1. S CAN N I N G TH E H O R I Z O N
MARCUS WELBY
MEETS THE 21ST
CENTURY
Innovative Healthcare Delivery Options Will Help Meet The Challenges Of The
Healthcare Reform Law
BY DARCY LEWIS
T
here’s an old saying about not being able to fit 10 As a result of these challenges, the hunt is on to find new ways
pounds of flour in a five-pound sack. The healthcare to reduce healthcare costs and increase efficiency as more patients
reform bill President Barack Obama signed into law — enter an already strained system.
and the hundreds of regulations that government staff- “There is a perfect storm brewing as the population ages and
ers are writing to implement it — promise to significantly change requires more care. Meanwhile, more patients will be entering a
the practice of medicine, as millions of people who did not have healthcare system where there aren’t enough physicians to meet
or could not afford health insurance will be making routine ap- the needs of the patients we have already,” says Zeev Neuwirth,
pointments with primary care doctors, seeking consultations and M.D., Chief of Clinical Effectiveness and Innovation at Harvard
second opinions with specialists and getting diagnostic testing Vanguard Medical Associates in suburban Boston. “Finally, health-
without a proportional increase in the number of providers and fa- care costs are a tremendous burden on our economy. We must
cilities. Some facts and figures to consider: make healthcare more efficient for the health of the country, the
 Approximately 32 million uninsured people will be covered health of the economy — that is our imperative.”
by 2019. This includes 16 million who will enroll in Medicaid, Heathcare providers from solo practitioners to large medi-
the federal government’s health insurance program for low- cal centers are considering and trying out dozens of ideas and
income Americans. technologies to streamline the delivery of care without sacrificing
 In 2008, the U.S. Census Bureau projected that in 2010 quality. These initiatives range from multi-billion-dollar ideas, such
there would be 12.3 million Americans aged 65-69 who are as implementing electronic health records nationwide, to modest
eligible to receive Medicare, and that there would be 16.8 mil- innovations, such as a cell-phone app that helps patients man-
lion in the 60-64 age group — that is , next in line to receive age their health. Telemedicine, mobile medicine, shared medical
health benefits from the federal
government’s insurance for older
Americans. That’s a 25 percent
increase in just five years.
 According to the American Medi-
cal Association, the current phy-
sician shortage will swell to as
many as 159,000 physicians by
2025. Already, 22 states and 15
medical specialties have reported
not having enough practitioners
to meet patient demand. Given
the current system of health care
finance, better pay tends to draw
new physicians — who start their
careers saddled with hundreds of
thousands of dollars in medical
school loans — to lucrative spe-
cialties instead of primary care.
16 H EART I N S I G HT • N OVE M B E R 2010

2. When a colleague at a hospital 90 miles away sent this photo of a patient’s leg to Dr. Javeed Siddiqui’s cell phone, he was able to
diagnose a life-threatening infection.
appointments and E-mail consults are four that have the poten- says Lee Schwamm, M.D., F.A.H.A., Director of TeleStroke and
tial to be game-changers. “These technologies respond directly to Acute Stroke Services at Massachusetts General Hospital in Bos-
consumers’ preferences and permit doctors to focus on what they ton. “It’s an immersive experience that lets the physician feel as if
do best: provide safe, high quality care to their patients when they [he or she is] really at the patient’s bedside.”
need it and where they need it,” says Catherine Dower, Associate The Health Information Technology for Economic and Clinical
Director of Research for the Center for the Health Professions at Health Act (HITECH Act) of 2009, which provides federal incen-
the University of California-San Francisco. tives for healthcare providers to invest in health information tech-
nology, will spur wider adoption of telemedicine. “The HITECH Act
A DOC AT YOUR BEDSIDE WITHOUT BEING IN THE includes a lot more federal money and support for telehealth,” says
ROOM Dower. “People will finally have the money to test these innovative
Doctors are leading the charge for telemedicine — videoconfer- ideas and see what really works.”
encing that lets physicians diagnose and treat patients remotely Stroke telemedicine (or telestroke), has already gained rapid
— to become more widely used throughout the medical system. acceptance by doctors and patients alike, because it increases ac-
“The term generally refers to the ability to review real-time, cess to stroke specialists, especially in rural or other underserved
high-quality video and the ability to zoom in and out as needed,” areas. The U.S. averages only four neurologists per 100,000 peo-
H EART I N S I G HT • N OVE M B E R 2010 17

3. ple, and not all of them specialize in stroke. In areas where there tors can do without actually laying hands on a patient — for instance,
aren’t enough stroke specialists to go around, a telestroke evalu- a telemedicine stethoscope that can allow pediatric cardiologists,
ation is as effective as a bedside stroke evaluation to determine if who are in short supply in many parts of the country, to hear the
a suspected acute stroke patient is a candidate for treatment with heart sounds and “see” a young patient visit via a teleconference.
tPA, according to a 2009 scientific statement on telestroke issued
by the American Heart Association/American Stroke Association. DIAGNOSING ON THE GO
The clot-busting drug can reduce brain damage if administered Mobile health, an emerging field within telemedicine, uses cell
within three hours of the onset of symptoms. phones and smart phones that can take photographs or short vid-
“Every hospital has a CT scanner, a lab and a pharmacy to pro- eos to enable doctors to make diagnoses from wherever they hap-
vide tPA — and now telestroke provides the specialist expertise,” pen to be, not just where the video equipment is located.
says Schwamm, who was the lead author of the AHA/ASA scien- Javeed Siddiqui, M.D., Associate Medical Director at the Center for
tific statement. Harvard Medical School reinforced the AHA/ASA Health and Technology, University of California-Davis, had been doing
findings in a special report issued in September, “Stroke: Prevent- regular telemedicine consults with a small hospital 90 miles away. But
ing and Treating ‘Brain Attack’”, which noted: “Telestroke programs one night, he received a text at home from a colleague who was con-
are especially useful for helping physicians at smaller hospitals cerned about a newly admitted patient with a serious infection. After
determine when to use clot-busting therapy. In these hospitals, some discussion, Siddiqui asked his colleague to take a picture of the
telestroke may be the only way for a patient to receive potentially man’s leg with his cell phone and E-mail it to him.
brain-preserving treatment in time.” Using his cell phone, Siddiqui was able to magnify the image
As telestroke proves its value and more institutions are invest- and determine that the patient had a strep infection that had pro-
ing in the necessary video equipment, other medical specialties gressed to life-threatening toxic shock syndrome. He ordered the
are getting in on the act. “Video consults from academic health most effective antibiotics, and the patient was wheeled into sur-
systems to rural hospitals are growing significantly for both acute gery just two hours later. “So much of medicine is getting the right
situations and managing chronic conditions like uncontrolled high information to the right person at the right time,” he says. “Because
blood pressure,” says Thomas Nesbitt, M.D., a senior administrator my colleague and I both had our cell phones, we were able to start
in the University of California-Davis Health System and Execu- the correct treatment without losing time and the patient walked
tive Director for Telehealth Services at the Center for Connected out of the hospital just five days later.”
Health Policy in Sacramento, CA. “That’s a better way to use the
scarce resource, which is the specialist’s time, and it keeps people SHARING IS CARING
from having to travel great distances.” As promising as telemedicine is, there is one thing it cannot do:
Take the 25-bed Grande Ronde Hospital in La Grande, OR, increase the number of hours in the day that a doctor can see
which obtains remote care from 11 different medical special- patients. But what if the doctor instead increases the number of
ist teams in four states. One of their telemedicine offerings is patients he or she can see in a day — while also increasing the
a remote pacemaker clinic. “Our patients used to have to travel amount of time spent with each of them? Impossible, you say?
three-plus hours each way to Boise just to get their pacemak- Then you haven’t heard of shared medical appointments that
ers checked, which takes all of 10 minutes,” says Doug Romer, group several patients with the same medical condition.
R.N., Grande Ronde’s Executive Director of Patient Care Services. In addition to the doctor, each shared appointment includes a
“Needless to say, we have lots of happy patients now.” nurse to take vital signs, a trained facilitator to guide discussions, a
And new technologies are being developed to expand what doc- medical documenter who completes the doctor’s notes in real time
18 H EART I N S I G HT • N OVE M B E R 2010

4. S CAN N I N G TH E H O R I Z O N
and a care coordinator outside the room who provides an after- Patient satisfaction with shared appointments at Harvard Van-
visit summary with follow-up instructions. guard has been very high, with more than 80 percent of first-time
“As a doctor, it’s wonderful to walk into that room knowing that shared appointment patients returning for a second group visit.
all the administrative tasks have been taken care of and all you One such satisfied patient is James Chamberlain of Drakut,
have to do is focus on the patients,” says Neuwirth, whose medical MA, who attends quarterly shared appointments to help manage
group, Harvard Vanguard, is known as a national leader in shared his diabetes. He also continues to have a private physical with his
visits. “Doctors love to talk, to teach, to listen — this allows the doc- doctor each year. “I really enjoy the group appointments and I learn
tor to do all the things he or she does best.” so many things I never thought of before,” he says. “You see how
Neuwirth estimates that shared appointments can save a prac- your numbers compare with others in the room and that really
titioner an hour or more each day because instead of repeating the makes you think about your health and how you can improve it.”
same instructions on how to take blood pressure or when to check
blood sugar to patients one by one, the doctor can educate several E-CONSULTS CONNECT DOCTORS AND PATIENTS
patients at the same time. Patients can also learn from each other, Another way to streamline communications between doctors and
he adds. “Say you’ve got angina, but the person next to you has patients is E-mail, but while patients love it, doctors have been less
had it much longer. He or she can really offer you some wisdom, than enthusiastic.
[and] tell you things you never even thought to ask.” (Just so you Take Judy Balacz of Mount Prospect, IL, who likes E-mailing
her doctor because “I feel like I’m taking up less of her time than I
would with a phone call for something that’s not urgent. I can send
an E-mail at my convenience and she can answer at hers.”
Cheryl Alkon of Natick, MA, also likes E-mailing her doctors,
but her obstetrician told her she prefers phone calls because “she
can’t always respond to an E-mail quickly and is afraid she will miss
something important.” Other doctors are also concerned about
protecting patient privacy, being swamped by patient E-mails or
insurance companies in some states not reimbursing them for E-
consults (CA is a notable exception; insurers are not allowed to
deny claims for E-consults if an in-office visit would have been
covered).
Michael Crocetti, M.D., a pediatrician at Johns Hopkins Chil-
dren’s Center in Baltimore, exchanges E-mails with his patients’
parents only at their request. When the number of parents E-mail-
ing him reached about 25 percent of his practice, he surveyed
them and found they “very much want to use E-mail to communi-
cate with their providers, think it would strengthen the relationship
and see it as a necessary next step in healthcare because it’s so
convenient for them.”
Crocetti says that while hospitals may set policies on E-mail
communication between doctors and patients, practitioners often
make their own personal decision whether to do so. “We have to
figure out how to embrace this because it’s what patients want,” he
says. “But we also have to figure out a way to get the [compensa-
tion] issue addressed in the health care reform law.”
Despite the promise and potential of healthcare reform, confu-
sion will undoubtedly reign for years to come as healthcare in-
novations are developed and adopted by doctors, patients – and
perhaps most important, insurers. “Right now, it’s largely regulatory
and financial barriers that keep us from making all kinds of in-
novations throughout the healthcare system,” says Schwamm. “If
know: all patients must sign a confidentiality agreement before doctors would be allowed to figure out the best way to take care
being allowed to participate in a shared appointment.) of patients while using resources efficiently, we would rise to that
Harvard Vanguard currently has 30 clinicians offering more challenge in a heartbeat.”
than 50 shared appointments in a dozen specialties. “I have a So the spirit of Marcus Welby is alive and well, but the TV heal-
waiting list of 20 doctors in the practice who want to do shared er’s real-life counterparts have to navigate a convoluted and com-
appointments and I get a couple calls every week from outside plex healthcare system while also trying out new technologies that
physician groups and medical centers that are interested in what will eventually allow them to spend more time practicing medicine
we do,” Neuwirth says. and less time on paperwork. HI
H EART I N S I G HT • N OVE M B E R 2010 19