Richard S. Bakalar, MD, who has two decades of experience in telemedicine following a decade of clinical practice, has witnessed an evolution in the field that has moved distance medicine from being deployed almost exclusively to address exceptions to care to being employed to reach a much broader audience.

Denver-based Bakalar, a managing director for KPMG, spent 25 years in nuclear medicine and internal medicine practice in the U.S. Navy. “I was asked by the Navy Surgeon General to set up a Navy telemedicine program,” he recalled, adding the goal was to provide continuity of care across 30 ships, 23 clinics and hospitals and four medical centers around the world … including the South Pole.

“We had underserved populations on ships without access to specialty care,” he explained. With the telemedicine initiative, he continued, “They got the same kind of care as if they were in a major U.S. medical center.”

The Navy’s use of the program mirrored what most telemedicine programs looked like 20 years ago, but Bakalar said the field is expanding beyond its traditional uses. “Today, telemedicine initiatives are around not only access to care but also quality of care and reducing costs,” he said. Telemedicine allows smaller facilities and those in rural areas to maintain the quality typically found in major academic medical centers. With shortages in a number of specialties, Bakalar pointed out, telemedicine offers a unique solution to allow more patients access to specialty care.

Cost and reimbursement were initially a concern for payers. However, Bakalar said time has allayed those fears. “The concern for the payers was this would become something that would be overused and abused and wouldn’t be affordable,” he said. “The evidence hasn’t borne that out.”

In fact, it has shown the opposite. For example, Bakalar said, a family with a child who becomes sick with an infection could utilize a virtual visit for a cost to the system of about $50, to a clinic for a cost in excess of $100, or to an Emergency Department for a bill typically in the neighborhood of $1000.

Now, he continued, “Utilization is being driven by payers who are seeing the savings that can be accrued by these alternative models of care.”

The difference in ‘telemedicine’ and ‘telehealth’ Bakalar explained is initiation by the consumer. Where telemedicine is a provider-to-provider interaction, telehealth is driven by consumers, who go online to see a virtual doctor licensed in their state. “That’s a newer, more modern approach of using technology to give patients the control and the ability to engage with their health providers in a way that’s more timely and convenient,” he noted.

Obviously, Bakalar continued, remote care doesn’t work in every instance. “If you have chest pains, you are still going to go to the ER,” he said. Bakalar added virtual visits are a great option, however, for complaints that are relatively minor or chronic in nature that could be addressed without emergency intervention.

Despite the promises of the technology, there are still issues to be addressed. “One of the challenges with telehealth or telemedicine is to keep the network of providers connected,” Bakalar said. The technology is there. “The cloud has made mobile health very effective,” he noted. However, the biggest hurdles are issues with governance, regulation, reimbursement and licensing … which are more programmatic in nature … that need to be resolved before telehealth reaches its full potential.

Increasingly, the reimbursement piece is being addressed as states adopt parity laws that mandate reimbursement for telemedicine and telehealth. The technology also plays into the Affordable Care Act’s emphasis on prevention and can help ACOs more easily address health promotion. Additionally, it has the opportunity to engage patients in a way that healthcare hasn’t before.

“People are having choices they didn’t have before,” Bakalar said of the bottom line. “As we get into quality-based or value-based purchasing, we believe telehealth will become more prevalent and more widely accepted and more widely desired,” he concluded.

The Virtuous Cycle

Everyone’s heard of a vicious cycle … why not a virtuous one?

As individuals become more conscious of their health, they engage in healthy habits and activities more frequently … the more they engage in activities to get healthier, the more they change their behaviors and become more conscious of their health.

Richard Bakalar, MD, said telehealth applications have the ability to expand beyond care provision to increase this type of health promotion. “Where we really want to start impacting people is before they become sick so we can reduce consumption of health resources,” he said.

Telehealth – which encompasses all the mobile health application devices plus personal computers – has a range of decision support tools and data to help individuals make more informed choices. “Both tools and information allow people to become more engaged and more proactive in changing behaviors,” Bakalar noted.

RELATED LINKS:

American Telemedicine Association