Telemedicine:Healthcare Paradigm Shift

Douglas Stuart, MDMS Center of AtlantaPeachtree Neurological Clinic

Doctor-Patient Interaction and the Physical Exam

Medical School- taught medical history and full medical exam

Diagnosis should be narrowed down to 1-2 problems after the history 85% of time Exam and testing solidify the diagnosis

Many fields of medicine lend themselves largely to the history Cognitive fields- neurology, psychiatry Primary care follow-ups ER care- non surgical orthopedics

Realized quickly in my practice that I examined about 25% of my return patients and they were driving 4-6 hours to see me Gas costing many more than the visit itself Problem that needed a solution

Future Exam

Point now where technology allows us to often do remote exams, same proficiency many cases History 100% of the time Standard of excellence the same

Stethoscope, otoscope, opthalmoscope Imaging

Even performing surgeries remotely with robots Military

Technology advances making it preferable by patients Patient demand and technology will drive this industry

Where Will Future Generation Seek Care?

Where will people access information and expertise in the future?

How long will they want to wait?

How far will they be willing to travel?

How will they travel?

Future of Medicine

Estimate that we will be short 150,000 physicians in the next 10 yrs Primary care- rural and urban Specialists rural Volume driven- critical # of patients in an area to

keep physician busy Varies per specialty

Georgia- 159 counties 65 have no pediatrician 68 have no Ob/Gyn 1/3 of the state’s docs will retire in next 10 yrs

Future

Excellence in healthcare is driven by pattern recognition Seeing the same thing over and over

Can’t train enough MD’s to make up for the shortage NP’s, PA’s, and other para-professionals

Quick solution Faster to train Won’t be enough

Will take even longer for pattern recognition Will not be trained in specialty and subspecialty care

Do we accept substandard delivery of care or find another solution?

Medico-legal implications!

Future

Specialty care will not go away Driven by advancing, complicated knowledge in

different fields of medicine Has become too complicated for primary care alone As mentioned, too complex for even some specialists

Complex evaluations and management of disease Life threatening diseases Life threatening treatments Complex monitoring Multidisciplinary teams

Neurology

13K in the USA Many are academic- see few patients

Estimated need - 20K by 2010

New trained = those who retire

Neurologists function as PCP’s Need more as more function as PCP’s ACA allows patients to designate specialists as

their PCP Those with complex, chronic disease

Neurology

Neurologists as subspecialists MS example

Treatment became ultra-specialized Effective treatments, life threatening complications Care centralized

Concussion care will follow the same path Scarcity of providers trained, complex evaluations, life

altering risks to inappropriate management

Legal implications As evaluations becomes more complex in certain centers,

leads to increased liability for others Standard of care

Future Healthcare Battlefield

Technology will allow us to bring pattern recognition and experience to the provider Bring to 1000 people vs train 1000 people

Clinical Judgment Human, not computer quality Patterns, voices, experience

True vs false symptoms, complaints Science will make disease management more

complex, not less

Future Healthcare Battlefield

Will allow for increased access and decreased cost Transportation

Nursing home, schools, offices Safety- patients unstable Prison

Savings Gas Time off work

Reach anywhere where there is a broadband access Georgia- most “wired” medical state

Makes sense under any healthcare model ACO, HMO Private insurance Self pay/HSA

Not a new problem

Georgia MS (multiple sclerosis) example: MS Center of Atlanta

Patients from 23/50 states 118/159 counties Complex disease

Neurologists/specialists send for subspecialty care

Rural patients diagnosed 1.5 years later Delay diagnosis leads to increased disability

Avg rural patient drives 103 miles for care Gas, loss work

Challenges In Extending MS Care Outside Metro Atlanta…Original MSCA Plan for Expanding MS Care : Develop brick and mortar sites that would be staffed by local neurologists and primary care physicians

Current Satellite Location:

• Weekly Office and Infusion presence in Villa Rica on the Tanner Medical Campus

• Costly, ongoing operational expenses that would limit the number of satellite facilities

• Because of extensive federal regulations, rigid professional services agreements are necessary between the local physician and the MS Center. These PSA’s limit availability of local physicians and restrict changes that reflect patient volume.

• Limited number of neurologists that have available time for lengthy and reoccurring MS office visits

• Patient apprehension to a new physician for their long-term care

Hurdles to expansion of long-term care at satellite location

Solutions for MS Care Through Georgia Telehealth…..

For the MS Patient: Local physician versus a physician office that is an extended distance away More available locations for ongoing MS care Continued long term-care with the neurologist that developed their MS treatment

program Real time evaluation by a MS specialist when disease relapses or flare-ups occur. Elimination of travel expense and time as a barrier to ongoing care

For the Rural Physician:• Greater flexibility in the use of staff and resources for

administering long-term MS care• Limited investment and reoccurring costs in the treatment

of patients with MS• MS specialist available to assist in the comprehensive

treatment of the MS patient

For the MS Center:• Greater flexibility in the use of staff and resources

for administering long-term MS care• Limited investment and reoccurring costs in the

treatment of patients with MS• A solution that aligns with the MS Center’s mission

to extend long-term, ongoing care to a medically under-served population.

SCI Model

Increased education Digital Certification process

Spoke clinics Training on site personel

Baseline testing Evaluation and management

Appropriate disposition History, examination, imaging, testing presented through

telemedicine Follow up care

Telemedicine outside 25 mile radius From schools

Model ChallengesChallenges

Initial evaluation Comfort- patient and provider Experience Lies in education and comfort with sites

Laws regarding establishment of legal doctor-patient relationship License, state based Concerns for nationalizing license

Payment systems FFS Global

Technology Access

Solutions

Regional networks SCI/MS regional centers covering 5-10 states

License laws States- easier access to telemed license in

state Not national

State Fed laws Payments Care establishments

Home/Office/Medical Office

Summary

We have a problem Cost, access, expansion of knowledge Will NEVER have enough experienced

healthcare providers physically located in all locations

Not a new problem, but solution has become easier Technology and patient demand will deliver

state-of-the-art specialty care to all areas at a fraction of the cost