Six years ago, Timothy Howard, M.D., a family physician located in Owens Cross Roads, Ala.—a town of less than 2,000 people, received a mass mailer and didn’t throw it away.
Instead, Dr. Howard, with his first of four children about to start college, read about an opportunity to earn more money from a company called Teladoc and decided to see what it was about. He saw Teladoc, then still in its relative infancy and now one of the most recognizable telehealth companies of its kind, as a way to connect with patients directly. Despite the fact patients and physicians connect through the phone or a over online video platform, and not face-to-face, he found it brought the joy back in practicing medicine.
“I saw the changes coming our way with the complicated electronic medical records (EMR) coming in our office and taking less of our margins and diminishing us even more. I was having to cut my patient workload 25 percent just to keep up with the EMR. I saw that coming and saw the frustration, so I ended up deciding to leave my private practice and do telehealth full time,” Howard says. “It’s revolutionized my ability to care for patients and in some senses, it’s brought closer to patient care. I don’t have all these buttons to punch in the office EMR that took me away from taking care of patients.”
Direct-to-consumer telehealth is on the rise. Companies such as Teladoc, MDLive, AmericanWell, and multiple others, are bringing telehealth capabilities directly to the patient. They have started up, received millions from investors, and formed partnerships with large health systems like Mount Sinai in New York, pharmacies like Walgreens, and others. More patients are buying in.
Who are the doctors behind the trend? Who are the faces that patients see when they connect over their phone and why are they there? Healthcare Informatics Senior Editor Gabriel Perna interviewed Dr. Howard to find out one man’s motivations. Below are excerpts from that interview.
What attracted you to this type of care?
I was in private practice for 25 years and saw all of these things come down the pike that don’t seem to make things more efficient, they just seems to let them mine data easier. And I’m not even talking about the Affordable Care Act (ACA). The ACA is very positive it will bring more people to our door step because we are putting many more people in the system, as far as being actual patients outside of emergency room/walk-in clinic. [With Teladoc] we are now going to be able to take some of that burden, which so many private practices are facing, because there is not enough physicians to go around.
It’s the three A’s of what we do. First, it’s accessibility. One of the things we find all over nation— I’m licensed in a lot of states— is issues with geographical accessibility to physicians. They just can’t get to them when something comes up. These are non-emergency issues. Second, they may be accessible, but they’re not available. Their schedule is packed. We’re in the middle of cold and flu season and it is packed in physicians’ offices. The third part of the A is affordability. We’ve taken those folks with non- emergency issues and we’ve taken them out of the ERs and walk-in clinics where all kinds of money was being spent. Industry and the insurance companies appreciate what we do. When I started, we were 4,000 members nationwide. We’re at eight million now and we’ll be much higher than that.
How often do you get pinged? Are you on a schedule?
From the physician’s standpoint, you’re on call, on demand. Our service is 24/7 and you have the ability to sign up for as little or as much time as you want. Because of my schedule, and because I’m still putting three kids through college, I stay on most of the time. When you’re available, you get an outreach by text or email that says there is a consult available in a state where you’re licensed in. Whoever is able to press the button to lock in that consults, gets it. Because we want to show deference, physicians practicing in that state get first priority. My state is Alabama. I get first priority, of any consultation that comes in Alabama. The second part is, because we respect the patient and their time, if after certain period of time, [the patient] is not notified or a physician in that state doesn’t contact them, it goes to any physician licensed in that state.
How does reimbursement work?
Our consultation costs 40 dollars. We receive a portion of that. When you look at overhead and those kinds of things, what you don’t have to put in means that’s as good as private practice. You don’t have the overhead. What you’d have in overhead is taken care of and what you get for each consultation, we get paid a fee for service based on how many we do. I get a direct deposit, twice a month, based on the number of consultations I have done. There is no waiting for co-pays.
How does it work with the EMR? Are all Teladoc doctors on one EMR? Where do you coordinate care with the person’s primary?
We have a default, which they have to uncheck, that sends their information to their primary care physician (PCP). Our goal is to bridge them back to the primary care physician. We are not their primary care physician. We monitor to make sure the PCP gets a copy of what we do and to see if the patient is using [our service] too often. We’ll red flag that. We want PCP to be number one and I tell patients all the time, their best care will be a physical exam and sitting in front of the primary care physician. If they’re not available, accessible, or affordable, our service can help bridge that.
The EMR is straightforward and uniform. It takes you screen by screen that flows from the chief complaint, to the symptoms given, to the SOAP (subjective, objective, assessment, and plan) notes, to the diagnosis, to the treatment, and recommendations, which you can email, and then finally you have the follow-up. The visit takes about six to 10 minutes.
What have been some surprises as you’ve gone down this journey?
The most pleasant surprise for, like I said, is the direct aspect of it. You are talking with the patient. You’re not punching buttons to see if you get meaningful use out of this visit. You actually recognize the note that you typed in rather than templates galore during the office visit, where you don’t recognize what you’ve done. In my private practice, when I had a patient come in that needed follow up in the EMR, I literally would look at my note and wonder why they are here. I’d wonder why they were there following up with me. I’d look for a cheat note somewhere why I was following up. They were nice and neat and clean but it got you away from patient care. This is so simple it keeps you focused on the patient.
Also, reimbursement was a surprise. You don’t have to haggle, or hire full time staff to haggle with insurance companies on how we’re going to get paid. I get a direct deposit twice a month. It’s simple.
What have been some challenges?
The biggest challenge is putting a boundary around a bounder less enterprise. It can eat you alive. I had to force myself to take a day off. Honor the Sabbath. I purposely don’t do consults one day per week so I can refresh and be ready for the next week. As in anything, you can get burned out real quickly.
How much do you average per day?
Right now, because of cold and flu season, it’s 40-plus per day. Just in talking to you, I’ve seen 15 in the queue ready to take care of. In a non flu season, it’s 25-30 per day.
What will it take for telehealth to get fully integrated into mainstream healthcare and not just used as a niche?
I think it’s time. I’ll give you an example, I’m privileged to serve on the admissions committee of the medical school I attended over the last 18 years, and of course I’m partial towards family practice, having watched over that time frame, no more students going to residency in family practice than there was when I started. It’s six percent. Take that number and that’s your denominator, take the numerator and add it with the ACA, and hundreds of thousands of new patients are coming into the picture. You can send them to urgent care or the emergency room, which is not cost efficient. You can send them to midlevel providers, nurse practitioners and physician assistants. Quite honestly, they do a very good job in well care but part of our training is knowing what to do when someone is really sick, as a rule they are not trained in that. If we really want to keep medicine excellent as far as quality we give patients, this has got to become mainstream because there is so much room for patient care outside of the traditional office.
