Telehealth: The Ultimate in Convenience Care

Dr. Teresa Myers, a family practice physician in Copley, Ohio, describes what she can see on her computer screen during a telehealth conference. "You know what HD television looks like. You can actually see the pimples on the actors' faces," she says. "I had a patient who was able to shine her iPhone flashlight to the back of her throat. I could see the exudates [pus-like fluid]. If you see that, you can be pretty sure." A few more questions, as well as having the patient take her temperature and feel and describe her lymph nodes, and Myers felt confident diagnosing strep throat and prescribing an antibiotic.

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The consultation started less than five minutes after the patient logged in, cost $49 and lasted 10 minutes. The patient never left home, learned a few things about examining her own body and, two days later, said she felt much better when Myers followed up.

Myers is with American Well, a telehealth service which, for seven years, has employed physicians like her for e-visits, or virtual computer consultations, for patients within specific insurance plans or physician practices.

But now the service, joining a growing trend toward medical care based on patient convenience rather than physician schedules, is available directly to consumers—whether insured or uninsured, and whether they have a primary care physician or haven't seen a doctor in years. Anyone can download an app at americanwell.com, enroll, choose from a panel of physicians and talk to a doctor nearly immediately. Using smart phones, tablets or web browsers, people with common symptoms like sore throats, or who need quick advice in ongoing care for chronic conditions, or even those looking for support in kicking the cigarette habit can have a virtual face-to-face with the board certified primary care physician of their choice.

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Just a few years ago, when patients had symptoms, they could either call their doctors, go to emergency rooms, or tough it out at home. Now options for care designed for consumer convenience are mounting.

The most common alternatives to a scheduled doctor's office visit include urgent care in free-standing clinics staffed by physicians, employer-based clinics offering a range of care from diagnosing infections to full primary care, and retail clinics within drug stores or big box stores like Walmart, usually staffed by nurse practitioners or physician assistants and often limited to common conditions like colds, flu and urinary tract infections. This direct-to-consumer app adds one more possibility to the growing field of convenience medical care.

The demand for quick and convenient consultation with doctors has produced other options such as TeleDoc, in which patients with a limited set of symptoms can get a call back within an hour from the first available doctor. White Glove is a company that offers, in four states, a clinic in a car. The half million White Glove users can call in and receive a home visit from a physician or nurse practitioner whose black bag might contain a rapid test for strep throat or some of the most commonly used prescription drugs.

Americans seem to like convenience care. Visits to retail clinics, for example, grew four-fold between 2007 and 2009, with nearly 6 million visits to such clinics in 2009 at an average cost of $78 per visit.

In fact, says Dr. Ateev Mehrotra , an associate professor of health care policy at the Harvard Medical School who has studied alternatives to brick-and-mortar doctor visits, convenience ranks high among the benefits of those alternatives. "One aspect of health care costs we don't talk about much is patient time," he says. That includes time in the car, time away from work, time in the waiting room, as well as time with the doctor. "When you start counting up all those hours, it turns into a huge amount of time, which adds up to a huge amount of money," says Mehrotra.

Options in convenience care, including virtual doctor visits via technology, may become even more popular as the new health care law goes into effect. Formerly uninsured people will be trying to make appointments with doctors—perhaps for the first time in their lives. "With the Affordable Care Act, millions of Americans are going to be hitting the healthcare system. Access is going to be more challenging," says Roy Schoenberg, CEO of American Well. "This form of care stretches the health care system, making it available to more people, without an intermediary."

The Congressional Budget Office estimates that an additional 11 million people will be newly insured under Obamacare next year, and up to 24 million more people will have insurance by 2016.

Health care organizations are gearing up to absorb the greatest number of newly insured patients since Medicare enrollees began signing up in 1966. And consumers have granted convenience medicine a place in the changing health care market. One study compared traditional office visits to e-visits at four primary care practices for two conditions: sinusitis and urinary tract infections. The patients in the study used their own physicians for both types of visits. Researchers found equivalent rates of follow-up care, indicating equal rates of misdiagnosis or failed treatment. They found similar rates of patient satisfaction. But they also found a trend toward higher rates of prescriptions for antibiotics as a result of e-visits, leading them to speculate that without a hands-on exam, doctors may use a more conservative approach and be quicker to prescribe an antibiotic.

Other studies largely suggest that electronic visits with primary care doctors provide lower-cost care with similar quality outcomes to traditional trips to the doctor's office. They're useful for common, short-term ailments and health advice, not more serious or chronic diseases, and patients who need hands-on exams, lab work or imaging tests are referred to doctors' offices, clinics or emergency rooms for care.

But the health care system in general is moving toward less-fragmented care, and any new players need to work with established systems and physicians if they are to provide consistent, efficient care for patients. "I live in Nevada. Some of my patients live 300 miles from anywhere," says Dr. Daniel Spogen, board member with the American Academy of Family Physicians. If one of his patients had a consultation with a telehealth provider, he'd want to see the medical record. "The ability to increase accessibility for patients can really be a benefit of using telehealth technology," he says. "What's very important is that it doesn't operate independently, but serves as another arm for getting overall information on that patient."

Research shows that when patients get their care from multiple physicians who don't communicate with one another, services are duplicated and the quality of care goes down, adding to the overall cost of health care. Ideally, a record of each outside medical encounter should be shared with a patient's primary care provider. But only patients themselves can approve the transfer of their medical records. Schoenberg says American Well physicians strongly encourage patients to approve sharing the records with their own doctors. "We go a long way to make sure that full documentation of the encounter is passed on to the primary care provider," he says. "But if a patient says no, we can't force it."

Medicine will always need expert hands-on care to listen to a heartbeat, collect a urine sample, or feel for a lump. But sometimes people don't need to drag their achy bodies into a car, drive for 45 minutes, and sit in a waiting room with other sick people for a half an hour only to be told their cold symptoms are normal and will run their course. For many such patients, Schoenberg says, "…click, click, click, and you see a physician."

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