Video, online care replace in-person visits

July 27--From a desktop computer at Riverside Regional Medical Center in Newport News or from a laptop on the third floor of his home, Riverside psychiatrist Anthony Caterine can treat geriatric patients at nine far-flung locations.

He can treat patients in facilities in Gloucester, the Eastern Shore and Smithfield in the same day. The use of two-way video has given his rural and disabled patients unprecedented access to care and for the physician it has eliminated 10,000 miles of driving each year.

In the first five months of the year, he "saw" 440 patients remotely, according to Christy Helsel, director of "telehealth" programs for Riverside.

While he misses the physical touch and it's easier for patients to reject such treatment, Caterine has found it to have many positives. "Most patients do well with it, and many find it more comfortable," he said, after using the secure system since last April.

Telemedicine has been expanding its reach for more than a decade on the Peninsula with local health systems adding services as technological advances allow. The associated savings -- mostly in time for patients and physicians -- create additional incentive. Routinely, emergency departments use remote access to consult with specialists around the clock, and home-care services provide follow-up via phone and video for patients with chronic diseases.

"It's a great win for patients and for us," said Helsel. "If we can intervene quicker, we can keep costs down and people healthier."

With the launch this month of virtuwell.com by an out-of-state provider, telemedicine has taken another step in Virginia. Now, those living, working or traveling in the state can receive a diagnosis and prescription for 50 common ailments after a structured online interview, submitted on a computer or mobile device.

The Minneapolis-based company, part of an integrated health system that includes several hospitals, an insurance company and research foundation, employs 20 nurse practitioners in Minnesota and Iowa. Patients pay a $45 fee, fill out a questionnaire online, and receive a diagnosis, along with appropriate prescription -- mostly antibiotics and antifungals, no narcotics -- sent electronically to a local pharmacy, all within 30 minutes. It operates around the clock, seven days a week.

"A good medical interview and a good medical history can yield a good medical diagnosis. We've established a relationship through our process, asking the same questions as we would in a clinic, ruling out chronic conditions and multiple conditions," said virtuwell vice president Kevin Palattao, adding that to date the company has served 100,000 patients "safely and effectively."

Palattao estimated that about 50 percent of potential patients are redirected to in-person care in the course of the interview, which the company has refined over time to use everyday language understandable to the average consumer. The top four conditions treated, all associated with high diagnostic accuracy and effective treatment in primary care settings, are sinusitis, urinary tract infections, conjunctivitis and viral upper respiratory infections.

Virginia is the sixth and most recent state to open its doors to the 4-year-old company.

"We look for states with some experience with convenience, with nurse practitioners and physician assistants. We look at areas where we as an insurance company might have some insurance relationship with businesses interested for their employees," said Palattao, adding that in its home market, most insurers have elected to offer the service without a co-pay.

<p>Virginia requires that individual practitioners be licensed in the state and that nurse practitioners work in collaboration with a physician (25 states allow independent practice by a nurse practitioner). The latter requirement is met by virtuwell's physician advisory board, which has oversight and does chart reviews.

Regarding regulation and accountability, executive director of the Virginia Board of Medicine William Harp, M.D. advised in a written statement that, "The board licenses individual practitioners. Telemedicine is allowed to be practiced into Virginia consistent with the law. A practitioner must hold a current active Virginia license to do so. The same standard of care is expected from the telemedicine visit as if the visit were in-person. Practitioners are held accountable to the laws and regulations governing the practice of medicine in Virginia as are practitioners delivering care in-person in the commonwealth."

At Bon Secours, physicians who provide telemedicine services to stroke patients in its emergency department must be on staff at its medical centers and are regulated by medical staff bylaws, according to Lynne Zultanky, spokeswoman for Bon Secours Hampton Roads. The health system doesn't currently use telemedicine for other diagnostic purposes, but does use the telephone, and data sent via secure phone lines, for nurses to monitor established home health patients.

For veterans, the Hampton VA Medical Center uses telemedicine to provide access to specialists across the country and for those at other locations to be treated by specialists in Hampton. The Teleretinal Imaging program provides eye screening for diabetics, with the images read by an ophthalmologist in Salisbury, N.C.; the TeleDermatology program allows those seen at outpatient clinics to receive diagnosis by a Hampton specialist. The programs have treated 1,700 veterans between them since October, said telehealth coordinator Sharon Durio.

Riverside, an early adopter of both electronic health records and telemedicine, and consistently rated as among Hospitals and Health Networks' "Most Wired" systems in the nation, started with telepsychiatry and has expanded to multiple medical areas, including diagnostics for sleep apnea in pulmonary telemedicine. In the latter, a pulmonologist in Newport News is able to listen to the lungs of a patient in Riverside'sTappahannock hospital using a Bluetooth-enabled stethoscope.

"We'd like to take it on a larger scale for something as simple as a (urinary tract infection) or pink eye, and treat via a video encounter," said Helsel, a registered nurse. "It would save so much time for children missing school and parents getting to the office. We're looking at doing more virtual visits in their homes."

In a study published in Health Affairs two years into its operation, virtuwell claimed that each visit to its online clinic was an average of $88 cheaper than an office visit and saved patients an average of two and half hours.

The use of appropriate technology can help determine whether treatment is needed -- another cost-savings element, if it reduces hospitalizations and emergency room use -- and helps staff monitor more patients effectively, according to practitioners. In 2000, Sentara was the first health system in the nation to remotely monitor intensive care unit beds across multiple hospitals with its eICU system, which is credited with a 25 percent reduction in mortality, according to Sentara spokesman Dale T. Gauding.

Coverage and charges for telemedicine keep changing with the technology. In May, Cynthia B. Jones, director of the Virginia Department of Medical Assistance Services, which administers Medicaid for the state, issued an update to its telemedicine coverage after four years. It included expanding those allowed to provide services via telemedicine to physicians located outside Virginia, and an expansion of services for which telemedicine can be used, to include radiology. Prior covered services included evaluation and management, psychiatric care, echocardiography and obstetric ultrasound, and speech therapy.

While Mediciad-reimbursed physicians may be located out of state, they must be physically present in the continental United States, and coverage does not extend to out-of-state nurse practitioners. Neither Medicare fee-for-service plans nor Medicaid currently cover virtuwell.com visits.

However, both government insurance plans cover telemedicine provided by physicians to patients who live in health-provider shortage areas, according to Helsel, which applies to many of the patients receiving psychiatric treatment from Caterine.

"Virginia is considered progressive for telemedicine benefits because private insurance reimburses at the same rate as for face-to-face visits," Helsel added.

Salasky can be reached by phone at 757-247-4784.

Telemedicine

The Virginia Department of Medical Assistance Services, DMAS, which administers the state's Medicaid program, defines telemedicine as "the real-time or near real-time two-way transfer of medical data and information using an interactive audio/video connection for the purposes of medical diagnosis and treatment." The equipment must "be functionally equivalent to a face-to-face encounter for professional medical services" and meet HIPAA privacy requirements. DMAS has covered telemedicine on a limited, statewide basis since July 2003, as a cost-effective alternative that offers improved access. It does not include online-only care in the definition.

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