At her south Charlotte home one night in September, Beth Straeten got her kids to bed and grabbed her iPhone to download a new app. Within minutes, she was talking face-to-face with a physician assistant.
As Straeten described the poison ivy rash on her arms, PA Dimple Joshi sat across town at Carolinas Medical Center-Pineville, in front of two computer monitors. On one, Joshi could see Straeten and on the other she could read Straeten’s medical record.
Their conversation lasted for about 10 minutes, and Straeten came away with a prescription to help stop the itching, called in to her local drugstore.
This “Virtual Visit” cost Straeten $49 but allowed her to avoid a trip to the doctor’s office or a long wait in an emergency room. It’s one of the latest conveniences emerging from Charlotte-area hospital systems and doctors groups as they embrace the world of electronic health records.
“Finally someone gets it that you’re not sick from 8 to 5,” said Straeten, 32, a working mother of two small children. “It’s just so nice to have this technology around the clock.”
In the past decade, as both Carolinas HealthCare System and Novant Health moved from paper to digital health records, the most dramatic change was often internal. Doctors and nurses spent hours learning to document patient care and input billing codes. Patients benefited from better coordination of care and sharing of information. But for a while, the most noticeable difference was the computer in the exam room.
Today, the “patient engagement” phase has taken hold.
Using laptops, tablets or smartphones, patients can talk to doctors face-to-face via the Internet. They can schedule appointments (sometimes for the same day), read their medical histories, view test results and correspond with medical providers by email.
This has been called medicine’s “Gutenberg moment” by Dr. Eric Topol, one of the nation’s leading cardiologists. Much like the printing press liberated knowledge from control of the elite class, Topol says digital health technology is poised to democratize medicine in ways that were unimaginable until now.
“It goes from being the doctor’s medical record to being the patient’s medical record,” said Dr. R. Henry Capps Jr. of Novant Health Lakeside Family Physicians in Cornelius. “That’s a cultural transformation.”
While these virtual contacts may be more cost-effective than office or emergency room visits, officials at both hospital systems say their motivation is to make health care more convenient for patients.
“This is not about making money. It’s about being a vibrant organization that can take care of a community,” said Dr. Greg Weidner, of Mecklenburg Medical Group-Ballantyne and one of the champions of Carolinas HealthCare’s changeover. “The business case to be made for doing this is (about) engaging people in their health.”
Capps, one of the physicians who led Novant’s switch to electronic records, said the goal has been to create “a new kind of experience for the patient when they’re not inside our four walls.”
“What’s more convenient,” he asked, “than jumping on the Web and finding an appointment with a doctor near you, who you can see quickly?”
Consumers expect easier access
Telemedicine, the traditional name for telephone and video visits with doctors, has been used for years to expand patient access to specialists, such as psychiatrists, who are in short supply in some communities. For many years, doctors have consulted with other doctors about patients via telemedicine. But treating patients and writing prescriptions via telemedicine is fairly new. And even five years ago, it was uncommon for doctors and patients to communicate by email.
Then came the American Recovery and Reinvestment Act of 2009, otherwise known as the “stimulus package,” intended to lift the country out of the recession. Among other things, it authorized the federal Medicare program to make incentive payments to doctors and hospitals to convert to electronic health records.
By the end of last year, nearly 60 percent of hospitals had adopted a basic electronic health record, up from 12 percent in 2009.
The change wasn’t easy. Many doctors still complain that filling out electronic records is tedious and time-consuming.
But the spread of broadband Internet connections and the popularity of mobile devices led consumers to expect easier access to health information in the same way Amazon changed shopping.
Patients like convenience
Both Novant and Carolinas HealthCare introduced their online patient portals in 2011. Novant’s is called MyChart. Carolinas HealthCare chose the name MyCarolinas.
As part of MyChart, Novant last year began offering video visits and e-visits, which, unlike simple emails, involve filling out questionnaires to describe symptoms and then waiting for a provider’s response.
Capps expected video visits to be more popular, but the opposite is true. Novant patients participate in hundreds of e-visits per month, compared with fewer than 100 video visits.
“They can ask a question at 2 in the morning when they have the question and not have to wait until everybody else is trying to call the office at 8 in the morning,” Capps said. “Patients will tell you that this is the coolest thing they have ever had in their health care.”
Capps said email and e-visits have enabled him to increase his “direct connection” with patients. “It’s an easier way to reach out to patients, even if you’re just doing a (prescription) refill and say, ‘How are you doing?’ It’s just another opportunity to build relationships.”
It’s not just young, tech-savvy patients who like the service, Capps said. The biggest group of users is age 50 to 70. And nearly 8,000 MyChart users are over 80 – and 14 are over 100.
Among the older patients is Virginia DeLong, 87, who in the past two years has recovered from two knee replacements and the removal of a kidney as a result of cancer. She frequently logs on to MyChart on her desktop computer to make appointments and email her primary care doctor, Dr. Michael Hoben at Cotswold Medical Clinic.
In March, for example, she wrote: “I am wondering if I may have had a mini-stroke on Sun. night or mon. morning. I slept til 2:30 on Mon. PM which is very unusual for me…Also I have felt dizziness and lack of good balance…Is this something to be concerned about?”
Hoben said a triage nurse quickly reviewed DeLong’s email and called her to arrange an appointment. DeLong sent the email at 3:26 p.m., and Hoben saw her at 4:10 in his office. “That’s a good example” of how it works, he said.
“She’s been a patient of mine for a decade, so I know her very well,” Hoben said. After an examination, he was able to rule out a ministroke. And DeLong said she’s been pleased with the online communication system.
“I ask him questions, and he answers right away,” DeLong said. “Many times you don’t need to speak to the doctor. I just need to have his OK. Sometimes he’ll say, ‘Come on in.’ I think it’s really neat.”
Some want a ‘quick buck’
Carolinas HealthCare recently launched “Virtual Visit,” offering established patients access to unscheduled video visits with on-call health care providers. Like Beth Straeten, these patients will usually speak with providers they’ve never seen before, but who are part of the hospital system and have access to electronic medical records.
That’s different from what’s offered by some telemedicine companies, such as Teladoc, that match patients across the country with out-of-state health care providers.
“There are organizations that see an opportunity to make a quick buck providing this service,” said Dr. Charles Rich, an internist with Mecklenburg Medical Group-Uptown. “There’s a lot of entrepreneurial, venture capital-funded interest in this. But picture a doctor in Arizona or New Mexico dialing in and purporting to take care of Beth (Straeten). That’s a vastly different proposition than what we’re talking about.”
Video visits are intended for minor, uncomplicated conditions, such as allergies, coughs and upper respiratory infections. If patients describe more serious problems, such as serious chest pain or very low blood pressure, Rich said, providers will call 911 or make an appointment for an office visit.
“It takes a system to deliver safety, accountability and quality if we’re going to use these technologies,” said Rich, who led development of “Virtual Visit.” “Some of those who purport to be able to provide this service don’t have the kind of backup for that handoff or coordination of care.”
Is it safe?
Some doctors still doubt the safety of treating some patients and conditions virtually.
Dr. Henry Smith, a Charlotte pediatrician for more than 40 years, said he recently saw four children who had been prescribed antibiotics from “virtual” health care providers that he did not identify. Such prescribing is a “dangerous practice,” he said, because of the risk of a mistaken diagnosis and the potential for overuse of antibiotics that contributes to drug resistance.
Smith didn’t distinguish between types of telemedicine services, but he said, when it comes to prescribing antibiotics for children, “exams with an iPhone are not adequate to see and treat pediatric infections,” even if providers have access to the patients’ records.
He said it’s almost impossible to diagnose some children’s ailments, such as ear infections and strep throat, without an in-person examination. Without that, “you are only guessing,” Smith says in a handout for parents.
Medical board concerns
This issue has been a concern of the N.C. Medical Board, which until recently had a policy that appeared to preclude video visits. It said doctors should “ordinarily” examine patients in person before prescribing medicine.
In November, the board revised the policy to clarify what is allowed. Doctors using telemedicine are held “to the same standard of care as (those) employing more traditional in-person medical care,” said spokeswoman Jean Fisher Brinkley. But the policy now makes clear that an “in-person encounter need not have occurred as long as they’re able to obtain information sufficient to make an appropriate diagnosis.”
For now, Carolinas HealthCare offers “Virtual Visit” only to patients physically located in North Carolina, partly because the system’s on-call providers are licensed only in North Carolina. But Rich and his Charlotte colleagues recently met with the S.C. Board of Medical Examiners to understand its policy if the hospital system decides to expand its virtual service.
Dr. Stephen Gardner, a Greenville neurosurgeon and chairman of the South Carolina board, said “telemedicine is a very useful tool and not something that South Carolina is trying to restrict.” But there are conditions.
“It has to be a physician who’s licensed in the state and in good standing (working with) a patient who is established in that practice already. That means somebody in that practice has at some point examined and diagnosed the patient,” he said. “ …You’ve got to have sufficient information about that patient to reach a safe diagnosis before you prescribe or treat.”
Carolinas HealthCare’s “Virtual Visit” would be “totally within our policy,” Gardner said, because it involves patients established within the hospital system being treated by hospital-based providers. In large physician groups, most doctors share on-call duties, covering for each other with patients they may not have met but whose records they can access.
“People will try to take advantage of this virtual medical portal,” Gardner said. “We can’t allow the fringe advantage-takers to disrupt safe care. … This is the future, and we’ve got to get it right.”