CHAPTER 4

Reframing Healthcare Delivery

My Time and My Place

The demise of the house call doctor ended the true convenience of being taken care of where we were sick. When my grandmother got sick, the doctor, who spoke Chinese, would come with his big black doctor bag to our bedroom at night to tend to her. My 85-year-old grandmother didn’t need to get out of bed, dressed, loaded into a car, and sit in a hospital emergency room (ER) for hours waiting to be evaluated. It absolved the need for my mother to get up, drive to the ER, and wait with her for an unknown amount of time.

The new retail healthcare consumer is asking for care that is more convenient than having to go to the doctor’s office or ER when the problem is not an emergency. As the Intel mom said to me, “I can tell when it is an emergency and most of the time when it is urgent. But sometimes I don’t know for sure and I want to ask the doctor. If I can avoid a trip to the doctor’s office, I will. We are a time constrained family.”

The new consumer is looking for a healthcare system that meets their needs and lifestyle. Healthcare is, for the most part, a system of transactions where people go to a provider, receive care, and leave. This behavior is driven by the way healthcare insurers reimburse providers for care; treatment (a transaction) is translated into diagnostic and procedure codes that describe what was performed for the purpose of payment.

A Doctor’s Distinctive Practice

For decades now, the primary care doctor has been driven by reimbursements of healthcare insurance. The healthcare business is based on fee-for-service—the more services a doctor performs, the more he gets paid. The problem is that there are a limited number of working hours in a day and week, so the patient visit got shorter in order to cram more patients in a day.

The challenges to the traditional primary doctor visit are:

• Number of working hours constrains how many patients can be seen.

• Communication with patients is limited to phone calls.

• Appointments are made by telephone only.

• Urgent appointments are difficult to accommodate.

• Sharing patient information with other clinicians is cumber-some and time consuming.

The primary care business model is shifting as the healthcare system is starting to reward providers for outcomes instead of volume. The federal government announced that it will make changes to the reimbursement model for Medicare and Medicaid patients to reflect quality and outcome measures. Once that occurs, more providers will follow. Being ahead of the game is the trick.

Simple, convenient, accessible—that’s what consumers expect. It’s not high tech that’s expected, but consumers have become accustomed to ease and convenience in other industries—online restaurant, air and hotel reservations, and even cooking fresh meals are convenient by selecting it online and all the ingredients including spices are delivered to our door.

Transforming the Delivery System

The transformation of the healthcare system is creating a consumer who is looking for value for their dollar. In some cases, it means they are willing to pay more for easier access to their doctor, less hassle in reaching their doctor, ability to book same-day appointments, and medical advice 24/7. In exchange for an annual fee that rivals the cost of a good pair of athletic shoes, the new healthcare consumer also gets more time to discuss their health situation when meeting with the doctor.

The federal requirement for individuals to possess health insurance forced the consumer to become a shopper in healthcare. Healthcare has become a retail business where the consumers are getting savvier every day. These consumers will act more like retail shoppers and look for value for every dollar they must pay out-of-pocket in healthcare. This includes everything from insurance premiums to lab tests, computerized scans, and elective procedures. Shopping is already evident in cosmetic treatments and procedures that are typically not paid for by health insurance. As more public data sources of quality become available with prices, shopping will be easier and consumers will be attracted to transparent healthcare providers.

Now that the consumer is paying more for their care, they are looking for healthcare transactions from providers that offer convenience, accessibility, and value without compromising quality of care.

In response to the demands of the new consumer, healthcare delivery is being reframed in five key ways:

• Concierge care

• Speed clinics

• mHealth

• Telehealth

• Housecalls reenacted

The Price of Entry—Less Hassle and Better Care

High visit volumes result in patients in crowded waiting rooms, stressed doctors with little time to listen to their patients, and an overall unpleasant experience—one that most patients want to avoid if possible. The question is how do primary care doctors survive in an environment where volume equals pay? Let’s take a look at another industry.

Air travel has programs in place for flyers who want to avoid the trouble of stripping down to their basic clothing, removing their shoes, and pulling their laptops and liquids from their carry-on bag onto the conveyor belt. Travelers can bypass this time-consuming hassle for five years by paying a $85 fee and applying to the TSA Precheck program for a Known Traveler ID. If approved, the ID allows travelers access to expedited security lines at airports; enjoy the convenience of leaving on your clothes, shoes, belts; and your carry-on stays packed.

Using technology, the U.S. Customs and Border Protection Global Entry program allows preapproved citizens of the United States and select foreign countries to expedite their entry into the United States using a machine-readable passport, their fingertips, and an online customs form. It costs a mere $100 and is good for five years. Global Entry travelers are also automatically entitled to enter the TSA Precheck security lines at domestic airports.

These two priority service programs illustrate a simple concept: Accelerated security for preapproved travelers who pay a fee in advance that is good for a substantial period of time.

We pay extra to skip the long lines at the airport, buy memberships at museums to get in earlier, or belong to clubs to avoid the masses of people. Healthcare’s response to paying more for priority service is concierge medicine. We, as impatient patients with little time to spare, are willing to pay a little more to our primary care doctor to forgo some of the hassle involved with seeing the doctor. Two newer models for primary care, one that is technology based and the other that is known as retainer care, are described next.

Traditional Concierge-Based Care

Concierge medicine is a different business model for primary care practices. Traditional primary care physicians have patient panels that average 2,000 to 3,000, while a concierge practice has closer to 500 to 1,000 patients. The national average annual concierge fee is $150 per year but can range from $50 a month to $25,000 a year. Patients typically have access to their doctor 24/7. High-end concierge practices charge for services in addition to a monthly retainer fee that can run up to thousands of dollars a month for celebrity-type treatment. Of the estimated 5,500 concierge practices nationwide, around two-thirds charge less than $135 per month.¹ Services and treatment are in addition to the membership fee and insurance is not accepted. Not dealing with insurance allows concierge practices to save time and money.

A concierge practice allows a doctor to spend more time with their patients because they don’t need to see as many patients to earn the same income. Traditional practices see 25 or more patients a day, while a concierge doctor will see closer to 15 patients. Concierge practices may also offer tests and labs at lower cost than prices charged by a hospital, lab, or screening facility. The prices are often listed on a menu and the patient pays up front for services called “direct primary care.” The ACA allows direct primary care to count as ACA-compliant insurance as long as it is bundled with a wraparound catastrophic medical policy to cover emergencies.

A concierge practice requires a change in the provider’s mindset from the fee-for-service habit to how they can best meet their patient’s needs and satisfy their own personal goals of being a physician with a little creativity and tools. The good news is that a practice can transition from traditional to concierge at its own pace. Doctors may end up firing their patients and patients may fire their doctors depending upon the style of care offered and sought. With patients paying more out-of-pocket because of high deductible plans, they are more inclined to find a provider who fits their lifestyle.

Technology-Enabled Model for Primary Care

One Medical, a national primary care group based out of San Francisco, uses a combination of technology and high-touch medicine to deliver on their business model. They function as an integrated group model for primary care that includes acupuncturists, nutritionists, and prenatal nurse practitioners. For an annual fee of $199, patients can make same-day appointments online, request prescriptions, view digital lab results, see their personal health summary, communicate with physicians via e-mail, and fill out forms online to cut down on time in the waiting room. One Medical says that appointments are 95 percent on time or early. Patients have access to virtual care via their mobile app and have access to 24/7 medical support.

Founder and CEO of One Medical, Tom Lee, MD, built their model by creating their electronic health record (EHR) and the clinical and business systems to support the practice. He describes their new way of delivering primary care. “We have a technology-enabled model that allows us to deliver higher quality care at lower cost. Unlike a concierge practice in which the fee is used to reduce the number of patients, we’ve instead lowered our overhead by improving efficiency. The fee helps us offer aspects of care that are not traditionally covered by health insurance. The difference between the One Medical model and concierge practices is that we’ve designed it for everyone—through better design and process.” Unlike pure concierge practices that accept cash for services, One Medical accepts health insurance in keeping with their broad mission to serve all populations, while still seeing half the volume of traditional doctors.

As a measure of the model’s success, One Medical has expanded to seven major cities with over 40 locations in six years—including San Francisco Bay Area, Boston, New York, Chicago, Los Angeles, Phoenix, and Washington D.C. A unique aspect of this high-touch practice is the employee health benefits program, which allows employers to offer One Medical as a perk.

While the offices are in larger urban markets today, Lee says that they plan to expand into other markets shortly. “We’re excited that our high quality, high touch model can be done affordably in the current healthcare system and it doesn’t require a big leap of faith. We know that we can do this at scale and can continue to improve quality, service, and afford-ability. We’d like to broaden the model to other populations thoughtfully; that requires designing for different delivery market demographics, health conditions, and challenges specific to those populations.”

Speed Clinics

Speed clinics offer convenient access, quality, and low cost for basic services. Commonly known as convenience clinics, these are walk-in clinics sharing the brick and mortar of retail stores, company office buildings, or malls. Since 2006, the number of retail clinic sites has increased almost 900 percent from 200 to 1,800, and in 2012 they recorded some 10.5 million patient visits.² They tend to be located in higher-income, urban, and suburban settings with higher concentration of white and fewer blacks and Hispanics. A 2010 report³ found the characteristics among retail clinic use is heaviest among younger adults, minority families, and families with children. Clinic users are typically younger than the patients seen in primary care or emergency departments. However, retail clinic consumers are less likely to have insurance or a personal physician,⁴ regardless of the setting or income, in comparison to the general population.

Why do consumers go to retail clinics?⁵ The reasons cited most often by users were convenient hours, no need for appointments, more convenient location, low-cost services, and no usual source of care. For users whose reason for going to a retail clinic was “lower cost compared to another source of care,” 30.7 percent were insured customers,⁶ which indicates price sensitivity. Over half the customers whose reason was “did not have usual source of care” were uninsured.

There are two current types of speed clinics:

1. Shared retail clinics. These clinics offer more than convenience—they save time. Although insurance is accepted, the charges are less than a doctor’s office visit or a trip to an ER. Customers can drop-in without an appointment and do not have to take time away from work or family.

   Speed clinics offer a wide array of nonemergency services including school and sport physicals; vaccinations; treatment for minor injuries; routine lab tests; screenings for cholesterol, high blood pressure, and diabetes; travel medications; epi-pen renewals; and monitoring and management of ongoing health conditions such as asthma, chronic bronchitis, and osteoarthritis. With your permission, they share the information with your primary care doctor so she can maintain a complete record of your treatments.

   The two largest drug store chains are the largest implementers of speed clinics with over 800 Minute Clinics in CVS retail locations in 27 states and 420 Healthcare Clinics are housed in Walgreens stores across 21 states, which offer nonemergency care by certified family nurse practitioners and physician assistants within their retail pharmacy locations. These clinics offer services typically performed by a primary care physician.

   Walmart, the largest retail chain in the nation with 5,220 stores in 2016, opened Walmart Care Clinics staffed by nurse practitioners in Texas, Georgia, and South Carolina. These 18 clinics demonstrate the Walmart way—setting the price bar for retail clinics by offering access to a nurse practitioner for $40, or $4 for the 1.1 million workers and dependents covered by the company health plan. They also offer an $8 bladder infection test, cholesterol and mono tests and $15 for hemoglobin blood sugar, urine protein, and HIV tests.

   Retailers are increasingly bundling clinic services with pharmacy, nutrition, lifestyle, and obesity management programs to deliver more comprehensive offerings. The high foot traffic that these retailers generate can serve as a platform for offering services not traditionally delivered in retail setting, such as enrollment assistance for public or private coverage, nutrition, and housing support.

2. Kiosks. At a kiosk, you can have a private physician visit via video telehealth, such as American Well or HealthSpot.⁷ The kiosk-enclosed station functions as a doctor’s micro-examination room, while a console style saves space by not having walls and a ceiling and can be placed in a separate room for privacy. American Well’s clinicians are licensed independent physicians and serve people who would seek care from a primary care doctor. The difference between a high-tech kiosk and a shared retail clinic is you meet via videoconference with a physician on a screen in the kiosk instead of a nurse practitioner or physician assistant who treats you in person at a convenience clinic. The kiosk utilizes high-definition video conferencing and an array of biometric devices in the kiosk to measure your temperature, blood pressure, and pulse and more specialized instruments that transmit biomedical information such as close-ups of your skin, eyes, and ear to the clinician in real time. The doctor can also electronically prescribe medication during the visit.

Like retail clinics, appointments can be scheduled online or you can drop-in at a kiosk. The solution is being piloted across several states by healthcare, pharmacy, and retail services providers. Today, employers are the main implementers of kiosks to provide healthcare access that is convenient for employees or to supplement on site clinics. Kiosks can also be set up for use at schools, shopping malls, long-term care sites, retirement communities, and pharmacies.

Healthcare consumers want basic services such as school and camp physicals, flu shots, strep throat tests done as fast and economically possible. Online appointment scheduling appeals to on-the-go families. Mobile scheduling using an app is even better.

For nonemergency care, people are more likely to use convenience clinics or kiosks instead of ERs or their primary care doctor because they don’t need to wait for an appointment. Individuals who don’t necessarily have a close relationship with their doctor because they consider themselves healthy may be more apt to use the kiosk or convenience clinic services.

Consumers want same-day attention for minor issues without the hassle of calling a doctor’s office for an appointment. Doctor’s offices often don’t have the flexibility to add unscheduled patients for a same-day appointment. Kiosks and convenience clinics allow families and individuals to go in when they have the time in their busy work and school schedules, not the provider’s schedule.

Payment is not a big concern. The prices are reasonable and posted so the consumer knows what he will pay even if health insurance does not pay for the visit. Retail clinics will set new standards for prices, hours, and location in nonurgent healthcare.

An important aspect of speed clinics and other ambulatory care services is to ensure that the care provided is documented electronically and transmitted to the consumer’s regular primary care physician in order to maintain a complete integrated health record.

Virtual Care—On Demand

Telehealth and mobile health are viewed as two industries in the business world. To the consumer, however, they converge to provide convenience, accessibility, and simplicity in obtaining healthcare. The process of getting medical advice and assurance for minor injuries and illnesses quickly is in high demand. No one really wants to go to an ER and sit with sick or contagious people especially if you are bringing your child. But waiting a week or more (national average of 19.5 days according to a 2014 Merritt Hawkins study) for an appointment with your primary care physician doesn’t work either.

Welcome to the new and fast-growing segment of companies offering virtual care. These companies such as Teladoc, Doctor on Demand, American Well, MD Live, and Health Tap provide only virtual visits on mobile devices or the Internet for nonemergency care. Access to a doctor is available from a mobile phone, tablet, or PC. Many of these services can connect the patient with a doctor in less than two minutes. The advantage is that consumers can reach a doctor from a device that they use every day. Virtual doctors range from general medicine, psychology, and pediatrics to lactation counseling.

Consumers want an alternative to the traditional doctor’s office visit that is affordable and convenient. On demand is the pinnacle of convenience—it means my time and my place when I ask for it. Consumers are used to 24/7 on-demand availability such as requesting a car using Uber that is faster than standing on a street waving at taxis, bank services that allow the check deposits using a mobile phone, watching TV shows and movies anywhere you are at any time, shopping for groceries on your phone, or having packages delivered at a specific time and day. Virtual doctors are not intended to replace a patient’s primary care physician. They are a supplement to the regular primary care doctor—on demand. Because of their 24/7 and 365 days’ availability, virtual doctors are used for:

• Nonurgent medical situation—minor illness or injury

• Travel—on vacation or business

• Children

• Specialist needed

• Short-term prescription

Patients are able to connect with a licensed physician, usually within a few minutes, by smartphone, tablet, or computer. During the visit, a doctor can evaluate symptoms, offer a diagnosis, and provide a prescription if needed. Their low-cost flat fee structure makes them an ideal supplement for these situations, especially if it means you can receive advice and necessary prescriptions at home or work. Most virtual visits are $40–50 for 15 minutes. In comparison to a $20 copay at the doctor’s office, the fee is reasonable since you can avoid the travel time and waiting in the office. For consumers who have Flexible Savings Account (FSA) or Health Savings Accounts (HSA) that take advantage of tax-free deductions, using the funds to pay for virtual care makes sense even if insurance pays for the visit. The predictable cost is appealing to consumers.

University health systems such as UCLA (LiveHealthOnline) and Thomas Jefferson University Hospitals (Amwell) make their physicians available through telehealth virtual visits for consults and follow-up appointments instead of coming into the office.

Connected Care—Power to Telehealth

Telehealth provides access to patients who are in rural areas and to physician specialists where they don’t exist or are not easily available. As a delivery method, it’s been around for a long time. I worked on a U.S. Public Health project in the 1970s that took NASA technology developed for space and applied it for use in healthcare. For the project, advanced technical medical equipment was installed in a customized mobile home that allowed patient visits to be conducted from the mobile health unit (MHU). The MHU could perform close-up skin and eye exams, take images, and transmit data via microwave towers to the main hospital. The exams were conducted by nurses as the MHU traveled around the Papago Indian reservation in Arizona, which had a population of 900. Because a drive to the central clinic took hours, the mobile unit enabled the residents to receive care without travel time or taking time off work.

Telehealth is not a specific service, but a collection of means to enhance care and education delivery. It is defined by the Health Resources and Services Administration (HRSA) as “The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration.”

Telehealth comprises a wide range of diagnosis and management, education, and other related fields of healthcare. These include, but are not at all limited to: dentistry, counseling, physical and occupational therapy, home health, chronic disease monitoring and management, disaster management, consumer and professional education. The term telemedicine is a subset of telehealth and is commonly used when referring to traditional clinical diagnosis and monitoring that is delivered by technology.

There are three modalities⁸ of telemedicine⁹ as shown in Figure 4.1:

Figure 4.1  Digital Health Taxonomy

Source: Ingenium Telehealth Consulting.

• Live videoconferencing (synchronous): Live, two-way interaction between a person and a provider using audiovisual telecommunications technology. Videoconferencing is often used for ER consultations, remote monitoring of ICUs, rural or urban underserved locations when direct observation of the patient is needed, psychiatric patient consults, and patients with limited mobility. It is also used for professional education and patient health education.

• Store and forward (asynchronous): Transmission of images, documents, patient information, and prerecorded video through secure e-mail to a practitioner, usually a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction. This reduces wait times for specialty care, especially in areas where there is a dearth of specialists. The most common specialties using this mode are dermatology, radiology, ophthalmology, and pathology. The store-and-forward process can overcome language and cultural barriers.

• Remote patient monitoring (RPM) (synchronous and asynchronous): Personal health and medical data collected by monitoring programs is transmitted to monitoring centers in primary care settings, hospitals, intensive care facilities, skilled nursing facilities, and other case management programs where providers in a different location review the information for use in care and related support.

Some providers, such as Kaiser, include telephone visits in their telehealth services. The appointment is scheduled online or through the appointment line and the provider calls the patient at the appointment time. Kaiser also has advice nurses who generally walk a patient through a series of questions to decide on whether a patient needs to see a doctor, book an urgent appointment if needed, provide advice on monitoring symptoms, and home treatments. The advice nurse triages patients for urgency of care. While the telephone appointment is with a doctor, there may not be an appointment soon enough and an urgent appointment would likely require the attention of a physician in person.

Telemedicine can reduce cost through monitoring of intensive care unit (ICU) patients. These are more elaborate configurations that transmit the signals for each patient located in multiple hospital ICUs to a remote location where many patients can be monitored by a staff of doctors and nurses. The software for monitoring is sophisticated and can alert the remote ICU staff when measurements that precede negative events occur so ICU on-site staff can be given instructions on resolving issues quickly.

Mobile health (mHealth) is healthcare and public health practice and education supported by mobile communication devices such as cell phones, tablet computers, and personal digital assistants. Applications can range from targeted text messages that promote healthy behavior to wide-scale alerts about disease outbreaks. Because mobile health is the newest of telehealth technologies, federal policies are in the process of being developed by the Food and Drug Administration (FDA), the Federal Trade Commission (FTC), the Federal Communication Commission (FCC), and the Department of Health and Human Services (HHS) to ensure that consumers are not harmed by mHealth apps that provide clinical information.

The Downsides and Upsides of Telehealth

Telehealth comes with its concerns. When it comes to retail telehealth, there are concerns that a virtual visit with a doctor can contribute to fragmented healthcare. In other words, the consumer will see a doctor who is not their primary care physician for an ailment or problem and the care documentation does not find its way back to the primary care doctor’s records. Therefore, a gap in the patient’s EHR is created.

Another concern is that consumers will not select a primary care doctor. Instead, when the need for a doctor visit arises, the patient will see a virtual doctor. Research shows that young adults aged 18 to 34 years (millennials) favor cost and convenience over a long-term physician– patient relationship. On-demand convenience, access, and price rank higher than the need for patients to be seen by their own physician for every problem that arises. Some retail telehealth services include getting health forms completed for children’s sports, which is a huge convenience and time saver. Consumers using retail telehealth, presumably, have the ability to judge when telehealth meets their needs. For their part, CVS, Walgreens, and other retail telehealth outlets say they don’t want to replace the primary care physician and that patients should follow-up with their primary care doctor.

More than half of the respondents in a 2016 survey conducted by HealthMine say they wouldn’t use telemedicine, either because they don’t trust the technology or because they prefer an in-person visit. At the same time, more than 90 percent of those who have used telemedicine say it has reduced their healthcare costs. The inconsistency in the responses of 500 insured consumers indicates a majority of the public still doesn’t understand what telemedicine is or what it can do. In fact, 39 percent of those surveyed said they hadn’t even heard of telemedicine.

Although it has some skeptics, telehealth is on the rise. A 2015 National Business Group on Health survey showed:

• 74 percent of large employers plan to expand the telehealth services they offer in 2016, up from 48 percent in the prior year.

• 70 percent preferred a telehealth visit to obtain common prescriptions, such as refills, antibiotics, or chronic illness medications, to an in-office visit.

• Consumers perceive video as the best form of telehealth because video visits are more likely to lead to an accurate diagnosis than e-mail or phone.

Virtual health visits are equivalent to ATMs when they first launched: At first, bank customers were very wary about using a machine to deposit and withdraw money—they trusted the teller more than the machine. As lines and wait times in banks grew longer, customers became more willing to use ATMs for simple transactions. Banks provided incentives because the service was free to the consumer and money could be withdrawn at any ATM on the same network. As the number of bank branches diminished with the overall downturns in the economy, banks increasingly pushed their customers to use ATMs as they reduced branch staff. Some charged customers to conduct transactions with bank staff instead of using the ATM. As the new generation joined the workforce, an ATM satisfied their most common transactions. The rise in ATM usage came with a price—charging to withdraw cash from ATMs that were not owned by the customer’s bank. Those fees are now standard with most banks with brick and mortar branches. Today, most individuals who need cash from their bank account simply go to an ATM without having to know a bank’s hours. In fact, ATMs are located in many retail locations other than banks. Similarly, in 10 years, we might look back at telehealth and not remember when it wasn’t commonplace.

Today, telehealth is less expensive than a visit to the ER, urgent care clinic, and office visit for the consumer, in addition to saving time traveling to and from a healthcare facility. The low cost and on-demand appointment is incentive for consumers to try it. If they like it, they will use it more often to fill their desire for convenience. As more employers offer the option, and employees use it to keep their out-of-pocket costs down, telehealth could become increasingly popular even though the cost of a visit might rise to equal the cost of in-office visit. When updating a patient’s EHR can be easily integrated from a telehealth visit, the value of telehealth increases for both the patient and the primary care doctor. Sixty-four percent of U.S. consumers said that they would see a doctor via video and seven percent said they would switch to a doctor who offered telehealth visits in an American Well 2015 Telehealth survey.

Telehealth will serve a variety of patients for many different reasons. The healthcare system can accommodate many of these patients in different venues for convenience, easy access, and even lower cost. If a patient wants to use telehealth instead of a primary care physician because they feel they don’t need one, then that’s their choice as long as they understand the downside of not having someone who knows their medical history well. But if the person is usually healthy, and can get flu shots and other preventive care outside of the doctor’s office, it seems acceptable. The backlash will happen if the availability of this type of primary care is plentiful, and the young and healthy question whether they need to purchase health insurance in spite of the federal requirement. The consumer may also believe that all she needs is catastrophic health insurance, especially with the current high deductibles and copays. In the face of telehealth, health insurance companies will need to come up with new offerings that suit this healthy and mostly younger consumer.

The Future of Telehealth

Telehealth has introduced legal and ethical issues not encountered in the regulation of traditional healthcare systems. Because telehealth crosses geographic boundaries, it presents challenges for functions that had been controlled by states. These include credentialing and privileging process, online prescribing, malpractice liability, licensing of physicians and other providers, and informed consent. This is being addressed by the Interstate Medical Licensure Compact, which makes it easier for physicians to obtain licenses to practice in multiple states and offer telehealth. The Compact strengthens public protection by enhancing the ability of states to share investigative and disciplinary information on physicians. It has been implemented in 12 states and legislation has been introduced in another 14 states.

The consumer appetite for telehealth in the next five years will increase because it is a delivery method that suits the new on-demand consumer who wants convenience, quality, and value. Telehealth will serve consumers who receive little or no regular healthcare, such as professional truck drivers, who are considered to have one of the nation’s most stressful jobs and have a higher than normal risk of developing chronic conditions and suffering on-the-job issues. Of the seven million drivers, 65 percent don’t have a primary care doctor and many have no insurance or policies with high deductibles. To aid these drivers, a joint project with Elizabethtown graduate students and Professional Drivers Health Net is converting nine chapels into care centers equipped with telehealth tools and services, relaxation spaces, a chapel, and an area for traveling companions. A $24.95 annual charge to truckers covers the cost of health and behavioral counseling, copays, and any scheduled video consults. There is also a growing network that is providing on-demand healthcare for remote and often-itinerant workers, including truck drivers, airline employees, oil rig workers, cruise ship employees, and even entertainers.

Future predictions:

• Congress will lift restrictions on Medicare so reimbursement is not an issue.

• Large academic health centers and hospital systems will continue to lead the way and offer specialists via telehealth to hospitals and doctors in the United States and around the world. This will makes it easier for primary care doctors to consult with specialists.

• Mental health services will see more providers offering services as the price of technology decreases.

• Policies will continue to be developed at the national level and barriers will come down slowly as states adapt and adjust to issues that a new delivery method brings.

Telehealth cements the relationship and trust between doctor and patient; otherwise, the value of having a primary care physician is severely decreased when he is not available for advice. Imagine the comfort you would feel if, after getting sick in another country where you don’t speak the language, you could videoconference and instantly send your doctor test results from your phone to diagnose your problem when you are far away from home.

In the future, telehealth will be a service expected by healthcare consumers. It will aid in serving rural areas where doctors are far away and specialists even further. In a highly mobile society, consumers will want to bring their own doctor with them when they travel for vacation and work via telehealth.

In the next section, we see the ubiquitous mobile phone sets the framework that most anything can be done using a smart mobile device.

mHealth = Mobile, Masses, Motivated

Adoption of mobile technology has been rapid, with 90 percent of adults owning a mobile phone. As of October 2014, 64 percent of American adults own a smartphone.¹⁰ Mobile devices, including Apple’s watch, are the consumer’s health instruments. The apps allow us to track daily health activities such as walking, exercise, food, calories, heart rate, and other measures important to adjusting our behaviors and satisfying self-curiosity. However, these devices can do much more for those who have health issues that benefit from monitoring specific indicators for status. Mobile devices can be used to create home-based monitoring for chronic disease management programs, which in turn reduce hospital readmissions. It is important to providers to have reliable data from mHealth devices when making decisions about their patients with chronic diseases.

Future use of mobile to engage patients
App-enabled patient portals	56%
Telehealth services	47%
Text communication	44%
Remote monitoring devices	36%
Prescribing apps	28%

Source: HIMSS 2015 HIMSS Mobile Technology Survey.

Over half of the respondents to a 2015 mobile technology survey conducted by the Health Information Management Systems Society (HIMSS) said they would use app-enabled patient portals to engage patients on mobile devices in the next two years.

The mHealth movement is critical to patient engagement. Consumers can take charge and participate in their own care through apps on mobile devices. Many health and fitness apps allow the user to track their lifestyle and manage their health.

According to a study by Manhattan Research, more than a third of U.S. physicians in 2014 recommended that patients use one or more apps. HealthTap surveyed more than 65,000 physicians in its network and another 500,000 in its referral network on their recommendations on a wide variety of health and wellness apps. The company then listed the top 100 iOS and Android apps, then broke the recommendations down into roughly 30 lists on more specific categories, like running and diabetes care. These are apps approved by doctors, not ratings on app stores that both clinicians and consumers can use. The apps are judged on three standards—ease of use, effectiveness and medical accuracy, validity and soundness. They’re not given a number rating, but are ranked solely based on how many doctors would recommend them.

There are over 100,000 fitness and health apps on the market. A small number of clinical apps will fall under the Federal Drug Administration (FDA) regulation, but the vast majority will not. The FDA will exercise its authority on mobile apps that are medical devices and whose functionality could cause a risk to patient safety if the mobile app does not function as intended. Still, consumers are looking for apps that are curated and recommended by physicians, preferably their own doctors.

Apps can help patients manage medical conditions such as an app for monitoring food eaten to help identify food allergies in discussion with a physician. These apps provide information and data to have meaningful dialog between an engaged and empowered patient with their doctor.

The consumer needs to beware of privacy policies for apps. Many people want to be part of the bigger picture of contributing data and analytics, but each person needs to be sure that she is comfortable with the terms of how her data will be used. Each person needs to understand the rights of ownership, use of the data, and the rights of a consumer to their data once it is captured by a mobile device and transferred to an mHealth vendor.

Security of the data is dependent upon the vendor. Databases will always be subject to hacking and vendors that hold identifiable personal health data are expected to have the latest contemporary means of data protection in place.

House Calls Encore

As more consumers’ needs are quickly satisfied with new delivery options that are technology driven, there is another alternative—the old-fashioned house call. House calls in rural areas for homebound patients mean the difference between receiving timely care or waiting until arrangements can be made for transportation to a doctor’s office. House calls save the patient travel time to the office, which they may not be able to arrange easily, and waiting in a doctor’s office for a 15-minute visit. A house call may make the difference between seeing a doctor or skipping an appointment. During a house call, an advantage is that the doctor can see the patient’s environment—look in the refrigerator and see what the patient is eating, or check on household conditions that may cause a fall. In the United States, only about 14 percent of physicians make house calls.

Doctors who do make house calls are making a comeback. Dr. Cindy Pinson founded Travel MD¹¹ in 2005 to serve rural residents in West Virginia, Ohio, and Kentucky. Most of the patients are elderly, and some would not go out to see a doctor because it is not convenient. Travel MD also makes regular visits to nursing homes and assisted living facilities.

Another house call doctor, Dr. Laura Moiré of Priority Care Hawaii,¹² serves patients on the northwest coast of the island of Hawai‘i. She is trained in emergency and holistic medicine and provides 24/7 urgent house call services for residents and visitors who have difficulty accessing local doctors for care. Patients can avoid the inconvenience and cost of going to the local ER for services. The team is equipped with medications, EKG equipment, IV fluids, stitches, splints, and more. Essential labs are performed on site, while X-rays and other images are done at the nearest facility. With starting fees that range from $450 for new patients to $295 for existing patients, the cost is much less than an ER visit. As a sign of Dr. Laura’s breadth of services, a partnership provides emergency transport to facilities on other islands when needed. The availability of multilingual services demonstrates the need to serve a diverse resident and visitor population.

References

Bachrach, D., J. Frohlich, A. Garcimonde, and K. Nevitt. April 2015. The Value Proposition of Retail Clinics. Manatt: Robert Wood Johnson Foundation.

Laura, M. 2015. Priority Care Hawaii Offers the only 24 Hour Medical Urgent Care on the Big Island. Priority Care Hawaii: Waikoloa. www.prioritycarehawaii.com/about/

Oakman, T. May 6, 2015. Retail Clinics Are Expanding their Role Within the Healthcare System: Culture of Health blog. Austin: Robert Wood Johnson Foundation.

Smith, A. 2015. U.S. Smartphone Use in 2015. Washington DC: Pew Research Centre. www.pewInternet.org/2015/04/01/us-smartphone-use-in-2015/

Weinick, R.M., C.E. Pollack, M.P. Fisher, E.M. Gillen, and A. Mehrotra. 2010. Policy Implications of the Use of Retail Clinics. Santa Monica, CA: RAND Corporation. www.rand.org/pubs/technical_reports/TR810.html

Wieczner, J. 2013. “Pros and Cons of Concierge Medicine.” The Wall Street Journal. November 10.

¹ Wieczner (2013).

² Oakman (2015).

³ Weinick et al. (2010).

⁴ Bachrach et al. (2015).

⁵ Bachrach et al. (2015).

⁶ Bachrach et al. (2015).

⁷ HealthSpot closed in early 2016.

⁸ Center for Connected Health Policy http://cchpca.org/sites/default/files/uploader/Telehealth%20Definintion%20Framework%20for%20TRCs_0.pdf

⁹ Some definitions include telephone consultations in synchronous mode.

¹⁰ Smith (2015).

¹¹ www.travelmdtristate.com/index.html

¹² Laura (2015).