House Call Overhaul
Does telemedicine offer healthcare systems and customers cost-savings potential?
When you’re sick, visiting a doctor’s office or an urgent care facility can sometimes seem worse than the illness itself. You usually need to take unplanned time off work, drive to the provider’s location, wedge yourself between other sick people, visit with a doctor who’s running late and crunched for time and, finally, get a prescription written that you have to pick up from a pharmacy.
Maybe those days are over.
Today, telemedicine lets patients avoid the dreaded waiting room and videoconference with doctors on smartphones or tablets to diagnose ailments. Some pharmacies also have installed kiosks for patients to conference with doctors. This approach offers patients conveniences in two key scenarios: diagnosis and treatment of nonurgent ailments (such as ear infections) and continuous monitoring of high-risk patients (such as those with congestive heart failure).
For the high-risk patients, telemedicine can connect wearable devices to remotely monitor their vitals and automatically send reports to medical staff for analysis. This has been shown to improve these patients’ survival rates and can reduce healthcare costs by allowing one nurse to treat hundreds of patients, preventing costly ER visits.1
"There’s been a push to lower hospital readmission rates along with healthcare reform," said Sarah Turk, a healthcare industry analyst for IBISWorld, a research company. "You can use telehealth to examine and monitor fluctuations in their system and then address it before it becomes a costly complication."
Telemedicine also has been proven effective in mental health treatment. A 2012 study showed that for patients who participated in videoconferencing, the number of psychiatric admissions and days of hospitalization decreased 83.3%.2 Because these patients can avoid social anxieties such as sitting in waiting rooms with other patients and the stress of traveling to an office, providers can better reveal their daily state of being.3
Doing more with less
Due to the expanding global population, Turk said she believes telemedicine could become a $3.5 billion industry by 2020.4 By the end of this year, 5 million patients are expected to be seen in virtual visits.5 Last January, a reimbursement code for non face-to-face healthcare services was created by the Centers for Medicare and Medicaid Services, signaling industry recognition of rising remote-care treatments.6
As baby boomers age and populations grow, the number of U.S. physicians is expected to shrink, and the United States could face a shortage of up to 90,000 physicians by 2025. "[The doctor shortage] is significant, and it’s particularly serious for the kind of medical care that our aging population is going to need," said Darrell G. Kirch, president and CEO of the Association of American Medical Colleges.7
Fewer doctors handling more patients is a troubling prospect, especially because doctors not having enough time with patients and time to analyze their medical situations are considered major factors for why one in 20 patients is misdiagnosed every year.8 Telemedicine could be the right prescription for healthcare’s grim prognosis.
"The smartest and most sensible solution to the problem of access [to doctors] lies not in creating more time, which requires graduating tens of thousands more doctors, but in using our time more efficiently," wrote Joydeep Bhattacharyya, founder and CEO of liveClinic, a provider of telemedicine platforms.9
Dan Diamond, a family practitioner at one of Catholic Health Initiatives Franciscan’s urgent care centers, recently began conducting virtual visits and noticed they were more patient-focused. "I don’t have people knocking on the door and saying, ‘Doc, we need you in another room,’" Diamond said. "I’m able to focus on that one patient, without all the commotion that happens in an urgent care or an emergency room."10
For rural patients, time is often the most costly element of healthcare, especially for those with conditions that require routine maintenance, such as diabetes. In Delaware, for example, before diabetes patients Kelly Durham and her two daughters had access to telemedicine, they traveled three hours every three months for their appointments. "That’s a lot of school missed," Durham said, "A lot of tolls paid and gas."11
The needs of its rural patients led Mercy Health System, which provides care at 33 hospitals in Missouri, Oklahoma, Kansas and Arkansas, to open a $54 million virtual-care center in Chesterfield, MO. Contracted with mostly rural hospitals, the facility has 290 clinical workers who can remotely monitor 2,431 patient beds at 34 facilities in five states 24/7.12
"Why do we still need to go to a doctor’s office and sit in a waiting room for something that can be done, especially something like daily monitoring, better and faster online?" asked Shana Alex Charles, an assistant professor in the health services department at California State University, Fullerton.
What’s the cost?
A telemedicine visit can cost $40, but a primary care physician visit can cost between $130 and $190. ER visits can cost between $1,500 and $3,000.
Evolving pay-for-performance models of reimbursement are emphasizing quality and efficiency, moving healthcare away from traditional pay-for-service models.13 Some healthcare professionals question whether telemedicine truly delivers cost savings to healthcare organizations and patients.
Proponents believe telemedicine offers long-term savings due to fewer urgent care and ER visits. They also see more flexible access to doctors leading to healthier and more satisfied patients.
Ateev Mehrotra, a professor of health policy at Harvard Medical School, suggests it could actually increase overall healthcare spending: "I think it’s very plausible, and probably likely, that a lot of people who do a virtual visit would otherwise have stayed home."14
From the insurer’s perspective, telemedicine has been restricted in terms of what services can be reimbursed because of concerns over whether these services are actually increasing costs.
"If telemedicine really saved money, payers would be falling over themselves paying for this stuff, right?" said Ashish Jha, a health policy analyst and professor at the Harvard T.H. Chan School of Public Health. Telemedicine can often lead to more tests and follow-up visits, he said.
"And, over time, when you look at the data, it turns out that telemedicine overall is not necessarily a big cost saver," Jha said.15
Reducing the red tape
For telemedicine to become more prominent, a number of legal knots also must be untangled. Many state laws restrict or ban the use of telemedicine, and 100 bills related to telemedicine were introduced in 36 states as of February 2015. Bill Frist, a heart and lung transplant surgeon, outlined four legislative elements that are needed to move telemedicine forward:
- Payment parity: Healthcare providers must receive equal reimbursements for services delivered remotely or in person. This type of legislation exists in 21 states, and only 15 are without technology restrictions.
- Same standards: Whether delivered remotely or in person, the same standard of practice must apply. "This means codifying the questions and ‘images’ a physician uses to adequately diagnose and treat a condition are the same whether they are gathered in person, or over the phone and with pictures," Frist wrote.
- Fewer restrictive licensing requirements: State medical licensing entities should be restricted from creating requirements such as "in-person visits before or after telemedicine encounters," which can drive up the cost of care.
- Out-of-state practice exemptions: All states have various restrictions on physicians practicing out of state.
Despite the conveniences telemedicine may offer doctors and patients, some doctors feel face-to-face visits are more effective and have less potential for misdiagnoses. Diamond concedes that telemedicine has limitations: "There are some times where we just can’t do it virtually and we need to lay hands on a patient."16
—compiled by Tyler Gaskill, contributing editor
- Stephen Agboola, Kamal Jethwani, Kholoud Khateeb, Stephanie Moore and Joseph Kvedar, "Heart Failure Remote Monitoring: Evidence From the Retrospective Evaluation of a Real-World Remote Monitoring Program," Journal of Medical Internet Research, Vol. 17, No. 4, 2015, www.jmir.org/2015/4/e101.
- Linda Godleski, Adam Darkins and John Peters, "Outcomes of 98,609 U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services, 2006–2010," Psychiatric Services, Vol. 63, No. 4, 2012, pp. 383-385, http://tinyurl.com/telemedicinementalhealth.
- Alex Smith, "Telemedicine Expands, Though Financial Prospects Still Uncertain," NPR.org, Sept. 30, 2015, http://tinyurl.com/telemedicineexpands.
- Emily Richardson-Lorente, "Healthcare in 10 Years: Telemedicine Will Just Be Medicine," Forbes, Sept. 25, 2015, http://tinyurl.com/justmedicine.
- Joseph C. Kvedar, "Telemedicine Is Vital to Reforming Healthcare Delivery," Harvard Business Review, Oct. 5, 2015, http://tinyurl.com/hbrtelemedicine.
of American Medical Colleges, "The Complexities of Physician Supply and Demand:
Projects From 2013
to 2025," March 3, 2015, http://tinyurl.com/aamctelemedicinepdf.
- Laura Landro, "A Medical Detective Story: Why Doctors Make Diagnostic Errors," Wall Street Journal, Sept. 26, 2015, http://tinyurl.com/wsjmedicaldetective.
- Joydeep Bhattacharyya, "Going Beyond the Symptoms: The Case for Telemedicine," Huffington Post, Oct. 10, 2015, http://tinyurl.com/casefortelemedicine.
- Abby Goodnough, "Modern Doctors’ House Calls: Skype Chat and Fast Diagnosis," New York Times, July 11, 2015, http://tinyurl.com/skypehousecall.
- "Telemedicine: Future of Rural Healthcare," RFDTV.com, http://tinyurl.com/futureofruralhealthcare.
- Liss, "Mercy Debuts New $54 Million Virtual Care Center," St. Louis Post-Dispatch, Oct. 4, 2015, http://tinyurl.com/vitrualcaredebuts.
- Kvedar, "Telemedicine Is Vital to Reforming Healthcare Delivery," see reference 6.
- Goodnough, "Modern Doctors’ House Calls: Skype Chat and Fast Diagnosis," see reference 10.
- Smith, "Telemedicine Expands, Though Financial Prospects Still Uncertain," see reference 4.
- Goodnough, "Modern Doctors’ House Calls: Skype Chat and Fast Diagnosis," see reference 10.
- Braverman, Beth, "Are You Ready to Visit Your Doctor Online? Telemedicine Has Arrived," The Fiscal Times, Oct. 21, 2015, http://tinyurl.com/telemedicinevisit.
- Frist, Bill, "Telemedicine Is a Game-Changer for Patients, the System," Forbes, March 12, 2015, http://tinyurl.com/telemedicinegamechanger.
Who’s Who in Q
NAME: Steven C. Leggett.
EDUCATION: Master’s degree in quality management from Rochville University.
INTRODUCTION TO QUALITY: During high school, Leggett held a co-op job inspecting metal stamping and weldments. After he graduated, he took a class on metrology, calibration and quality control at a local community college.
CURRENT JOB: Senior supplier quality engineer at American Axle & Manufacturing in Detroit and adjunct professor at Macomb Community College.
PREVIOUS JOB: Senior supplier quality engineer at General Motors in Warren, MI.
ASQ ACTIVITIES: ASQ Detroit Section 1000 chair, as well as many other ASQ activities and projects.
OTHER ACTIVITIES/ACHIEVEMENTS: Leggett has portrayed Santa Claus for 40 years and "Slopoke the Klown" for 35 years. He is also an ordained minister and elder at Rose Ministries.
PUBLISHED WORKS: "TPS Troubles," Quality Progress, April 2010; co-author, Driving Operational Excellence: Successful Lean Six Sigma Secrets to Improve the Bottom Line, (McNaughton & Gunn, February 2010); co-author, AIAG Potential Failure Mode and Effects Analysis Manual, third edition (AIAG, July 2001); co-author, AIAG Machinery Failure Mode and Effects Analysis Manual, first edition, (AIAG, 2011).
RECENT HONORS: Elected to ASQ’s 2015 class of fellows.
PERSONAL: Two children and two stepchildren.
FAVORITE WAYS TO RELAX: Playing Santa Claus, making animal balloons and face painting.
QUALITY QUOTE: "Have a quality day!"
A HEALTHCARE ADVOCACY organization has released its biannual study on hospital safety. The Leapfrog Group’s "Hospital Safety Scores" report includes grades for 2,530 U.S. hospitals. Of the 2,530 hospitals issued a safety score, 773 earned an A, 724 earned a B, 866 earned a C, 133 earned a D and 34 earned an F. For more specifics on findings from the study, visit www.leapfroggroup.org/policy_leadership/leapfrog_news/5398408.
A NEW INTERNATIONAL Organization for Standardization (ISO) standard will help assess the sustainability of products and processes related to bioenergy. ISO 13065—Sustainability criteria for bioenergy gives a practical framework for considering environmental, social and economic aspects to facilitate the evaluation and comparability of bioenergy production and products, supply chains and applications. ISO 13065 can be applied to a whole supply chain, parts of a supply chain or a single process in a supply chain. It also applies to all forms of bioenergy, regardless of raw material, geographical location, technology or end use. For more information, visit http://tinyurl.com/bioenergy-standard.
THE HIGHER LEARNING Commission’s annual conference will take place April 15-19 in Chicago. Conference presentations and sessions will examine the relationship between higher learning and accreditation, and how innovation in higher learning affects that relationship. For more details on the event, visit http://annualconference.hlcommission.org.
MAUREEN A. BISOGNANO, president and CEO of the Institute for Healthcare Improvement (IHI), will resign at the end of the year. Bisognano, a senior ASQ member, will be succeeded by Derek Feeley, IHI’s executive vice president. Bisognano served 15 years as IHI’s executive vice president and chief operating officer before she was named president and CEO in 2010. IHI is a not-for-profit healthcare advocacy group based in Cambridge, MA.
JACK POMPEO, corporate director of quality and customer advocacy at Huawei Technologies and an ASQ fellow, has been named a QuEST Forum fellow. QuEST Forum is an association of telecommunication service providers and suppliers. Pompeo is also QuEST Forum’s executive director for its China region. For more on Pompeo’s honor, visit www.questforum.org/news-events/press-releases/quest-forum-names-jack-pompeo-as-fellows-recipient.
ASQ Journal Spotlight
QP occasionally highlights an open-access article from one of ASQ’s seven other journals.
This month, read "Overview of Principal-Components Analysis (PCA)-Based Statistical Process-Monitoring Methods for Time-Dependent, High-Dimensional Data."
The 18-page article appeared in the October edition of the Journal of Quality Technology (JQT).
In it, authors Bart De Ketelaere, Mia Hubert and Eric Schmitt present a comprehensive review of the literature for the practitioner encountering high-dimensional and time-dependent data.
To access the article, as well as download it in PDF format, click on the "Current Issue" link on JQT’s webpage at http://asq.org/pub/jqt. From there, you also can find a link to information about subscribing to the quarterly publication.
Medical Device Standard Advances
A standard for quality management systems specific to the medical devices industry is under review and has just moved a step closer to completion.
ISO 13485—Medical devices—Quality management systems—Requirements for regulatory purposes reached the final draft international standard (FDIS) stage in late October. ISO member countries can now form a national position and vote.
ISO 13485 is for organizations involved in the design, production, installation and servicing of medical devices, as well as in the design, development and provision of related services. It also can be used by internal and external parties, including certification bodies, to assess an organization’s ability to meet the requirements.
ISO 13485:2015 is due to be published in early 2016.