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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.

November 20, 2017

Wall Street Journal: Can Marijuana Alleviate the Opioid Crisis?

November 20, 2017/ Richard Boxer

Can Marijuana Alleviate the Opioid Crisis?

The federal government should stop blocking research into the drug’s medical potential.

Richard Boxer

Nov. 19, 2017 1:23 p.m. ET

Jennifer, a 37-year-old Virginia school teacher now unable to work due to unrelenting pain caused by a genetic spinal disease, stared hopelessly at the bottle of opioids her doctor had prescribed her. Beset by desperation discomfort, she faced a difficult choice. The opioids would provide limited relief but came with a high risk of addiction. Or she could try marijuana, which would likely be safer but put her on the wrong side of the law.

Jennifer chose marijuana. She drove to Washington, D.C., where the drug is sold legally, and visited three medical marijuana storefronts offering ridiculously named products like “Kush,” “Diesel” and “Head Trip.” While the offerings were of unknown concentrations and efficacy for her pain, they worked to a greater degree and with fewer side effects than any previous medication Jennifer had tried. Her experience (she is the daughter of a patient in Los Angeles, where I practice) inspired me to advocate for further research into clinical uses of the drug for pain relief.

For the most part, doctors and patients rely on anecdotal information when deciding on a treatment path involving cannabinoids. No rigorous scientific studies have been published that corroborate claims about marijuana’s medical benefits when prescribed and used properly. The federal government should remove the drug from Schedule I of the Federal Controlled Substances Act so researchers can lawfully assess its medical potential.

In September, Sen. Orrin Hatch introduced a bill “to improve the process for conducting scientific research on marijuana as a safe and effective medical treatment.” The Marijuana Effective Drug Study Act of 2017 has bipartisan support. “To be blunt, we need to remove the administrative barriers preventing legitimate research into medical marijuana,” Sen. Hatch said in a press release.

Any research on medical marijuana must first assess the potential for addiction to other, harder drugs. The notion that marijuana is a “gateway” is so far unsupported. “There is no conclusive evidence that the drug effects of marijuana are causally linked to the subsequent abuse of other illicit drugs,” wrote researchers for the Institute of Medicine in 1999. Still, the idea lives on, underscoring the need for real research.

Not only is marijuana a potentially effective pain treatment, it may also help alleviate the opioid crisis. States that have legalized medical marijuana enjoy significantly lower levels of opioid consumption and overdose deaths than states that continue to penalize possession and use, according to the Journal of the American Medical Association: “States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate . . . compared with states without medical cannabis laws.”

Researchers from the University of California, San Diego found that hospitalization rates of people suffering from painkiller abuse and addiction dropped 23% and overdoses requiring hospitalization fell 13% in places where medical marijuana was made legal. And a recent study found that Colorado, which legalized the drug for recreational use in 2014, experienced a 6.5% reduction in opioid-related deaths.

Last year alone, more than 64,000 Americans died from drug overdoses. Recognizing the link between decriminalizing marijuana and reducing opioid overdoses could save thousands of lives. With 650,000 prescriptions for opioids filled each day (3,900 for new patients) the epidemic seems likely to continue. Although scientific proof is no guarantee of an end to partisan squabbling, evidence-based medical data may offer hope for a consensus about the effectiveness of cannabis in the alleviation of human suffering.

Jennifer is not a criminal. She uses marijuana to relieve her debilitating pain because it is effective, non-addictive and almost impossible to overdose on. By preventing essential research on the medical uses of the drug, the federal government forces Jennifer, and thousands like her, into an impossible position.

Dr. Richard Boxer is a clinical professor at UCLA’s David Geffen School of Medicine and medical adviser to iAnthus Capital Management, which invests in the cannabis industry.

Thought leadership in the healthcare industry

Boxer Health Strategies

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Blog

Using Telemedicine to Reduce Wait Times for Veterans

Boxer Health Strategies

Can Marijuana Alleviate the Opioid Crisis?

The federal government should stop blocking research into the drug’s medical potential.

Boxer Health Strategies

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