The Last Word – Issue 2, Winter 2017

The interest in and adoption of telemedicine is growing. Providers are interested, patients are interested, vendors are developing, and investors are watching and making their moves.  How is telemedicine being deployed? What decisions are providers making and what decisions would they like to see investors and entrepreneurs make?   I had the opportunity to speak with Dr. Matthew Koenig and Dr. Burke Holbrook, from The Queen’s Health System (Queen’s) in Honolulu, Hawaii to share their story with HIT*IQ.

Dr. Koenig and Burke, thank you for taking the time to share some of Queens telemedicine journey with me today. What are the top two goals of the Queen’s Telemedicine program?

Dr. Koenig:  We have many goals. The first is to provide better access to care for all of our patients, but especially those on the neighboring islands that lack easy access to specialty care.  Telemedicine is allowing us to care for those patients in ways that were just not possible before these technologies.

The second is to better leverage our existing staff resources and avoid redundancy to provide specialty care without having to stand up separate departments. Queens started as one hospital and is now formally The Queen’s Health System through our growth to seven locations on Oahu, Hawaii Island, and Molokai.

Dr. Holbrook:  We see telemedicine as the right way to move into the future and fulfill our mission.  With our unique need to provide care across islands spread so far apart, telemedicine has an important role in care delivery as well as ensuring provider and resource efficiency.


How did Queen’s decide which service lines to deploy?

Dr. Koenig:  We looked from several perspectives. First, we are fortune to have access to solid data so we didn’t have to guess. Kelley Withy, MD, PhD of the University of Hawaii has done much good research documenting specialties with the greatest shortages, so we know the gaps. That is the access perspective.

There is also a practical perspective to standing up telemedicine and that is to go where we have the greatest chance to succeed.  A tip I can share with others planning telemedicine programs is to go with early adopter providers that want to participate.  When a provider asks for help to start, they go to the top of the list.  We have found that if you start with the need and willing participants, the greater the chance of success.  We’ve had a few experiences over the years trying to lead with the idea or a technology and not the provider or patient and that almost always fails.


What surprises and challenges have you had with your telemedicine deployments?

Dr. Holbrook: In a good way, we’ve been surprised and fortunate to find so many providers that are excited and engaged and willing to collaborate to make the initiative work.  Many of our challenges are related to reimbursement.  I will note that we are fortunate to have a telehealth parity law. In 2014 Hawaii passed a bill that requires equivalent reimbursement for services provided through telehealth, so that makes us different form most states.


What about on the patient side of things? Anything unexpected?

Dr. Koenig:  Our telemedicine is driven by our commitment to quality and consumer demand, only sometimes consumers are surprised at the solution.  Patients in hard-to-access areas are increasingly demanding timely access to specialty care, and might not realize or expect at first that what they are asking for is telemedicine.   So much now is being done on our phones, it is just one more short step to receive care on a device. Of course, not all patients are ready for it, but that is changing.

Dr. Holbrook:  Even though adapting to telemedicine might be a major change for some patients, especially those new to emerging technologies, we are experiencing great appreciation and acceptance by the patients because it is starting to resolve some of the travel challenges faced by many on the neighboring islands.


What do they see as the major benefits of telemedicine use to the patients and healthcare organization?

Dr. Koenig: Telemedicine is no longer optional for many providers, to be strategic and meet market needs, they must adopt. The patients want it, more providers want it, the payers want it, and vendors and investors want it.  As care is increasingly delivered across state lines, other remote provider networks will step in to fill the void.

Another major market force is capitation.  In a capitated model, it makes sense to provide care in the least expensive manner possible while also still providing excellent care.  In short, with telemedicine, while there are acquisition and training costs, you don’t have the extra overhead of physical space.

Dr. Holbrook:  Another major benefit of telemedicine is with transitions of care.  We are already seeing improved communication and care and we expect to see more as the telemedicine program expands.

Here is a great example.  We are rolling out a new cardiology care model that requires cardiology patients to be seen within seven days of discharge. Following-up with a patient after a procedure can be difficult enough for any patient that lives far away from the facility, but what about if you live on a neighboring island?  That patient comes to Oahu for care, might be discharged in a few days and all they want to do (and all we want them to as well) is to go home to recuperate. But here is the challenge; a Cardiac Intensivist needs to follow-up with the patient within seven days of discharge.  In the past the patient would have had to decide if they wanted to stay close to the facility or if they wanted to go home and return to Oahu for their appointment within the next week.  Under our new model, qualified patients can choose to go home and complete the required 7 day follow-up via telemedicine in the comfort of their own home.

Dr. Koenig:  Here is another great benefit example – the post accurate care model.   When a patient is discharged to a skilled nursing facility (SNF), they need to be seen by a discharging provider in a timely manner and may need care between visits if an issue arises.  Like the cardiology example, what if the SNF is located on the other side of the island?  It is expensive, unsafe, and unrealistic to have these ill patients travel between facilities, so we are using telemedicine to bridge the gap.  As a result, the same care team can follow the patient, and the SNFs are more willing to accept medically fragile patients, reducing readmits and improving patient care.  And in a capitated environment, every possible cost savings is necessary.


Where do they see telemedicine going in the future?

Dr. Koenig:  Many think that the future of telemedicine will be the model of big companies with large provider networks that do nothing but telemedicine.  They do exist and there will be more, but I think that is not where the real growth will be:  the real growth will be when telemedicine becomes a seamless aspect of ordinary practice.

I already use telemedicine as a tool to see patients, but I would not want to sit at my desk all day and just do telemedicine consults. It is not that telemedicine is bad, it’s just that most physicians went into practice to be with patients, not just see them remotely.  If it’s done well, telemedicine will eventually be just like the phone where you don’t just see patients by phone, you use it to do some aspect of care delivery, but it is not the only aspect; it will just become part of what we do. So, I see a model where the delivery of medicine will become more fluid, some by email, some by phone, even some by text, and some by telemedicine.

Another important change will happen when telemedicine is incorporated into residency programs.  New physicians will simply learn to practice this way and it will not be identified as telemedicine; it will just be part of the program. Psychiatry has already begun to incorporate telemedicine into residency training and Neurology is on the horizon.


What limits the use of telemedicine? Will it be accepted by clinicians? Patients?

Dr. Koenig:  For organizations, the real limiting factor for telemedicine is related to provider adoption concerns and workflow followed by limited Medicare reimbursement.  As earlier noted, we are fortunate to have the telemedicine payment parity so that helps. However, just as it is across America, increasing numbers of patients are Medicare eligible, so if a provider is getting paid ½ as much to see patients, they are not going to do so. Telemedicine can help keep the overall cost down, but not if providers are not fairly reimbursed.

Dr. Holbrook:  There are technology issues slowing telemedicine growth. The problems are not so much with the technology itself, and a major one for us is limited broadband access.  There are many rural areas on the islands that have low access, so if we want to run a new program where we’ve validated the need and have provider support, we still might be stopped simply due to limited broadband.  The federal government does have some programs to expand broadband, but it is going slowly which in turn limits what we can do.

Dr. Koenig:  Here is a suggestion for providers that are planning new telemedicine programs. First, you must be clear about your target patient population.  What is the documented need and do they have broadband access? If not, maybe it would be better at first to secure a satellite clinic that can run it for you.   In our planning research, we saw cases where providers launched an ambitious program only to have it fail not so much for the technology, but for lack of patient access to broadband or smart phones.


HIT*IQ is read by many investors and entrepreneurs, so you can use this opportunity to send them advice.  As a target end user, what should vendors develop and what should investors drive?

Dr. Koenig:  Entrepreneurs and investors, start with the need, pay attention to how medicine is practiced and be aware of the technology, such as the EMR, that is already in place.  Think about your development and investments from provider and care quality perspectives. Even if we had 100% reimbursement and resolved bandwidth challenges, there will be provider pushback if the workflows are not considered.

How do they schedule?  How do they document? How do they do patient follow-up? How do they get paid and how will that change?  I’ve seen too much new technology that is stand-alone requiring additional and different workflows. That may not sound like a big deal but multiply that with all the actions and steps a practice much already do, and it quickly becomes a big deal.   I know what people will think when they read that.  It is not that all providers are unwilling to change, most expect and embrace it when it makes sense. But so many technologies are designed in a way that clearly shows that they never took the time to see how medicine is practiced and if the change is even possible.

Learning good patient care is based on learning the perfect way and doing it the same way every time so that you don’t miss things and make mistakes. Being methodical is baked in because when you don’t do that, you will miss things.  When new technology and modified workflows are just shoved in it is not just that one aspect, the change will impact other aspects of the encounter and this can lead to unexpected outcomes, including reduced patient safety. So, pushback it’s not just resistance to change, it is about patient care and safety.

Dr. Holbrook:  We do a lot of research and testing before we bring any new technologies onboard, so we expect the vendors and new products to have done their research and provide appropriate documentation.


Do you have any closing thoughts you would like to share?

Dr. Holbrook:  We each have a role to play, and it’s important for vendors and everyone involved to remember that.  Change cannot be done just for the sake of using some cool new technology.

Dr. Koenig:  Successful expansion of care and the addition of new technologies cannot be done alone.  The patients need to ask for telemedicine and accept it when it comes; the providers need to work through the issues, payers need to be on board and the vendors and investors need to bring truly useful and well-designed technologies to the market. If we can get all of these players and the government to improve reimbursement models for all, the world will take notice, and it will result in important and positive changes.


Dr. Matthew Koenig, MD:  Medical Director of Telemedicine
Dr. Burke Holbrook, DC:   Clinical Operations Manager of Telemedicine