The Doctor Is…Online: The Emerging Role of Telehealth
By Gary Fitzgerald
Jonas Miller, 12, leaned back on his living room couch, iPad in one hand, Asthma Action Plan in the other. A few moments later, his mom Elizabeth sat beside him. Time for their 8 a.m. appointment with his allergist.
Within minutes, Jonas was describing his persistent cough to the allergist, face-to-face via FaceTime videochat.
The allergist examined his eyes and throat and ruled out a cold or virus. “I actually brought the iPad up close to my face,” Jonas recalled.
Jonas pulled out his digital peak flow meter, took a deep breath and blew into the mouthpiece. The reading – 85 percent of his previous best result, up from 80 percent the day before – signaled his symptoms were in the green zone and that his asthma was improving. With one click, the peak flow meter data was instantly forwarded to the allergist.
The allergist encouraged Jonas to monitor his breathing with the peak flow meter at least twice a day and continue taking his daily corticosteroid medication.
They discussed potential asthma triggers – Elizabeth thought Jonas’s cough could be related to a recent spell of cold, dry air – and reviewed his Asthma Action Plan.
An hour later, Jonas was in school – he had missed just 10 minutes of first period.
This is the promise of telehealth.
‘Delivering Care Over Distance’
Telehealth – the use of technology to support long-distance clinical healthcare or patient health education – accounts for only a small fraction of medical visits currently, but it’s expected to explode in the next few years. A recent report predicts the number of people worldwide using telehealth will jump to 7 million in 2018, up from less than 350,000 in 2013.
“There’s no doubt in my mind the use of technology to deliver healthcare will soon be widespread,” says Morgan Waller, MBA, BSN, RN, director of telemedicine professional services at Children’s Mercy Hospital in Kansas City. “Delivering care over distance will be a standard of care.”
“Routine office visits and asthma education are the most important factors to controlling asthma,” Waller says. “Telehealth improves access to healthcare professionals and the necessary educational resources.”
More doctors are starting to add aspects of telehealth to their practices:
- Secure online portals and carebooks allow you to upload and access personal medical information at any time and communicate with your doctor via email service or two-way texting.
- Healthcare apps, including many that specialize in asthma and allergies, allow you to submit data and obtain feedback from your doctor. Some are free, some require a fee. Asthma Storylines, for example, is a free app that allows you to document daily symptoms and health trends, and then work with a healthcare professional to develop a personalized plan for prevention and treatment.
- Video calls via smartphone or tablet allow you to connect one-on-one with your doctor from anywhere. Log on to the clinic’s appointment app to request a video call when the doctor is available. (Learn more about Allergy & Asthma Network’s partnership with Doctor on Demand.)
- High-tech medical devices – digital stethoscopes and otoscopes with live streaming and audio/video recording capability, peak flow meters, spirometers and exhaled nitric oxide monitors for asthma and lung function measurement – allow you to send data to your physician or a diagnostic testing facility for evaluation.
- Even low-tech telehealth – simple telephone calls – allow you to connect with healthcare providers in today’s high-tech world. The Women Breathe Free program helps women gain better control of their asthma through a series of 30-60 minute telephone calls with an asthma educator.
“The old-fashioned notion that every doctor’s visit needs to be a hands-on visit, it’s really not true,” says pediatrician Peter Antall, MD, President and Medical Director of Online Care Group at American Well, a Boston-based company that facilitates secure telehealth video visits with doctors.
“We can examine patients through video,” Dr. Antall says. “We can look for signs of respiratory distress and we can evaluate skin rashes or eczema. Or we can advise them whether or not they need to go to the ER. These are real, useful visits.”
At Your Convenience
Some telehealth arrangements still require patients to go to a healthcare facility – just not the same one as their doctor.
Children’s Mercy Hospital in Kansas City started its telehealth program in 2013. It has outreach clinics and offices in Missouri and Kansas, drawing patients from small rural towns that sometimes cannot support their own allergist or pediatrician. That’s where telehealth comes in.
A family with an asthmatic son living 200 miles west of Children’s Mercy Hospital can instead go to its regional specialty clinic in Wichita, Kansas, for a telehealth visit – saving 3-4 hours of driving each way.
During the visit, a nurse telefacilitator is present with the family while an allergist appears via live streaming on a kiosk or computer monitor. The telefacilitator looks in the patient’s ear, nose and throat, listens to breathing sounds, and may take lung function, or exhaled nitric oxide tests, if necessary. Digital devices connect to the kiosk or monitor and the assessments are forwarded, in real time, to the doctor.
The allergist and patient talk, just as they would in person. Once the exam is complete, the allergist makes recommendations, prints instructions, e-prescribes prescriptions, and sends a copy of the visit to the patient’s primary care doctor. That’s it.
“Most patients respond that the visits are much like the ones they experience in person,” Waller says.
Convenience is key. “When it becomes logistically hard for a patient or family to get to the facility, follow-up appointments are often the first things to get cancelled,” Waller says.
It’s not all perfect. On occasion, connectivity issues during power outages or Internet service provider problems can interrupt telehealth appointments – a frustration for both doctor and patient.
Despite the hiccups, early studies suggest telehealth improves patient outcomes.
In a two-year study of pediatric asthma patients who used telemedicine at Children’s Mercy, preliminary results “indicate that receiving asthma care by telemedicine is as good or better than through traditional in-person clinics,” Waller says.
The Future Is Now
When Gary Steven, MD, went to medical school in the 1980s, he never dreamed he would one day treat patients using a computer screen or handheld phone. Sounded too much like Star Trek. Or The Jetsons.
Now a board-certified allergist/immunologist with Allergy, Asthma & Sinus Center in Greenfield, Wisconsin, Dr. Steven thinks telehealth may not be moving fast enough. “We could have been doing some of this a long time ago,” he says.
Dr. Steven and fellow allergist/immunologist Don Bukstein, MD, are partnering with family practices in southeastern Wisconsin to assess and treat asthma and allergy patients using telehealth. They are also working to establish a secure mobile and web-based portal to connect with patients one-on-one from their home.
New patients can even see them via telehealth, as long as they are able to provide lung function test results.
“I think telemedicine will become an element of most allergy practices,” Dr. Steven says. “Allergists will see patients in person once a year, maybe once every few years, and then see them more regularly online, especially if it’s a patient who is well-known to the allergist.”
Telehealth is most practical when it “incorporates data” addressing the patient’s current health, symptoms and family health history, Dr. Steven says.
“Jumping online and tossing out a question to a doctor who does not know your medical history, what medications you’re taking, what else is going on – that’s where problems can occur,” he says.
Food Allergy E-Counseling
Fallon Schultz has worked with many food allergy patients and families both in person and online through Food Allergy E-Services, a counseling company she founded in 2014. She also works closely with patients and families affected by Food Protein-Induced Enterocolitis Syndrome (FPIES), an allergic reaction that occurs in the gastrointestinal system, and is president and founder of the International FPIES Association.
“Parents of kids with food allergies often will see the doctor, get instructions on what foods to avoid and what to do in a medical emergency … but then no one teaches them how to live with a food allergy,” she says. “You’re completely on your own.”
Schultz, who is the mother of a child with FPIES, saw a need to counsel parents and patients on such things as ensuring proper nutrition, avoiding allergens at birthday parties and holidays and navigating a 504 Plan at school.
Through Food Allergy E-Services (www.foodallergyeservices.com), Schultz has helped parents cook allergy-free meals in the kitchen and gone food shopping with them – online and in real-time.
“It can be overwhelming to go shopping if you’re a parent of a food-allergic child and you don’t know what safe foods to look for,” she says. “I will connect with you on a mobile phone or tablet and I’ll be with you as you walk up and down the aisles, showing you exactly which products to buy.”
Telehealth is anything but impersonal, Shultz says.
“If you have a good telehealth program, it’s clear, and there’s engagement, you can have the same level of connection as an in-person visit,” Schultz says. “I actually think it can be more intimate. When you’re a patient sitting at home, you’re more apt to open up, let your guard down.
“When your clients or patients are more comfortable, you can find out what is really going on – and then you get to a place where you can really help them.”
The End of Office Visits?
“I’ll still go to the doctor’s office for my annual physical and the flu shot,” says Bethany Moreland, 32, from York, Pennsylvania. “Every spring I have an allergy appointment to get my prescription refilled, and if I can do that online, that would be easier. I wouldn’t miss time from work.”
Telehealth will never completely replace in-person visits, agrees American Well’s Dr. Antall.
“There will always be a need for in-person visits for certain medical procedures, certain medications, and follow-up care,” Dr. Antall says. “But so much of asthma and allergy is about taking the patient’s history and working on symptom management. All of that can be done via telehealth.”
American Well is one of several emerging telehealth companies that provide consumers with a network of state-licensed doctors, dietitians, psychologists and other medical providers, available on demand for a $49, 10-minute appointment that can be reimbursable depending on your health insurance. Some private insurance companies offer similar telehealth platforms to members.
Telehealth is best used for the diagnosis, management and routine treatment of health conditions – and not for emergency situations such as an asthma flare or anaphylaxis reaction, according to American Well’s website. In those cases, patients should go to the hospital emergency department.
“A universal problem with asthma is improper use of inhalers and nebulizers,” Dr. Antall says. “With telehealth, you can have a nurse on a live video visit confirm if a patient is correctly using an inhaler or nebulizer – and if not then demonstrate proper technique.”
Is This Covered?
For all its promise, payment and insurance coverage remain one of the biggest hurdles for telehealth. Patients and healthcare providers may encounter a patchwork of insurance requirements and different payment streams that do not allow them to fully take advantage of telehealth.
Many private insurance companies now provide at least some telehealth coverage. According to the American Telemedicine Association (ATA), 24 states and Washington, D.C., require that private insurers cover telehealth the same as they cover in-person services.
On the federal government level, it appears technology is also well ahead of public policy.
Medicare will pay for telehealth only if it is used in rural or underserved areas – and only when video appointments are involved. Also, the originating site for the telehealth visit must be a medical facility, not a patient’s home, to ensure Medicare coverage.
“Reimbursement dictates where a patient may be located for a telemedicine appointment,” Waller of Children’s Mercy Hospital says. “People cannot yet sit in their living room and talk with their doctor on their 52-inch flat-screen; regardless of the many possible benefits of such a visit, Medicare and Medicaid will not reimburse providers for their time and expertise.”
Medicaid plans cover some telehealth services, but states vary in their coverage.
The Medicare Telehealth Parity Act of 2015, or HR-2948, would expand coverage of telehealth services under Medicare by putting it on the path toward parity with in-person visits. It would remove geographic barriers for telehealth coverage and expand the list of eligible providers to include respiratory therapists, among others.
U.S. Rep. Gregg Harper (R-MS), co-chair of the Congressional Allergy & Asthma Caucus, was among four bipartisan Congress members to introduce the bill in July 2015. Visit AllergyAsthmaNetwork.org/advocacy/current-issues to learn more.
How to Prepare For a Telehealth Appointment?
Reviewed by Stanley Fineman, MD, Eileen Censullo, RRT and Tera Crisalida, PA-C