Hotbeds of telemedicine like Ohio State University, the University of North Carolina and the University of Arizona deliver top-notch healthcare to underserved populations in rural areas.
Some telemed operations have even saved their states money by running programs in correctional facilities that virtually eliminate costly transport of prisoners to the doctor.
But few of them have put money into hard-pressed physicians' pockets or done much to ease the workload for docs stressed by the demands of managed care.
Now, a small coterie of entrepreneurial physicians is trying to do just that. They are taking a hard look at established telemedicine techniques and figuring out new ways to use technology to not only better the care they offer patients but improve their own lifestyles and incomes as well.
"Telehealth is inevitable because the technologies and economics underlying it are inevitable," says Doug Perednia, M.D., founder and president of the board of directors of the Association of Telehealth Service Providers, a trade organization based in Portland, Ore.
"The future of healthcare relies on achieving greater efficiencies because the resources of knowledge, expertise and caring are limited. Telehealth is about improving the distribution of care services to the benefit of patients, providers and payers. It's just a question of putting the pieces all together."
Jay Sanders, M.D., is a former professor of medicine and surgery at the Medical College of Georgia in Augusta, where he established one of the first statewide telemedical systems. Sanders is now a telemedicine consultant and adjunct professor at Johns Hopkins in Baltimore.
"The examination room tomorrow isn't the doctor's office," Sanders predicts. "It is anywhere the patient is."
David Vastola, M.D., a gastroenterologist in private practice in Palm Beach, Fla., sees a number of his older patients using technology provided by Cybercare, a home healthcare company that rents modified computer units with video cameras. Depending on which module they choose, patients pay between $40 and $100 a month for one of the units, which allow their physicians to monitor their heart, lungs, blood sugar and blood oxygen levels. The camera can be moved so the patient can focus it on wounds or other problems to give the doctor a closer look.
Vastola says he believes this is the best way to do business.
"It cuts way down on the overhead," he says. "You don't even really have to have an office; you could do this in your bathroom. And it's so much more efficient. You can see three times as many patients."
Since Oct. 1, Medicare has been willing to reimburse for these home telemedicine visits in all nonmetropolitan counties, including urban Palm Beach County where Vastola practices.
Vastola doesn't participate in any HMOs or other capitated managed care plans, but even he sees the loosening of Medicare regulations regarding telemedicine as a boon.
"Unless you are part of a stupid, capitated HMO that won't pay you beans for seeing patients, telemedicine has the potential for tripling your income," Vastola says.
Even if a physician still sees patients in an office, telemedicine can save big bucks, says John Janas III, M.D., an internist and pediatrician who practices at Family Care of Concord (N.H.). He also is medical director of Physician Information Services, the telemedicine arm of Capital Region Healthcare, an integrated delivery network.
Janas has written special software to expand the Medscape Logician electronic medical record program his company uses. As a result, he has installed computers with 17-inch monitors in every exam room.
Doctors sit with patients in front of the screen. Together they look at the patient's medical history, along with information and statistics about the ailment. The computer, for example, might tell a smoker with high cholesterol: "Your goal for lowering cholesterol hasn't been met. Your risk of dying of heart disease is 27%; quit smoking and it falls to 15%."
The doctor enters notes in front of the patient, e-mailing prescriptions and medical test authorizations immediately. Once the patient gets home, he can call up his own medical record, read his medication instructions and see his lab results.
Janas estimates that his two-doctor practice spends $120,000 a year less than it did before it installed this system five years ago at a cost of $85,000. The bulk of the savings came from eliminating $40,000 in annual transcription fees. Another $80,000 came from staffing reductions for clerical and coding personnel.
"The average physician group has three to four ancillary staff per provider," Janas says. "We're at 2.0 or less. We're very efficient."
Janas says the system also captures data on quality of care. Being able to present that information reliably allows Janas' practice to claim a higher reimbursement rate from several of the HMOs with which he is affiliated. And he has connected the system to a database that includes all the HMOs' regulations, so that doctors are automatically flagged if they try to order medication or a test that an HMO won't reimburse.
Janas, who has his own software company, Clinical Content Consultants, would like to take this system one step further and treat patients via e-mail. But he recognizes the reality that many physicians face: If you use e-mail to cut down on office visits, especially those that lend themselves to quick communication, a doctor can cost himself considerable income.
Healinx Corp., an Alameda, Calif.-based medical communications company, thinks it has solved that problem through a partnership with 15 Silicon Valley, Calif., self-insured major employers, including Cisco Systems, Oracle Corp., Adobe Systems, Cadence Design Systems and the NEC Electronics unit of Japan's NEC Corp.
With their support, Healinx has set up a Web-based, e-mail-like interface that translates patient's health concerns into medical terminology. Doctors or their assistants can review patients' problems, take a look at their medical records and either schedule an in-person appointment or prescribe treatment. Participating employers pay doctors a $20 fee for these e-mail consultations.
First Health Group Corp., a managed care company based in Downers Grove, Ill., has a similar project under way. It pays physicians $25 for Internet visits (see Jan. 1, 2001, page 9).
The company, which operates a national network of 280,000 physicians and serves major employers like Burger King, Shell Oil and Hyatt Hotels, limits the program to patients with chronic illnesses.
These include diabetes, asthma, depression and three cardiac conditions. Plans are in the works to offer it next to pregnant patients and those with HIV.
Giovanni Colella, M.D., CEO and president of Healinx, estimates that of 570 million primary care visits annually, 20% could be replaced by online communication, saving insurers $63 a visit for an estimated annual savings nationwide of $7.2 billion.
Radiology is another ripe area for telemedicine entrepreneurs. The Cleveland Clinic has stepped in to claim a share of the action.
"A number of years ago, we realized that if we could read images from multiple hospitals in the Cleveland area, there was nothing stopping us from doing the exact same thing anywhere in the state or the country," says Michael Recht, M.D. Recht is chairman of the department of e-radiology within the division of radiology of the Cleveland Clinic Foundation.
To connect with Cleveland, all a physician group or a medical center needs is an acquisition device such as an MRI, CT scan or X-ray machine. Cleveland Clinic insists on supplying everything else, from the communication line to training for the technologists. For the service, it charges what Recht calls a reasonable rate, taking into account the differences in costs and reimbursement in various parts of the country.
"We're not trying to take business away from local radiologists, but we are cheaper than hiring a subspecialty radiologist and adding him to your staff," he says.
E-radiology has become a profit center for the Cleveland Clinic, with a side benefit of letting staff radiologists with narrow subspecialties use and expand their expertise.
"The images look the same from every site and take no more time," Recht says.
There is one catch. Most states require that a doctor be licensed to practice in that state. So in order to expand the clinic's reach, Recht and others have had to go through the licensing procedure about 50 times.
Most states don't require exams, but several have training requirements. "It would be wonderful if there were a national license," Recht says.
The best way to get around the licensing problem is to sell services beyond the
boundaries of the United States.
Alaska Health Resources is a group of 24 doctors in private practice who offer online consultations. They use a desktop computer and off-the-shelf software modified by computer experts at the University of Alaska to accommodate transmission of large files over low bandwidth.
Kathy Boucha was hired by the Alaskan doctors to strike the first deal with a Russian insurer. She inked the deal with the Russian partner, but they're still haggling over the details.
"It's really hard to put a dollar or a ruble value on it," Boucha says. "They don't think they can afford to pay what Americans think this intelligence is worth."
But Boucha is confident that eventually e-commerce will work.
"We're doing this simply and manageably, and the business case is there."
Jennie L. Phipps is an independent business and health writer based in Farmington Hills, Mich.