Virtual medicine: Companies using webcams for real-time patient encounters

Two ventures promise to bring video-enabled doctors' visits to more patients, but physician groups caution that most medical care requires in-person contact.

By , — Posted Sept. 1, 2008

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The virtual physician visit is becoming a reality.

Companies that promise patients the chance to see a physician through video linkups are pushing into the mainstream. One is making it possible for anyone in the state of Hawaii to talk to a doctor of his or her choice via a webcam -- in a visit that could be reimbursed by the patient's health plan.

Meanwhile, in an effort to cut costs, a chain of retail clinics in Houston has replaced in-person visits to a nurse practitioner with online, webcam-enabled visits with doctors across town.

Telemedicine started as a way to remove access barriers. But it is now driven by people who value the convenience it offers, said Joseph Kvedar, MD, director of the Center for Connected Health, a Boston-based nonprofit group, affiliated with Partners HealthCare, whose stated mission is to expand the availability of medical care outside traditional settings.

The improved quality of the technology, the scale of adoption and the idea of health plans reimbursing for those visits have the potential to be game-changing, experts say. Proponents of telemedicine don't believe it will ever replace traditional practice-based care, but they do see it as a way to ease the load for busy physicians and overcrowded emergency departments, Dr. Kvedar said.

Health plans' reimbursement for virtual visits will be key to doctors' buy-in and thus the ventures' success, people behind these ventures say.

American Well

American Well, a Boston-based company, in partnership with the Hawaii Medical Service Assn., the state's Blue Cross Blue Shield-affiliated plan, says it will offer real-time webcam visits with doctors to the 1.3 million residents of Hawaii starting in January 2009. Half of those residents are HMSA members.

Brothers Roy Schoenberg, MD, MPH, and Ido Schoenberg, MD, are behind the company. American Well isn't their first startup. In 2005, they sold their first company, a care management software firm called CareKey, to health care technology company TriZetto for $60 million.

Dr. Roy Schoenberg said the company has addressed the things that tripped up some of its predecessors, like, a Roche Diagnostics subsidiary that didn't offer video but did promise examinations by doctors over the Internet with patients filling out questionnaires about their symptoms. folded in 2003, not long after regulators in Illinois ruled that its doctors were violating prescribing rules by writing scripts for patients they had never seen.

The doctors and other health professionals using American Well will be licensed in Hawaii and will be part of the Blues' network, but they won't necessarily be seeing established patients.

Michael Stollar, HMSA vice president for marketing and communications, said the plan is retaining American Well as a "convenience for the consumer and the physician." He said cost saving isn't the utmost concern but did say that "if the savings come, I believe they will be from the delivery of high-quality and appropriate care. If inappropriate utilization in the ER is cut down, that then is a cost savings for the entire community, and those things are good."

Conducting e-visits with unfamiliar patients runs counter to the policies of the AMA and the American Academy of Family Physicians. AMA President-elect J. James Rohack, MD, a cardiologist from Bryan, Texas, said there are simply parts of medicine that cannot be handled without an in-person visit. He spoke about virtual visits in general, not about American Well specifically.

"A face-to-face interaction to allow the nonverbal communication, and a physical examination is needed for most diagnosis and treatment," he said.

AAFP President James King, MD, a family physician in Selmer, Tenn., said virtual visits have very limited use. For example, he said, they could be employed to help manage chronic conditions.

Hawaii Medical Assn. Executive Director Paula Arcena said the group hasn't yet reached a position on the American Well project.

Physicians already make themselves available after hours by phone, but phone calls aren't usually reimbursed by insurers. The Hawaii Blues plans to pay for members' virtual visits with primary care doctors, specialists and certain nonphysicians. Stollar said reimbursement levels for participating Hawaii physicians won't be announced until later this year.

American Well says it plans on pitching its services to other health insurers.

My Healthy Access

Many venture capital firms who entered the retail clinic model have found it to be more difficult than they imagined to turn a profit, despite what they say is a high rate of patient satisfaction.

Many investors decided not to wait the estimated 18 months it takes to turn a profit and closed shop.

Tom Charland, president and CEO of Merchant Medicine, a Shoreview, Minn.-based retail clinic consultancy firm, said it's not a case of the venture-backed clinics losing more money than clinics backed by hospital groups or pharmacy chains; it's a case of the others being in a better position to take on the losses until they can turn a profit.

Kathleen Delaney, president of My Healthy Access, a retail clinic chain operator in Houston, thinks video visits are the answer to reducing overhead, and ultimately, the time it takes to turn a profit, as well as patient demand to interact with a doctor instead of a physician extender.

Under its current retail clinic model, which relies on nurse practitioners to administer patient care, each of My Healthy Access' six clinics, located in Wal-Mart stores, needed to see a minimum of 20 patients per day in order to be profitable, according to Delaney. Under the telemedicine model, that number is reduced to eight.

Delaney said that instead of employing a nurse practitioner and a physician to oversee the care, the nurse practitioner is replaced by a lower-paid emergency medical technician. The EMT takes the patients' vitals, conducts the initial exams and enters the patient information into the electronic medical record before alerting the physician that the patient is ready for the exam.

The physician works from a studio where one screen shows the patient's record and the chief complaint, and a split screen shows the patient in the exam room and the view the patient would see of the physician.

My Healthy Access has partnered with NuPhysicia, a telemedicine provider that spun out of the University of Texas Medical Branch in Galveston. NuPhysicia contracts with eCare Group, an independent physicians group, which staffs the studios with doctors.

NuPhysicia president Glenn Hammack, OD, said with the exception of especially busy days, one physician could staff all six clinics at once.

"The concept sounds right to me," Charland said. "But whether or not it's going to work, it's too early to tell." Before founding Merchant Medicine, Charland was senior vice president of strategy and business development for MinuteClinic, which is now owned by CVS/Caremark.

Though these new ventures will offer physicians new ways to practice and offer patients convenient care, don't expect traditional doctors to compete with video doctors for patients, said Dr. Kvedar.

"At the end of the day, there is so much volume that it is a problem for doctors," he said. "The most we can hope for is for doctors to come to their offices and not feel overburdened."

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Clinic's video link

My Healthy Access, which operates retail clinics in Houston-area Wal-Mart stores, allows patients to "see" a physician through a video linkup. Here is how it works:

  • Patient checks in with medical assistant at front desk.
  • Patient is sent into exam room.
  • Registered paramedic conducts initial interview, takes vitals and ascertains the nature of the problem.
  • The paramedic opens up the electronic medical record and inputs the patient's data.
  • A notification is sent by the paramedic to the physician at a studio equipped with screens allowing the physician to see the patient, the EMR and the patient's view of the physician on-screen.
  • The physician reviews the EMR, then opens the secure connection with the patient.
  • The exam is conducted with the paramedic acting as the hands of the physician.
  • The patient pays cash for the visit.
  • My Healthy Access pays the independent physician's group that provides the care, and the group pays the doctor. Pay is usually by the hour.

Source: My Healthy Access, Houston

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Virtual visits in Hawaii

The Hawaii Medical Service Assn., Hawaii's Blue Cross Blue Shield-affiliated plan, will launch its American Well program for both members and nonmembers across the state in January 2009. Here's how it will work:

  • A patient will log on to the system to request a visit with a medical professional, who will be part of the network of the sponsoring health plan and licensed in the state.
  • The patient will choose whether he or she would like to see a primary care physician, specialist or another medical professional. If the patient is not a member of the sponsoring health plan, he or she can pay by credit card. A co-pay by credit card also may be required of members.
  • If, for example, the patient would like to visit with a neurologist and there are none available, the system will place the patient in a virtual "waiting room" and ring the patient's telephone when the requested specialist becomes available.
  • If there is a patient record available through Microsoft's HealthVault, it will be available to the doctor who sees the patient. If not, the patient will fill out a health questionnaire.
  • Before the visit begins, the physician looks over the patient's record, evaluates the problem the patient is reporting, and decides whether to see the patient, refer the patient to another doctor online or refer the patient to the emergency room or in-person services.
  • If the doctor decides to hold a visit with the patient, the two can talk by phone, have a Web chat or have a virtual visit and see each other by webcam. The doctor is covered by a separate liability insurance policy specific to the virtual visit.
  • When the visit is complete, the physician is paid either by the sponsoring health plan or by the patient directly with a credit card. Reimbursement levels have not been established yet. In Hawaii, the only paperwork requirement for payment is for physicians to enter a summary of the visit after each encounter.
  • A record complete with a transcript or video of the session will be sent to the patient's primary care physician. The patient and physician can access that record at any later date.

Source: American Well, Hawaii Medical Service Assn. (Blue Cross Blue Shield of Hawaii)

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External links

American Well (link)

My Healthy Access (link)

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