skyblu Posted February 19, 2014 Share Posted February 19, 2014 And how the hell do they examine the patient? Have the kid shove an otoscope into their own ear and transmit to the camera? Pupil reaction? Peritoneal signs? Shifting dullness to abdominal percussion? Stinky BV? It seems you only get to use one or two senses rather than all five. Better as a House episode than real life medicine. Although I'd love to make money while in my robe and slippers! Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 19, 2014 Author Share Posted February 19, 2014 Paula may be willing to share a cigar ;-). Link to comment Share on other sites More sharing options...
Guest Paula Posted February 19, 2014 Share Posted February 19, 2014 The size of that one will serve many. I'm talking about the cigar. Not the script for the ED. Link to comment Share on other sites More sharing options...
jdumoch Posted February 23, 2014 Share Posted February 23, 2014 the DEA has also been very clear on their policy that if any of these patients get controlled substance without the physician/PA laying their hands directly on that patient-- your license will be revoked and you can be prosecuted. Link to comment Share on other sites More sharing options...
Guest Paula Posted February 23, 2014 Share Posted February 23, 2014 ^^^^^^ Is this true in every state? If so and I assume it would apply nationwide, would you report a physician who practiced medicine from his home with relatives and patients and it is without seeing them? A bit off topic. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 23, 2014 Author Share Posted February 23, 2014 ^^^ I didn't know that they did it any other way (the hypothetical physician), and it typically isn't the family member but instead the former patient who is now the live-in love interest. Link to comment Share on other sites More sharing options...
jdumoch Posted February 23, 2014 Share Posted February 23, 2014 yes it is a federal law so it is like that everywhere. typically if you rx for a family member they give you a slap on the wrist and maybe a fine from the state medical board... however.. controlled substances must be written under very specific circumstances with a well document physician (PA)/Patient relationship and not outside the course of usual practice. google "DEA Diversion" and have some fun reading about all the docs who have actually been arrested for writing controlled substances repeatedly for family/friends. the DEA hasn't been too big on this stuff but in the past year or two have made dozens of arrests for just this type of thing. Link to comment Share on other sites More sharing options...
PACdan Posted February 23, 2014 Share Posted February 23, 2014 Dr. Phil (yeah, the TV one) and his son started a "Doctor on Demand" app for iPads/smart phones. It's normally $40 per 15 min. to speak with an MD. Until Feb. 28 it's free (they're trying to advertise the service). At 13 minutes, a little pop-up comes on screen to continue for another $40/15min... How terrible, didn't naughty (1-900) phones lines used to work this way? ;)They site FAQ says no scripts will be written for narcotics/pain meds via the service listed as schedule I-IIISent from the Satellite of Love using Tapatalk Link to comment Share on other sites More sharing options...
whoRyou Posted February 24, 2014 Share Posted February 24, 2014 Dr. Phil (yeah, the TV one) and his son started a "Doctor on Demand" app for iPads/smart phones. It's normally $40 per 15 min. to speak with an MD. Until Feb. 28 it's free (they're trying to advertise the service). At 13 minutes, a little pop-up comes on screen to continue for another $40/15min... How terrible, didn't naughty (1-900) phones lines used to work this way? ;) They site FAQ says no scripts will be written for narcotics/pain meds via the service listed as schedule I-III Sent from the Satellite of Love using Tapatalk OK this is getting scarier by the fourteen minutes I have left. Hurry and look what I found online http://www.businessinsider.com/doctors-on-demand-medical-app-2013-12?op=1 otherwise your time might be up and I might charged another $40, so hurry everyone time is ticking. FYI here is a picture of "DR" Mcgraw in case you don't recognize him online. You know all those celebs err doctors look all the same. For $40, you can spend 15 minutes chatting with a psych ian who can diagnose your issue, prescribe you simple medication, advise your next actions, or simply ease your fears. Link to comment Share on other sites More sharing options...
Emerson Posted February 24, 2014 Share Posted February 24, 2014 I am curious how many of you actually have experience telemed or even have a baseline knowledge about the space. This is a new and evolving sector of medicine so I ask that you evaluate the future rather than criticize its entry into the market. I am actually involved in this space I can tell you that it provides a much needed service that would otherwise congest emergency departments and other facilities. For example: * family traveling to Hawaii and has no established care. teenager with long-standing hx of asthma didn't pack his inhaler * accidental 1st degree burn and the patient needs to know if they should go to the ER * patient who skipped their baseline insulin dose and is unsure if they should wait for tomorrow and take it now * simple gastroenteritis with education on when to seek further treatment * a farmer who is 60 miles from any medical care suffered a laceration and needs to know if it requires repair We are entering an era where people can't see their physician, fear the worst and sometimes need peace of mind along with some education on when to seek further treatment. For the price of $40 it is well worth the access. I was at HIMSS in New Orleans last year and I can tell you the mobile device technology for the medical home is amazing. Link to comment Share on other sites More sharing options...
Guest Paula Posted February 24, 2014 Share Posted February 24, 2014 Technology is amazing. We can get EKGs with smart phone placed on the chest. No electrodes needed, etc. Nurse phone lines used to be able to answer some of the questions patients had and when to go to ER or seek treatment. Those have gone by the wayside. Dang, you rained on our parade and gave us slaps with a wet noodle. I guess we cannot have any levity here at all. Link to comment Share on other sites More sharing options...
PACdan Posted February 24, 2014 Share Posted February 24, 2014 I am curious how many of you actually have experience telemed or even have a baseline knowledge about the space. This is a new and evolving sector of medicine so I ask that you evaluate the future rather than criticize its entry into the market. I am actually involved in this space I can tell you that it provides a much needed service that would otherwise congest emergency departments and other facilities. For example: * family traveling to Hawaii and has no established care. teenager with long-standing hx of asthma didn't pack his inhaler * accidental 1st degree burn and the patient needs to know if they should go to the ER * patient who skipped their baseline insulin dose and is unsure if they should wait for tomorrow and take it now * simple gastroenteritis with education on when to seek further treatment * a farmer who is 60 miles from any medical care suffered a laceration and needs to know if it requires repair We are entering an era where people can't see their physician, fear the worst and sometimes need peace of mind along with some education on when to seek further treatment. For the price of $40 it is well worth the access. I was at HIMSS in New Orleans last year and I can tell you the mobile device technology for the medical home is amazing. I will not stand in the way of technological progress. The future is happening everyday, and we must adapt it. But I don't see the pure altruism and helpfulness, I see dollar signs in the eyes of the companies offering this service with a detached sense of care. I see a lot of room for error and a potential health cost. I would love to be a fly on the wall when a pt. wants to get off the transaction before another 15 minutes rolls over... Stating that it's a "bargain for $40" fails to realize how many calls might exceed 15, 30, or 45 minutes before a pt. is safety diagnosed or satisfied. Sent from the Satellite of Love using Tapatalk Link to comment Share on other sites More sharing options...
Emerson Posted February 25, 2014 Share Posted February 25, 2014 I will not stand in the way of technological progress. The future is happening everyday, and we must adapt it. But I don't see the pure altruism and helpfulness, I see dollar signs in the eyes of the companies offering this service with a detached sense of care. I see a lot of room for error and a potential health cost. I would love to be a fly on the wall when a pt. wants to get off the transaction before another 15 minutes rolls over... Stating that it's a "bargain for $40" fails to realize how many calls might exceed 15, 30, or 45 minutes before a pt. is safety diagnosed or satisfied. Sent from the Satellite of Love using Tapatalk You either have extensive experience or just intuitively understand the business model behind telemedicine and what it delivers to patients. With that, can you please supply me with the evidence that demonstrates dissatisfaction amongst patients utilizing this service? Any analytics that you have to support your claim that the industry is 'minute gouging' patients would also be appreciated. Many companies have adopted telemed as part of their wellness programs and offer it to their employees for free. With that, you get decreased premiums as a result of low utilization and another channel for its members to gain access to a healthcare professional. While you are focused on the single payor, let me broaden your perspective to a population level. Researchers at the University of Mass found that the length of stay in the ICU for telemedicine patients was 20% lower than their control group (you do the ICU math - ok it's roughly $10,000 per patient). Overall, these patients spend about a day less in the hospital for a seven day stay and 3.6 days less for a two week stay. This research was released in CHEST Journal which included 56 ICU's in 32 hospitals and more than 110,00 patients. 110,00 x 10,000 = some pretty good savings on an already burdened system. And I thought $40 was a bargain.... What you also don't understand is that the future of medicine is about penalties and reimbursement. Those two variables will ultimately be determined by how well hospitals and providers coordinate patient care - wonder why ACO's are growing by a rate of 40%? Telemed will allow ACO's to better manage their patients while reducing hospital readmissions and decrease unnecessary visits to the emergency department. Last week I had a patient dial 911 stating her throat was closing from an allergic reaction. Turns out, she saw a posted internet wait time of 3 hours and simply wanted to bypass triage for her viral pharyngitis. ED + 911 bill and you get to pick up tab. 43 states now provide some form of Medicaid reimbursement for tele health services which could assist in detouring this type of abuse. 19 states allow reimbursement from private insurance and that number will grow. By the way, Doctor on Demand is free for the week. Link to comment Share on other sites More sharing options...
PACdan Posted February 25, 2014 Share Posted February 25, 2014 You either have extensive experience or just intuitively understand the business model behind telemedicine and what it delivers to patients. With that, can you please supply me with the evidence that demonstrates dissatisfaction amongst patients utilizing this service? Any analytics that you have to support your claim that the industry is 'minute gouging' patients would also be appreciated. Many companies have adopted telemed as part of their wellness programs and offer it to their employees for free. With that, you get decreased premiums as a result of low utilization and another channel for its members to gain access to a healthcare professional. While you are focused on the single payor, let me broaden your perspective to a population level. Oh no, I am by no means an expert in anything. I do have a little experience with many different things, and in this case I am more than apprehensive about the future of "iPhone medicine". But let us first draw a distinction. I think you're casting the telemedicine net a little too wide. Telemedicine as a remote means of physician consult, in-clinic or inpatient examination, or robotic assist is a MUCH different animal than the Apple store or Google Play market "telemedicine" apps for home consumers. Much of the telemedicine in literature is from the former, and not the emerging app market. Researchers at the University of Mass found that the length of stay in the ICU for telemedicine patients was 20% lower than their control group (you do the ICU math - ok it's roughly $10,000 per patient). Overall, these patients spend about a day less in the hospital for a seven day stay and 3.6 days less for a two week stay. This research was released in CHEST Journal which included 56 ICU's in 32 hospitals and more than 110,00 patients. 110,00 x 10,000 = some pretty good savings on an already burdened system. And I thought $40 was a bargain.... I think you need to differentiate between the hospital-based telemedicine and app/home based when drawing your conclusions. The ICU patients you referenced aren't using "Doctor on Demand". They're using intricate hospital to provider/hospital systems, with an inpatient on telemetry, vitals monitoring, etc. So this is not a valid comparison or efficacious evidence of the benefits of the type of "iPhone" telemedicine we're discussing here. The study: http://journal.publications.chestnet.org/article.aspx?articleid=1788059 What you also don't understand is that the future of medicine is about penalties and reimbursement. Those two variables will ultimately be determined by how well hospitals and providers coordinate patient care - wonder why ACO's are growing by a rate of 40%? Telemed will allow ACO's to better manage their patients while reducing hospital readmissions and decrease unnecessary visits to the emergency department. Last week I had a patient dial 911 stating her throat was closing from an allergic reaction. Turns out, she saw a posted internet wait time of 3 hours and simply wanted to bypass triage for her viral pharyngitis. ED + 911 bill and you get to pick up tab. 43 states now provide some form of Medicaid reimbursement for tele health services which could assist in detouring this type of abuse. 19 states allow reimbursement from private insurance and that number will grow. I live in a community where all emergency medical/rescue services are provided free of charge by volunteers; 24/7 - 365. All care, pick-up and transport to the ER are free, for every patient, every time. I help provide it, so yes I do "pick up that tab". :) The "iPhone" telemedicine may dissuade some "abuse" of emergency or urgent care, but at what costs to truly ill patients? Here the effect precedes the cause, the existence of the service helps to create and define its need in the market. More ERs, UCs, more docs or PAs, and the return of "small" medicine or the GP could fill this role over telemedicine phone apps and preclude their need. But the driving force behind this are large business interests, which in the for-profit world always comes down to money. Many other countries train their practitioners for much less, and are able to provide much cheaper, yet high quality care. We, as good and industrious people have made medicine a business akin to arms manufacturing. You have to step outside this simulacrum and examine the impact that these apps may have and on what populations, from a broader perspective. I'm very interested to see who the primary utilizers of these services turn out to be, what their socio-economic breakdown is, and how this type of "healthcare" access impacts them in the long term. These phone apps take credit cards, and many (not all) don't take insurance (ex: Doctors on Demand does not accept any insurance). I have no issue with these apps for use in the "forgotten inhaler" scenario, it's more along the lines of urgent care or unknown illness that makes me very wary. What I firmly believe, and you may debate me on it all you wish, is that you "need to touch the patient". This is how I will practice medicine for my career. Too many providers are losing or never learning the art of the physical exam, and I don't surmise that "iPhone" medicine will help this problem. Lisa Sanders describes this disconcerting trend quite well in her book, Every Patient Tells a Story. There is so much one can miss when so many of the senses are dulled or completely absent in a "Doctor" app visit. Most of all the ability to simply touch the pt. As someone who suffered through a decade long cancer misdiagnosis, I feel very strongly that this is an area that requires the utmost respect and care. The art of the patient history and examination is changing, but is it changing for the betterment of the patient's health or for convenience/profit? Thank you. Link to comment Share on other sites More sharing options...
whoRyou Posted February 25, 2014 Share Posted February 25, 2014 Predicting the future isn't an easy task. However, several technologies in their infancy holds tremendous potential to radically change the face of medicine over the next 10 years. Good or bad, time will only tell. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 25, 2014 Author Share Posted February 25, 2014 The "business model" is also built to include the financial costs of liability claims on the business, but not the associated toll, both psychologically and financially on the provider, since they are in fact disposable to the business. Link to comment Share on other sites More sharing options...
skyblu Posted February 28, 2014 Share Posted February 28, 2014 Emerson, what happens when the asthmatic traveling to Hawaii has a PE and not an asthma exacerbation? How do you know their vitals, or what their lungs sound like? The other scenarios describe less of a medical encounter and more of a "should I go get medical care in this scenario", which is similar to what nurses do when you call a pediatrician after hours. The default response is "go to the ER", because nobody wants to put their ass on the line to make a judgment call since they're not laying hands on the patient. I don't have a problem with technological advancement, and I could see hugely beneficial applications in telemedicine in global healthcare. But within the US? Less so. Link to comment Share on other sites More sharing options...
Emerson Posted March 2, 2014 Share Posted March 2, 2014 Emerson, what happens when the asthmatic traveling to Hawaii has a PE and not an asthma exacerbation? How do you know their vitals, or what their lungs sound like? The other scenarios describe less of a medical encounter and more of a "should I go get medical care in this scenario", which is similar to what nurses do when you call a pediatrician after hours. The default response is "go to the ER", because nobody wants to put their ass on the line to make a judgment call since they're not laying hands on the patient. I don't have a problem with technological advancement, and I could see hugely beneficial applications in telemedicine in global healthcare. But within the US? Less so. Your suggesting my example of a kid who forgot his inhaler is at risk for a PE in what way? A 55 y/o with PMH of CA with Rx of Estrogen would be referred for further evaluation. Look at India, who has been delivering telemedicine for quite sometime at one-fifteenth the cost of traditional health care. The technology at HIMSS last year in New Orleans is going to connect the medical home with the telemed space which includes vitals, high res imaging, etc. I suspect you support the current model with insurance companies? Have a patient call an RN and discuss over the telephone whether they should seek further medical treatment? Link to comment Share on other sites More sharing options...
skyblu Posted March 2, 2014 Share Posted March 2, 2014 Your suggesting my example of a kid who forgot his inhaler is at risk for a PE in what way? Undiagnosed hypercoagulable state or cancer, long flight to Hawaii, whatever it may be. Absence of risk factors does not equal absence of pathology. Sure, not likely. But what if you listened to his lungs and didn't hear wheezing? What if he was tachycardic/hypoxic? What if he had a positive Homan's sign? What if it wasn't a PE, but a pneumothorax? I just saw a 16 year old in my urgent care present exactly with what she thought was a mild asthma attack, and have really screwed up vitals and lung sounds, and on CXR she had a PTX. No risk factors (female, non-Marfanoid, etc), but it does happen. Again, it's more of a zebra in this situation. But in the litigious climate of this country, I would feel very uncomfortable diagnosing without a physical exam. I see the usefulness in other parts of the world, where access is a huge issue. But your kid in Hawaii can go to a local Urgent Care, minute clinic, or ER. Some people have to drive a long way for it, but in the US, it's not like anybody ever has to save money for 6 months and then ride a burro for 2 days to get some in=person medical care. Link to comment Share on other sites More sharing options...
Emerson Posted March 3, 2014 Share Posted March 3, 2014 Undiagnosed hypercoagulable state or cancer, long flight to Hawaii, whatever it may be. Absence of risk factors does not equal absence of pathology. Sure, not likely. But what if you listened to his lungs and didn't hear wheezing? What if he was tachycardic/hypoxic? What if he had a positive Homan's sign? What if it wasn't a PE, but a pneumothorax? I just saw a 16 year old in my urgent care present exactly with what she thought was a mild asthma attack, and have really screwed up vitals and lung sounds, and on CXR she had a PTX. No risk factors (female, non-Marfanoid, etc), but it does happen. Again, it's more of a zebra in this situation. But in the litigious climate of this country, I would feel very uncomfortable diagnosing without a physical exam. I see the usefulness in other parts of the world, where access is a huge issue. But your kid in Hawaii can go to a local Urgent Care, minute clinic, or ER. Some people have to drive a long way for it, but in the US, it's not like anybody ever has to save money for 6 months and then ride a burro for 2 days to get some in=person medical care. Telemedicine is appropriate care within the appropriate clinical context. Telemedicine is not meant to replace the role of the provider. This is a relatively new healthcare delivery model that will evolve. Just the other night, I had a 67 y/o patient complaining that Jimmy Fallon taking over the tonight show was "the worst thing ever. he's no Leno". Well, Leno was no Leno either when he took over for Carson. My mother has end-stage COPD and lacks the ability to ambulate 10 feet before gasping for air. While sharp as a tack, she lives alone and I am the only family member able to assist her. She is currently being treated for a Cellulitis and used telemedicine for a wound check to ensure it was getting better. The erythema had markedly decreased based on the skin marking and she had no systemic systems. She took her temperature, checked her pulse and her saturations were baseline. The inconvenience for her to fill her oxygen tanks, charge the battery on her chair, utilizer her walker to get to her van, drive, locate a handicap parking spot that is available, unload her chair, attend her appointment and do everything again in reverse is like riding a "burro". All this, to be told that her cellulitis is getting better, have a nice day and don't forget your copay. My point is that there are several socioeconomic factors that also come into play. Are you familiar with the telemedicine stations that are delivered to a patients home? This is not the Dr Phil app. This is a station obtains a full set of vitals (including HR/Lungs auscultation), HD Camera that enhances images by 12x and allows for file sharing amongst multiple providers, etc. I could also send you non-sponsored studies that demonstrate that these stations have done a better job than some of your colleagues. Given the future of healthcare where there are shortages in providers and people today present to the ED because they couldn't see their PCP, this simply provides an additional channel of care. Your litigious claim is unfounded and is just fear based justification to support your argument. I challenge you to provide me with evidence that telemedicine has a higher rate of malpractice than any other sector of medicine. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted March 3, 2014 Author Share Posted March 3, 2014 http://medicaleconomics.modernmedicine.com/medical-economics/news/telemedicines-next-big-leap Doesn't prove, or disprove your claim regarding liability but still an interesting read. Field is too new to have a definitive answer but I don't honestly expect the insurance carriers (malpractice) to say, "Hey, let's take a wait and see approach and take a pass on the ability to charge the provider even more than what we already are based on our suspicion that it might increase our risk." Don't get me wrong. I'd love to sit on my backside, on the beach, never have to dress up, and wear flip-flops and a Speedo...ok, drop the Speedo, while discussing your sore throat with you. If the legal profession would like to provide me some type of guarantee that it wouldn't increase my liability, I'd be all in. Again, referencing the House of God, the best type of patient is the one that you don't have to touch. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.