Everybody knows that physicians must embrace 21st-century communication and information technologies to improve health outcomes and increase convenience for patients. Telehealth allows patients to obtain care for a growing number of conditions without the burden of traveling to a doctor’s office. Nevertheless, many physicians hesitate to integrate telehealth into clinical practice. Overcoming that reluctance will require strong, effective leadership from physician-leaders who have the credibility to influence their colleagues’ behavior.
I help lead Kaiser Permanente’s telehealth efforts as CEO of both The Permanente Medical Group and the Mid-Atlantic Permanente Medical Group. In those roles, I am responsible for more than 9,000 physicians, 35,000 nurses and support staff, and 4.5 million patients. In 2015, Kaiser Permanente’s patients had 14 million “virtual visits” — care encounters by video, specialty consultations enabled by digital photography, and resolution of medical problems through secure email — compared with slightly more than 15 million in-person visits. We predict that by 2018, our virtual visits will outnumber the in-person ones.
The Big Opening Question
Before exploring the details of telehealth, people want to know how it affects health care costs. That’s not easy to quantify. On the one hand, the required physician and non-physician staff time is similar to that for an in-person visit. On the other hand, costs related to capital, transportation, parking, and time away from work are much lower. Likewise, although telehealth’s convenience increases the overall number of visits, its speed also reduces delays in diagnosis and treatment — and helps to avoid longer-term complications and hospitalizations. Overall, telehealth has similar costs to that of traditionally delivered care, but the improvements in quality and service are major.
Telehealth on the Front Lines
Let’s examine how Permanente physicians in California, Virginia, Maryland, and the District of Columbia use telehealth to improve clinical practice today:
Teledermatology. Consider a patient who sees a primary care physician (PCP) for a rash and needs a dermatology consultation. A medical assistant who has been trained to obtain high-resolution photos with a digital camera immediately sends the picture to a rotating team of dermatologists, from across the region, who provide this service each day.
For patients who otherwise would require an in-person specialty visit for a skin rash, a remote dermatologist can diagnose the condition from the digital picture 70% of the time and begin appropriate treatment immediately. Not only does the PCP’s patient get quick access to specialist expertise, but the added productivity frees up time in the dermatology department’s schedule to offer rapid (often same-day) in-person consultations to patients who need them. In short, this technological solution has multiple positive ripple effects.
On-site specialty consultation. Kaiser Permanente patients who see a PCP and would benefit from a specialty consultation can obtain one directly via video. All of our more than 40 medical and surgical specialties offer this telehealth solution. In addition to reducing delays in diagnosis and treatment, the video link among the patient, the PCP, and the specialist enhances care coordination and reduces the likelihood of medical errors. For example, a woman who visits her gynecologist for a mass in her breast can now get a definitive diagnosis within 48 hours.
Urgent-care virtual visits. When a Kaiser Permanente patient calls the nurse advice center for an urgent but not life-threatening problem, an emergency physician is available for consultation — not just by phone but increasingly by private, secure video. A single click on the patient’s smartphone or computer rapidly connects the ER physician and the patient. In 80% of cases, the problem can be resolved by phone, and the availability of video allows 60% of the remaining patients to avoid a trip to the ER. More than 90% of patients report being very or extremely satisfied with the care and advice they received.
Routine, follow-up, and specialist visits. All of our physicians, in every specialty, offer patients the option of a video visit for a variety of routine and urgent medical problems, specialty consultation, and surgical follow-up. The patient signs up for a free, internal, password-protected application behind a VPN firewall, and the physician uses a complementary software application to connect. Patients don’t need to miss work or school to travel to a physician’s office, which is especially important for people who already are losing time because of surgery, hospitalization, and rehabilitation. Although one third of patients choose the virtual-visit option, no patient is required to use it. Patients who prefer an in-person visit get an appointment that day for urgent problems and within a week for routine ones.
Five Steps to Engaging Physicians
Kaiser Permanente has successfully implemented telehealth to improve quality, service, and access. Given that nationwide adoption has been slower, how can we get physicians to embrace telehealth? Our experience has helped us identify five critical steps:
- Communicate the “why.” For most physicians, understanding the value for patients is what will drive them to change, not simply having new guidelines to follow. Physicians understand that patients value receiving truly expert care without having to miss school or work. As deductibles and out-of-pocket costs rise, offering convenient, high-quality service without additional cost becomes essential. Physician-leaders who believe in telehealth must talk with their colleagues directly using real patients’ stories, which are more powerful than raw data. For example, leaders might share an anecdote from a patient who did not have to take a day off from work to drive in heavy traffic to the doctor’s office, ultimately giving her more time to care for herself and her family during an illness. Once physicians start to experience that gratitude from patients firsthand, telehealth becomes even more attractive.
- Compensate accordingly. Although physicians are mission driven, they also must earn a living. At Kaiser Permanente, our physician medical group is capitated, and our physicians receive an annual salary, unrelated to relative value units (RVUs) or production incentives. That means no financial incentives for or against the use of telehealth services. Physicians who practice in a fee-for-service environment need to be reimbursed for their time when they provide care through telehealth.
- Keep it simple. Physicians will not use cumbersome tools that slow them down. In national surveys, physicians report flawed IT as a major source of dissatisfaction in their practices. For that reason, our medical groups have invested in developing easy-to-use applications that require only a single click for the physician to connect with the patient in a virtual visit (see these patient-view and physician-view screenshots).
In addition, macros we created for our electronic health record (EHR) and for mobile devices allow patients to make appointments and order testing in one or two clicks. We arrange for physicians who are adept in mobile and video technology to provide hands-on training and mentoring to colleagues within their clinical specialty. Having technologically sophisticated colleagues walk hesitant physicians through the process has proven to be very successful. Today, 100% of our physicians offer secure messaging to their patients, and all have completed at least some video visits.
- Mind the workload. Physicians are less likely to perceive telehealth as an added burden if these encounters are treated the same as in-person visits and doctors receive adequate support. That means, for example, having necessary staff available to assist during the visits. To help physicians see in-person and virtual visits as an equivalent workload, we use a panel-size approach rather than RVU reimbursement in primary care. We also reward specialty physicians for providing an appropriate number of new consultations each year (rather than RVUs) regardless of whether they happen in the office or through video.
- Invest in the culture. The Permanente Medical Group physicians use a shared, comprehensive EHR that is always available in their offices or from home. As a self-governing medical group, we make sure that physicians are well trained, supported, and rewarded for raising quality and providing personalized care. Once physicians know they won’t be penalized for offering the convenience of telehealth to their patients, they embrace it and figure out innovative ways to use it. Last year, we gave each of the 9000 physicians an iPhone and paid for their data plans. Already they have developed hundreds of new approaches to link with their colleagues and offer high-quality, time-saving alternatives to their patients. An example is our 5-star-rated KP Preventive Care app, which allows patients to make appointments, get advice, check their laboratory data, and obtain video visits from a smartphone.
Simply telling physicians about the value of mobile and video technology won’t generate enthusiasm. Physician-leaders must provide their colleagues with the necessary tools, training, and support — and then reward them for improving quality and increasing convenience for patients. Once doctors start to witness the value of telehealth with their own eyes and ears, they will run with the technology, as they have done at Kaiser Permanente.
This article originally appeared in NEJM Catalyst on March 29, 2016.