-face care, telemedicine could make a significant impact for those with simpler needs.

—Richard J. Boxer, MD

John Farrow, a 67-year-old Vietnam veteran, had not been able to sleep for days. A week ago, his primary care doctor at his local outpatient Veterans Administration (VA) clinic told him that his prostate-specific antigen (PSA) blood level was rapidly increasing, and his prostate was abnormal on examination. His brother and father had similar findings years ago, and they had prostate cancer.

To learn more, Mr. Farrow (not his real name) would need to see a specialist in West Los Angeles, the closest fully staffed VA in the state. But to get there, he’d have to drive 5 hours from his home in Atascadero, California, and back.

Over the past year, the VA has been accused of wrongdoing, ranging from administrative inefficiency to straight-out fraud. According to reports, many veterans were made to wait for months before receiving care—delays that are thought to account for upward of a few dozen preventable deaths. Three of the patients had prostate and bladder diseases and died as a result of delay in treatments.

The unconscionable behavior of a few has thrown a shadow across the efforts of the dedicated caregivers who work in earnest to fulfill the VA’s stated mission: “To serve those who serve.” But it has also given us a chance to rethink how we approach our service in the future.

Amid this fallout, Congress has allocated an additional $15 billion to help the VA address these issues.1 The challenge now is in using that funding effectively and efficiently to reshape its approach to patient care.

The New World of Connected Health

One avenue the VA could take to modernize its operations, provide more patients timely care, maintain quality standards, and save money at the same time is telemedicine. The new world of connected health has given rise to novel approaches, ranging from the simple availability of doctors via instant chat to military applications allowing instantaneous response and relief for wounded soldiers. This technology let’s them contact teletrauma specialists directly from the field, drastically improving the odds of survival.

Thus far, the VA’s use of telemedicine has been effective but limited. At the West Los Angeles VA, a new teleurology clinic opened 18 months ago, allowing veterans to opt for private video consultations with board-certified physicians instead of in-person meetings. Already, these efforts have brought down wait times from an average of 7 weeks to about 1.5 weeks—an 85% decrease. Not only that, but it has also increased the number of initial patient visits by nearly 10%—a remarkable number considering that 3,000 veterans seek new urologic consultations at the West Los Angeles VA alone.

As any doctor will tell you, getting patients to come in sooner has a tremendous impact on their odds for survival before the illness progresses too far. Early diagnosis could mean the difference between a bad cough and pneumonia or between a sore leg and a pulmonary embolism.

Although it’s not a replacement for all face-to-face care, telemedicine could make a significant impact for those with simpler needs. Digital health care is just as effective as in-person care in these scenarios, according to the American Medical Association.

In 2016, nearly 100 million outpatient visits will occur at the VA.2 Included in that number are a projected 800,000 televisits across 44 specialties. Based upon studies in the private sector, where 80 million doctor visits occur each month, estimates show that as many as 30% of visits could be performed via technology.3 Thus, in the VA system, there will be less than 5% of the potential televisits.

Changing that ratio could mean not only that more veterans will be able to see doctors sooner, but that they may be more likely to see them in the first place. In the long haul, it could significantly expand veterans’ access to quality care and add efficiencies across the system.

Telemedicine in Action

For Mr. Farrow, the choice was easy to make.

After our 30-minute video session, I ultimately recommended that he receive a biopsy, followed by a telemedicine visit to discuss the results of the test. In the end, he came to Los Angeles for the procedure—an outcome that could have taken two 10-hour drives and another 6 weeks of waiting had he gone the traditional route. Removing that wait time allowed him to make up his mind more quickly—and to receive care more swiftly.

“He would not admit it, but the stress of not knowing immediately was nearly overwhelming,” Mrs. Farrow confided to me during the initial consultation. “I never saw him that way before. Now, I can tell there has been a cloud lifted from him.” ■

Disclosure: Dr. Boxer reported no potential conflicts of interest.

References

1. VA got $15B from Congress,
still can’t fix problems. Newsmax. April 30, 2015. Available at http://www
.newsmax.com/Newsfront/va-billions-wait-times/2015/04/30/id/641658/. Accessed April 20, 2016.

2. U.S. Department of Veterans Affairs: Trends in the utilization of VA programs and services. Available athttp://www.va.gov/vetdata/docs/quickfacts/Utilization_trends_2012.pdf. Accessed April 20, 2016.

3. New England Healthcare Institute: A matter of urgency: Reducing emergency department overuse. An NEHI Research Brief, March 2010. Available at http://www.nehi.net/writable/
publication_files/file/nehi_ed_overuse_issue_brief_032610finaledits.pdf. Accessed April 20, 2016.

July 30, 2013

Telehealth/Telemedicine: Join the Band(width)

July 30, 2013/ Richard Boxer

Telehealth and telemedicine, sometimes the terms are used interchangeably, is the access point to medicine for millions of Americans, and will be greater every year. ASCO members and all health professionals who are caring every day for those impacted by cancer have found or will find that electronic communication is a tremendous advantage that if used wisely, will lead to greater access and affordability and quality convenient care.

Telemedicine Defined

"Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term 'telehealth,' which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth."

The use of electronic communications is a huge business growing at an estimated 55% annually. With the government mandating the use of electronic health records, the new health reform act (The Patient Protection and Affordable Care Act [PPACA]) bringing more than 30 million newly insured patients, the estimate that there will be a shortfall of tens of thousands of physicians, a Merritt Hawkins Consulting firm survey that it takes patients 2-6 weeks to obtain a consultation, the need for affordable, accessible, quality health care is not only a present crisis, it is only going to get worse...a lot worse.

Although telehealth is particularly well-suited for primary care, dermatology, cardiology, mental health, ophthalmology, pathology, radiology, and fetal medicine have all used electronic communication effectively. In 2004, the last year data is available, there were 1 billion outpatient visits in the US, including 104 million in emergency rooms, 430 million seen in primary care offices and 403 million seen in specialists offices and another 63 million in hospital outpatient departments. At least 100 million visits were for non-emergent health conditions for example 28 million were for symptoms of an upper respiratory infection. Many of these could easily been treated via electronic communication.

Rural populations commonly have difficulty getting to primary care physicians, and specialty care is extremely difficult. Telephonic or video consultations for acute, non-episodic, non-life threatening conditions are cost effective and convenient. These patients deserve quality care and electronic communications do not replace a personal "hands-on" consultation when necessary, but they are not always necessary.

Telemedicine offers the opportunity to achieve many goals, but it is not the panacea that solves all of the seemingly insurmountable issues that are inundating our profession. The government demands more care, yet provides regulatory barriers to creative solutions. Fortunately, private insurance companies and government insurance are beginning to pay for telehealth consultations.

The perfect cannot be the enemy of the good. There needs to be alternative access to quality health care. Thus, new, creative, affordable convenient care fills a need that is being created by the economics of medicine.

Oncologists care for a critical subset of patients with special needs, some physical and some emotional. Telehealth offers the opportunity for specialists to communicate and thus care for those patients who are unable to access high quality care in an affordable convenient manner.

All health care is advanced and improved through robust communication. The basis of the medical home is communication. With electronic health records and secure HIPPA compliant interface, the patient and family can communicate with the oncologist to discuss any health issue. Family conferences anywhere in the world can easily occur. Patients fears can be allayed. Routine follow-up visits can be easily occur without the hassle of travel whether urban or rural.

Like all technology and medical advancements, health professionals must be at the forefront to control to be certain that it is ethically used with the patient being the center of the process. It is our responsibility and will make our patients healthier and happier, and our practices more satisfying.

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Using Telemedicine to Reduce Wait Times for Veterans

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