Photo: Nicklaus Children's Hospital
Health care in Florida
Video diagnostics via telemedicine
Predictions call for the U.S. telemedicine market to grown more than 50% annually to $1.9 billion by 2018.
On a recent Friday morning, pediatric neurologist Dr. Roberto Tuchman enters an office cubicle at Nicklaus Children’s Hospital in Miami. There, behind frosted-glass partitions, he sits before a 32-inch video screen that displays a high-definition image of a young couple.
The two parents are speaking from a doctor’s office in Lima, Peru. They arranged a telemedicine consultation with Tuchman, whose specialty is treating development disorders, as a second opinion after physicians in Peru told them their 3-year-old son has autism.
For the next 30 minutes, Tuchman and the couple talk as if they’re sitting right across from each other. To the concerned father, Tuchman tries to explain autism and asks if he’s making any sense. The dad smiles and gives him a thumbs up.
Ultimately, Tuchman confirmed the autism diagnosis and spent the majority of their appointment providing basic information and answering the parents’ questions
The parents, who paid for the consult out of pocket — the hospital declined to specify the charge — scheduled a follow-up, in-person appointment for more testing at the hospital.
The video-conferencing system is part of a $3-million telemedicine command center that Nicklaus Children’s opened in 2013. The 289-bed hospital, located near Coral Gables, is the flagship of Miami Children’s Health System (MCHS), an independent, non-profit organization founded in 1950.
The center is a key component in MCHS’ strategy to find ways to reach new patients beyond south Florida — and keep the hospital financially viable and independent, says CEO Narendra Kini.
In the course of opening the telemedicine center, the hospital began training about 220 Miami-based pediatric specialists to conduct virtual exams for patients from as far away as Ecuador and Ukraine. Simultaneously, the hospital partnered with graduates of its pediatric residency program from around the world to connect with patients overseas.
MCHS charges a fee for each telemedicine consultation and bills patients or providers directly. Kini says that with help from telemedicine, families living outside the U.S. could account for 15% of MCHS’ patients by 2023, up from 5% today.
Overall, telemedicine remains a small part of the health care market, but providers, patients and even some payers are beginning to use it more often. Driving the trend are two main factors: The proliferation of mobile technology and consumer demand for faster, cheaper access to doctors.
Today, telemedicine services range from patient-doctor video consults like Tuchman’s to remote reading of X-rays and patient monitoring via robots and cameras.
Attorney Nate Lacktman, head of the telemedicine and virtual care practice at Foley & Lardner in Tampa, says providers and payers are embracing telemedicine, in part, to adjust to the changing reimbursement landscape as the industry moves away from the traditional fee-for-service model to value- based payments. Telemedicine, for example, can improve efficiency and lower costs by enabling patients who are sick or undergoing a routine checkup to skip the waiting room and receive Care from work or home — while also freeing up doctors to see patients who truly need in-person care.
Entrepreneurs and investors are taking note. So-called telemedicine companies have emerged to facilitate virtual doctor visits for patients with simple health problems. One such company, Sunrise-based MDLive, has raised about $74 million in funding since 2014.
MDLive contracts with Cigna and other insurers to offer employer-insured patients 24/7 access via PC or mobile device to doctors who can diagnose and treat non-emergency symptoms such as colds, rashes and headaches. MDLive charges both a monthly subscription fee, paid by the employer, and a per-use fee, which ranges from $40 to $50. Doctors earn $25 to $30 per consultation.
Justin Stone, MDLive’s general counsel, says the service draws doctors who want to either supplement their own practices and incomes or make a career out of telemedicine. “We remove administrative burdens, so it’s nice and refreshing for providers to just focus on treating patients,” he says.
For all the technological advancements, telemedicine faces a number of challenges. Insurers worry that patients, without the need to travel to a doctor’s office, may overuse telemedicine services. The electronic transmission of sensitive patient information carries the risk of privacy breaches. And not everyone feels comfortable discussing medical matters online.Problems with audio and video quality, if they arise, can make those conversations even more uncomfortable.
Kini says the personal touch isn’t going away anytime soon. There will always be a need for hands-on care, he says. “But for general day-to-day complaints, we think this is a very useful adjunct to doctors.”
MCHS’ telemedicine strategy isn’t just focused overseas. The hospital has partnered with several insurers to offer virtual visits to some employer-insured patients via kiosks installed in their workplaces. For a small co-pay, patients can get a live video consult with a family nurse practitioner based at the Miami telemedicine command center.
MCHS also plans to roll out a mobile app that enables patients to talk to doctors or nurse practitioners through video-conferencing on their smart phones or tablets. MCHS will charge $50 to $60 per visit — about the same as a traditional doctor’s office co-pay — and bill patients. MCHS is working to add a diagnostic tool kit to the app so that patients can check their temperature, blood pressure and other vital signs at home and transmit the data to doctors in real time.
Orlando Health offsets low staffing levels with robots.
Orlando Health uses telemedicine robots at three community hospitals it owns in central Florida to look after critical-care patients overnight. The non-profit health system says the robots enable fast, cost-effective care and have saved lives.
One such scenario played out in 2011, when a man with what appeared to be cellulitis, a common bacterial skin infection, lay in the intensive care unit at South Lake Hospital in Clermont.
During a series of robotic checkups, the on-call doctor saw that the man’s skin infection was rapidly getting worse and arranged for him to be airlifted to Orlando Regional Medical Center. The patient had contracted a flesh-eating infection and required immediate surgery.
Dr. Jeffrey Sadowsky, director of critical-care telemedicine for Orlando Health, says the doctor’s ability to be in several places at once proved crucial in saving the man’s life. “In the old days, that patient would have sat in the ICU until someone checked in on him hours later,” Sadowsky says.
Mayo Clinic Florida is using telemedicine robots to diagnose and treat stroke patients from a distance.
Six years ago, Mayo Clinic Florida implemented a robotic telemedicine program that connected Mayo’s stroke experts in Jacksonville with Parrish Medical Center in Titusville, some 140 miles away. When a patient suffering an acute stroke arrives at the Parrish center, a robot, called the RP-VITA, is deployed. Neurologists at Mayo’s Jacksonville campus connect to the robot via computer or mobile device, use its videoconferencing technology to assess the patient’s condition and consult with an on-site medical team to determine the best course of treatment.
Dr. Khalid Siddiqui, medical director of the emergency department at Parrish Medical Center, says the program has helped offset a shortage of stroke specialists in Brevard County. Given the time sensitivity of stroke care, he says, having 24/7 access to specialists in Jacksonville “really is a blessing to a community like this.
Mayo has since expanded its “telestroke” network to Baptist Hospital in Pensacola, Gulf Breeze Hospital in Santa Rosa County and Satilla Regional Medical Center in Waycross, Ga.
Mayo is now testing mobile telestroke units in ambulances to deliver faster stroke care. Mayo’s neurologists can use video conferencing to examine patients with stroke symptoms in an ambulance and then alert the hospital, if necessary, that a stroke patient is on the way.
“We’re documenting a savings of 7½ minutes of assessment time,” says Dr. Sarvam TerKonda, Mayo’s medical director for connected care in Florida. “Those 7½ minutes will save millions of brain cells. Seconds matter in this situation.”
Insurance coverage for telemedicine varies by state.Experts say one of the biggest barriers to widespread telemedicine adoption is a lack of insurance coverage.
About 40% of health care providers nationwide say they receive no reimbursement for telemedicine services, according to a 2014 survey by the Foley & Lardner law firm.Another 20% say they’re reimbursed for telemedicine at lower rates than face-toface examinations.
In the past few years, the Florida Legislature has rejected bills that would require insurers to cover virtual physician visits. The main sticking points are whether out-of-state doctors should be allowed to treat Florida patients via telemedicine and whether insurers should have to pay their usual rates for virtual visits.
Florida is one of 21 states that do not require insurers to cover telemedicine to the same extent as in-person visits.
Meanwhile, Medicare only reimburses for telemedicine for patients in rural areas.
“The market is showing that until a state passes a law, there’s no meaningful coverage” of telemedicine by private insurers, says Nate Lacktman, head of Foley & Lardner’s telemedicine and virtual care practice and a partner at the firm.
When medical care is more accessible and convenient to patients, he says, the need for later, more expensive care declines. But by creating new touch points, he adds, telemedicine enables patients to see doctors more often — and insurers “may fear that it could drive up claims volume in a manner they can’t predict, cutting into their profit margins,” he says.
Target: Minor Ailments
Nemours’ app aims to avoid unnecessary E.R. visits.
Nemours Children’s Health System in Orlando has developed an app called Nemours CareConnect, offering around-the- clock telemedicine consultations via a network of 30 board-certified pediatricians.
The app, launched last fall, enables parents of a sick child anywhere in Florida to video chat with a pediatrician for $49.
Dr. Shayan Vyas, medical director for Nemours telehealth in Florida, says it’s faster and cheaper than taking a sick child to the E.R. for routine issues such as colds and rashes. If an e-prescription is necessary, geo-location services built into a parent’s mobile device can identify the closest pharmacy.
For now, Nemours CareConnect appears ideally suited for treating minor ailments during nights and weekends, but Nemours also sees potential to expand virtual visits to pediatric specialty care, Vyas says.
Target: Patient Inconvenience
Oncologist Daniel Landau makes cancer care a ‘little easier.’
Last year, Dr. Daniel Landau, a hematologist/oncologist at UF Health Cancer Center-Orlando Health, began replacing in-person consultations with video chats for some patients as part of a pilot program he helped launch. He says he was responding to a common complaint from patients that they had to travel long distances and miss work for routine office checkups. “This was meant to make the patient’s life a little easier,” he says.
Landau’s office installed video-conferencing software to enable virtual visits via PC or mobile device and tested the service on about 30 patients. The response was “universally favorable,” he says.
The virtual visits are available only to established cancer patients and are used to review lab results or discuss the symptoms and side effects of treatment — “things we felt we could do remotely,” he says.
Patients pay $60 per virtual visit. Landau now offers the option to several patients a week. He estimates that he can see two to three patients remotely in the time that it would take to see them in person.
Telemedicine may be a health care buzzword these days, but the idea of examining, diagnosing and treating patients remotely has been around for decades. In the late 1960s, doctors at the University of Miami teamed up with the city’s fire department to send cardiac rhythms over voice radio channels to Jackson Memorial Hospital during emergencies.
More than a third of large U.S. employers now offer some sort of telemedicine service, and another 12% plan to do so by 2017, according to a Towers Watson survey. Experts say employers are looking to help their workers offset higher insurance co-pays and deductibles and avoid long waits for office appointments. “It’s a nice way to cut down on absenteeism and help people get the care they need,” says Rob Pariseau, employee benefits practice leader and executive vice president at Lykes Insurance in Tampa.
Founded in 1950, Miami Children’s Hospital
changed its name to Nicklaus Children’s Hospital last year after a $60-million gift from the Nicklaus Children’s Health Care Foundation, created by golfer Jack Nicklaus and his wife, Barbara. The hospital is expanding its main campus by 212,000 square feet and recently updated its emergency department. It also has nine outpatient facilities in south Florida.
Kiosks and Carts
Last year, Miami Children’s Health System partnered with UnitedHealthcare to offer some of its employer-insured patients quicker access to sick-visit consults via kiosks in workplaces.MCHS now has the kiosks at Seminole Hard Rock hotels and casinos in Tampa and Hollywood, as well as Crowley Maritime in Jacksonville and the Palm Beach County school district.
The walk-in kiosks measure 8 feet by 7 feet and are equipped with videoconferencing equipment for virtual communication between patients and caregivers. Digital medical devices such as stethoscopes and blood pressure cuffs stream diagnostic information to caregivers in real time.
Meanwhile, MCHS also has set up telemedicine carts at partner facilities in Ecuador, the Cayman Islands and Ukraine, among other places. Providers can bring the carts into a patient’s room to connect via video to an MCHS specialist in Miami.