Telemedicine or No Telemedicine: This is the Question

The debate and enthusiasm about telemedicine visits, as an alternative for an in person visit, are lurching in parallel tracks. Early adopters who are using it in rural areas have mainly adopted Telehealth for behavioral health and possibly dermatological consults. 

Dr. Glen Xiong at UC Davis has been doing research and providing clinical services using telemedicine for the last 12 years.  According to him, telepsychiatry services has been available to rural nursing homes for nearly 10 years. Since most psychiatric services do not require physical examination, telemedicine services is a natural application of video teleconferencing for clinical interviews and mental status examination. He is currently conducting a clinical trial sponsored by AHRQ to compare synchronous (real-time) versus asynchronous (video recorded) telepsychiatry.  Currently, telepsychiatry is not uniformly reimbursed by health insurance so novel funding models are needed. SCAN Health Plan is piloting new ways to deliver care to its members utilizing various methodologies. At the same time, skeptics are raising potential for abuse and concerns that beneficiaries in NH will not get the full benefit of a medical visit. 

In palliative care, there may be telehealth applications beyond the rural or underserved, geographically remote nursing home.  Innovative companies like Dr. Michael Fratkin’s Resolution Care have had success with this model. However, Dr. Karl Steinberg, a CALTCM Past President and longtime hospice medical director, suggests that “While telehealth palliative care may provide regular nursing home attending doctors some additional support with symptom control measures, I think most nursing home physicians are pretty knowledgeable about palliative interventions.  And there is something about direct human contact—not through a video screen—that seems emblematic of palliative care. Recall the “robot” in the ICU giving a patient bad news about his prognosis that we saw in the news recently; this leaves a bad taste in people’s mouths.” Obviously, if nursing homes are having trouble with symptom control, high-tech tele-palliative-health should be considered. But in general, Dr. Steinberg says, “We should try to keep specialty palliative care, including other team members like chaplains, as in-person and high-touch as possible.”

Personally I think it has the potential to fill gaps with more personal approach to NH care.  I have experience using Telehealth first hand in an Alzheimer’s community in the LA area. I found it useful in managing problems associated with Palliative care and end of life scenarios. It allowed me to be present with the family and their loved one during difficult times. It provided staff with the support they needed and allowed a more personal care experience to all involved. Telehealth using a “robot “ equipped with some peripherals such as a stethoscope or otoscope can be useful in making decisions about simple acute infections. Implementation requires some staff training, not far beyond their scope of work in face to face encounters. 

One of the challenges that remains to be solved is reimbursement for Part B services. In my case, I negotiated a monthly retainer fee that included administrative functions as well as coverage using Telehealth. 

Anecdotally, I remember situations where logging in and making observations after injury that went undetected by staff, led to a trip to the orthopedic doctor using facility limousine at 4pm. This definitely saved an ambulance trip to the nearest ED. In my opinion, saving a trip to the hospital improves the patient’s experience in scenarios like this, and save resources at the same time. With proper contracting arrangements telehealth could be introduced into practice in SNFs and ALFs earlier rather than later. It requires making the use case clear so the business arrangements could be beneficial to all parties, patient  and family, institution and payor. 

Michael Wasserman, a geriatrician and President of CALTCM, said “Theoretically, anything that we can do to bring geriatric care to nursing facilities needs to be considered.  My concern are the unintended consequences of bringing the wrong approach to care to facilities. For example, if telehealth allows physicians who see antipsychotics as the primary solution to behavioral problems to prescribe more, then we will not be improving quality.  It is critical that any telehealth solution embraces the core principles of a person centered geriatrics approach to care."


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