Telemedicine is one way to address specialty care needs of safety net populations, says Dr. Kim Dunn, a Texas physician who has practiced telemedicine since the ‘90s. Then, as now, she notes, compensation for telemedicine is an issue. “The problem is that nobody pays for it. It’s starting to be paid for, but this trend is not very widespread.”
Dr. Dunn is director of the HealthQuilt initiative, a pilot health information exchange, and founder and CEO of the Your Doctor Program L.P. HealthQuilt launched its telemedicine feature with depression management — the number one behavioral health problem identified in the safety net community. “The Your Doctor Program, L.P. took the national guidelines for depression and put them into a base protocol in HealthQuilt's Quality Health Record (QHR).
Academics-based telespecialists provide the base protocols for the project's teleconsults, explains Dr. Dunn. "The medical doctors who will participate in the HealthQuilt pilot will look at the protocol and customize it to their practice, which takes about two minutes per protocol. That training, provided by the Your Doctor Program, L.P., overcomes the traditional provider barrier of, “I practice differently,” which often prevents physicians from participating in quality initiatives, she says, and also overcomes the reluctance of specialists who often have big concerns about telemedicine source locations.
“Let’s say I’ve seen a patient, and I’m diagnosing him with depression,” says Dr. Dunn. “There are about five medications I feel comfortable using for depression. Or let’s say the patient’s case is really complicated — they’re elderly or have major problems and I’m feeling out of my league. We have two ways to use telemedicine to access specialty care in this case. First, via the QHR, I can go to our telepsychiatrist’s cell phone. [As part of the pilot, that specialist] is contractually obligated to answer his cell phone and speak with me. I ask the psychiatrist to look at this patient because he’s already cued up to look at the QHR when he gets the cell phone call. We have a one- or two-minute conversation, and then he messages me with his recommendation. The whole “curbside consult” takes about four minutes. Since I as a medical home physician manage the care plan, we automatically follow up on the outcomes of care.
“Through this collaborative practice model we’ve been able to impact that patient’s care through that process, and the patient hasn’t had to have an additional appointment. There hasn’t been a delay in their treatment,” says Dr. Dunn.
But in some cases, the psychiatrist may say, 'I don’t really know what to do with the patient.' HealthQuilt’s second option is its embedded live interactive telemedicine inside the QHR via a $100 webcam that enables the team to do acceptable quality video so there can be specialist-to-patient interaction, Dr. Dunn explains. The project is now piloting payment to physicians for this service.
Live interactive consults can also be scheduled, she adds. “Often, you really just need to talk about the problem and get a few questions answered, and then you can schedule either a live interactive follow-up via telemedicine or an in-person exam."