Innovations: Kaiser tests video visits to cut waits

Kaiser Permanente leaders in the system's mid-Atlantic region were frustrated by long patient wait times in their clinical decision units that handled urgent and short-term observation care.

Dr. Dennis Truong, telemedicine director for the Mid-Atlantic Permanente Medical Group mentioned to his mentor, Dr. Jody Crane, then-associate medical director for the region's clinical decision units, that when he was a military doctor, he often discussed cases with long-distance colleagues via Skype. That conversation gave them the idea to offer Kaiser members the option of a video visit with a Kaiser staff physician rather than seeing a doctor in the clinical decision units.

In August 2013, that Kaiser region launched such a demonstration, using video visits conducted by emergency physicians.

Kaiser members have two choices for arranging a video physician visit. Patients may contact the health plan call center and be offered a video visit at home with no co-pay, using their smartphone or computer to see a doctor. Or, they may be offered a video visit at one of the clinical decision units.

As an example, at Kaiser's Tysons Corner location in Virginia, patients are taken to a room in the clinical decision unit where they connect by video with a Kaiser doctor at another of the system's facilities. A camera and a screen are mounted on a podium. The remote examining doctor works with a nurse or clinical assistant who is with the patient, and can aid the doctor by applying a stethoscope or other instruments under the doctor's direction.

Truong said this type of assisted video visit is superior to the more common telemedicine approach in which doctors see patients alone through video connections and ask them to apply the stethoscope or other instruments themselves. “Can patients coordinate the breathing with the stethoscope in the right way?” Truong asks doubtfully.

One patient was seen by Truong for persistent elbow pain. But she found it difficult to take an image of her elbow with her smartphone camera. “Extremities are difficult,” Truong said. The patient enlisted a friend to hold the smartphone and take an image of her elbow. Truong decided that the patient needed follow-up care with an orthopedist, which he scheduled for her that afternoon.

During a video visit, the doctor sits in front of two screens. One screen televises the patient and the other shows the patient's electronic health record. Seeing the record while examining the patient gives the doctors a much better understanding of the patient's condition.

Truong said having doctors view patients' EHRs while conducting exams allows them to deliver better care. On occasion, he said, doctors will see patients whose immediate medical condition does not indicate a serious problem. But looking at the record may show that a patient currently presenting with a nasty cough has chronic obstructive pulmonary disease and is a heavy smoker.

Truong thinks care coordination is the key differentiator between Kaiser's video visit model and the models used by companies that focus on providing telehealth services. What those companies offer “is not comprehensive,” he said. “They go by whatever medical history you've got. They can't book follow-up care, labs or radiology.”

One of those companies, Teladoc, confirmed that it does not schedule follow-up care for its patients, but instead, refers them to a hospital emergency department or their regular doctor, as appropriate.

Kaiser's mid-Atlantic region has seen more than 4,200 members via video visits since the start of the demonstration. Kaiser doctors assigned to telemedicine duty can see an average of six patients per hour, compared with an average of 1.6 for in-person visits. Truong attributed those clinicians' higher productivity to the lower acuity of video visit patients.

Buoyed by strong patient-satisfaction numbers, Truong said he wants to expand the video visit program to allow more patients to schedule video visits directly rather than having to go through Kaiser's call center or a clinical decision unit. He said Kaiser Permanente offices in Northern California are beginning to test similar telemedicine initiatives.

Follow Darius Tahir on Twitter: @dariustahir