The Doctor-Patient Relationship is getting “cloudy”

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The Doctor -Patient Relationship is getting “Cloudy”–

The influence of telemedicine, virtual networks and chronic care reimbursement

More and more patients are interested in alternative options to the office visit.  In August, a Deloitte study predicted that of the 600 million general practitioner appointments in the US and Canada in 2014, up to 75 million could be electronic visits.  Multiple studies predict dramatic growth in these types of visits.  More and more patient care is being provided over the phone. The physician office and even the hospitals are less and less becoming the “hub” of patient care.

E-visits have many advantages for patients…. they do not have to take time off from work and sit in a waiting room (with other patients that could be contagious).  There are advantages for the care giver.. these e-visits can be done  in the office, off site,  or even at home.  More and more family physicians are resorting to texting, Skype, teleconferencing and other forms of E-medicine.  As a general rule, patients are responding positively.

This trend is not at all unique to medicine.  We have seen this phenomenon in multiple industries.  For example, with the advent of ATMs at virtually every corner, how many of you have been inside a bank within the past few years?  I remember as a child going into the bank every week with my mom and depositing my collection of spare change into my savings account.  I knew my banker’s name and he knew mine.  He even knew my birthday.   Did the banker-client relationship change over the years?  Absolutely, but the customers are happy, services are better, bank transactions are more convenient (24/7), and this trend will only increase.

Put simply, e-visits are evolving as an industry-wide efficiency trend that in my opinion can only become more commonplace.  It is completely compatible with the social media craze and very acceptable to more and more patients.

No doubt, there are many patients that absolutely require an office visit. Complicated medical conditions requiring evaluation of subtle changes in physical exam cannot be managed over the phone with today’s technology (Key concept…. today’s technology, as that may change.).   What about the importance of hand-holding and just basic human interactions? Especially during times of the acute stress of illness.  Do you want to tell a patient they have cancer over the phone?  Of course not.  The personal, human doctor-patient relationship will always be important in medicine.

But this importance is being challenged.   I was taught in medical school that a proper history and thorough physical exam should determine the diagnosis 75% of the time.  It was the bread and butter of the profession.  Could e-visits erode that fundamental value of the doctor-patient interaction?

Technology is making the issue even more interesting.. for example, the effects of remote auscultation devices for the heart and lungs… even listening to the heart and lungs can be done remotely with a high degree of accuracy.  And could some aspects  of the physician exam be delegated to another health professional while the physician watches remotely on the screen.  Put simply, the classic role of the physician conducting the physical exam can be at least to some degree replaced, and replaced accurately by technology.

Telemedicine certainly offers many benefits in terms of immediate access to medical care, especially in areas of physician shortage.  Electronic ICU monitoring is now commonplace.   Stroke care and psychiatric care are just a two other examples.    Telemedicine  will vastly change physician demographics and the ability to receive timely care.  Right now, the biggest impairments to continued rapid growth are state regulatory/ licensing issues and reimbursement methodologies.  I expect both of those to rapidly adapt as consumers continue to demand this service.

Breaking News… CMS Chronic Care Management Program…..

The process will be jump-started this year through CMS.  Starting this year, Medicare is creating a reimbursement for Chronic Care management whereby the PCP can receive approximately $40 per month delivering care to patients with two or more chronic diseases via non face to face visits.  There are some issues that participating physicians will have to face such as appropriate information systems, 24/7 coverage, patient 20% copays, etc., but this is just one other way that medical care is transitioning out of the office.  I foresee similar creative ways of financing out of office encounters.

Bottom line, the center of patient care is becoming less and less the office…or any other physical place.  The actual site of the patient encounter may become cyberspace.

I believe strongly in the concept of a Patient Centered Medical Home.  What I did not anticipate, is that this Home may actually be in the Cloud!!

One response to “The Doctor-Patient Relationship is getting “cloudy””

  1. Dr. Berkowitz:
    I appreciate your article on the changing Doctor-Patient Relationship. I, too, see this change coming. As a nurse I do worry that incidental findings that are found through the exam may be more difficult especially for our geriatric patients who are not able to attach monitors correctly or to answer the questions correctly (if there is not a trained person helping with the placement). Many times that patient will say what they think you want to hear. Sometimes just going through the exam while talking to the patient relaxes them enough to respond appropriately to the question being asked. If they are forgetful and don’t mention pertinent information, the examination may signal to the physician that there is a problem through the response (pain or reflex) during palpation.
    The younger patients are more knowledgeable and able to give good information. It is exciting to see how medicine will change over the next 10 years.
    Thank you for informing us of the changing role. You brought out a couple of things that I had not thought about, such as the reimbursement issue and the licensing issues.

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