TeleDoc

Published on January 10, 2015
Haywood Hall on how telemedicine allowed him to pursue his global health passions in Mexico...while earning U.S. dollars treating patients on his phone.

EPI: So you’re officially a telemedicine doc now. Who do you work for?

There are a few different providers out there who do telemedicine. I work with MDLIVE, but there’s Healthtap and ECI and others. They seem to be cropping up everywhere. My work is a partnership between MDLIVE and ECI TeleHealth. It’s actually a bit of a complicated landscape, as these things tend to be.

Give us some big picture background. Why is telemedicine necessary or useful?

The issue nowadays is really that there’s very limited access to primary care docs. We’re obviously trying to place people more in primary care settings and the emergency department continues to be a buffer for everything. So what’s happening is that there’s more and more people showing up to the ERs. And so now, because large groups of people are on prepaid health plans, insurers are incentivized to keep people from overusing the facilities – urgent care or emergency departments in particular. So they’re given an option to talk to a physician. We used to have something like this called a nursing hotline. The big difference was that the old nurs- ing hotlines were pretty consistent about punting patients to the ED. By having a physician involved, we’re actually able to resolve a fair number of problems over the phone. And that works to everyone’s benefit. They don’t have to hang out in the ER all day.

What kinds of complaints are you resolving over the phone that were previously punted to the ED?

A sore throat or an earache or urinary tract infection symptoms. In the old system they’d be more inclined to shunt it away and say: “Well, you could wait until tomorrow and go see your doctor,” or something like that. But the problem is that there’s actually fewer and fewer places to go for this episodic care. And so having a doc who can say: “Well, this does sound like a UTI,” and resolve the problem to some extent is really valuable.

About how many cases do you refer to a hospital versus resolving on the phone?

I’d say probably five percent get told that they have to go to the ER or urgent care to see their doctor first thing in the morning. I can put in my documentation that they don’t need follow-up or they can go to an emergency department or an urgent care or their primary doc. So it’s somewhere around five percent that I actually say: You know, somebody has to look at this.

Are you able to write prescription after a phone consult?

Yeah, we send prescriptions electronically. It’s a whole system that’s pretty clean. We cannot write for any narcotics. We can’t write for any psychotropic drugs. And we can’t write for lifestyle drugs such as Viagra. Apparently, the patients know that we can’t do that.

So what does telemedicine look like for you specifically, working through MDLIVE?

MDLIVE has an online platform through which I get calls to manage patients. These are patients who have been pre-screened to some extent; they might be urgent care patients or they might have considered going to the emergency department for something that is a very basic primary care problem: UTIs or something along those lines. Initially I found the patient encounter awkward because I was not really seeing a patient and I did not have their vital signs. Working in an emergency department, I’m expecting to see a disaster at every turn. So you really have to be pretty disciplined to keep a low threshold for saying: “I know it’s just a little stomach pain, but you called me. And you know, I don’t know, sometimes I have seen an appendicitis like this. It’s just too early.” So I keep a very low threshold.

Does the patient know who you are during this encounter?

Well, they know I’m a physician. I introduce myself as Dr. Hall from MDLIVE, so they can look me up. In terms of credentials, the MDLIVE contracts are for physicians who are emergency medicine, internal medicine, pediatrics or family medicine. So they select their physicians through the MDLIVE portal based on those kinds of profiles. Some telemedicine systems, like HealthTap, have almost a social network component where you can see a lot more about the physician.

Lets talk liability. What happens if you give bad advice?

We have malpractice insurance for this, but the fact is that you really need to be handling very low risk patients in the system. So anybody who’s handling chest pain over the phone is getting into deep water. Anybody who’s been seen by another physician in an ER and is continuing to have problems probably shouldn’t be handled over the phone. You know, it’s really designed for very simple episodic things. There is not likely to be much case law. That doesn’t mean that there aren’t any out there for bad advice. Even in a regular physical clinical setting you can always have a bad outcome and have somebody potentially try to sue. I mean, I think that’s part of practice unfortunately. It’s the United States; you can sue.

You’ve chosen to work in telemedicine in part for the lifestyle that it allows you to live. Tell us a bit about that.

Up until recently I was spending three weeks out of every month in Mexico, where I run PACE MD, a global health organization that offers free Basic Life Support Courses in Latin America. Thanks in part to doing telemedicine, I’m hoping to spend even more time in Mexico doing what I’m passionate about. I certainly don’t make nearly as much money as I would in an American emergency department, but I can handle 20 calls a day and I have very few expenses related to actually managing patients. You need a phone with good coverage and you need a computer in order to do the documentation.

In terms of freeing up my time personally, this has allowed me to start taking my kids to school in the mornings. That’s a real shock for me. Plus, it’s just a lot less wear and tear on me doing this.

I can handle 20 calls a day and I have very few expenses related to actually managing patients. You need a phone with good coverage and you need a computer in order to do the documentation. In terms of freeing up my time personally, this has allowed me to start taking my kids to school in the mornings. That’s a real shock for me. Plus, it’s just a lot less wear and tear on me doing this.

So you can take 20 calls a day. Walk us through what that looks like.

The calls are typically maybe ten minutes total. And I can get between 10 and 20 calls a day if I block some time aside. I fit these calls in around my other work, woven around a full day’s schedule of meetings.

Each call pays $25, but there’s other places that may pay more or less. There’s some days when I’m not really picking up calls and other days when I’m picking up a lot more calls. So it kind of averages out. They pay more when you’re working at night, too.

If you wanted to, could you choose to take more calls and make more money? What’s the limiting factor?

In terms of demand, I suspect that over time there’s just going to be more and more need for this. And also as the reimbursement mechanisms get into place – like whether Medicare, Medicaid cover telemedicine – will make a difference. Right now there are times when I’m available, but there aren’t any patients, but that’s also a function of how many state licenses you have. More licenses means more potential calls. Plus, influeza season is approaching and there are large contracts that the company is starting to ramp up for. For me, it’s about fitting telemedicine around my other work. If there’s a call and I can reasonably answer it, I answer it. I think if I was just sitting around just doing telemedicine, I’d be managing more calls.

What about tax implications?

Turns out that if you live in the United States less than 35 days out of the year, you get a $100,000 “Foreign income earned abroad” tax credit. Of course people need to talk to their accountants about it, but that’s a real thing. And so if you’re not paying any taxes on the first $100,000 or so of your income, then that’s pretty significant. So if you’ve got like 20 calls a day, you could live very well off of that in a lot of places, probably even in the United States. If you’re retired or anywhere near thinking about retiring, being able to take these calls for a few years might be enough to push you over the edge.

You mentioned that these are pretty low acuity calls. Is this mentally stimulating work?

In the emergency department we’re used to all kinds of excitement and all kinds of things and so the stimulation level is very, very high all the time. By definition, these telemedicine calls are very, very low complexity. So there’s not a lot of challenge there. You need to make sure that people don’t think you can resolve anything but the simplest, simplest problems. We don’t want to take any chances. On the flip side, I take satisfaction in knowing I’m decompressing the ER for serious cases. But you’re talking to people and if you like talking to people on the phone and stuff, if that’s enough for you then that may be fine. You’re not doing physical exams. You’re not reading x-rays. But that won’t always be the case. As time goes on, the technology is changing. I can see on our platform that there’s ways of ordering lab tests and there’s ways for people to send images of different sorts that I can look at. And I can see where this is going over time. This could get to be quite an interesting practice.

Can you speak a little more to the future of telemedicine?

I’m sure this is going to become much more complex, in terms of managing problems over time. There is a lot of medical telemetric stuff showing up. I saw a retinascope that clips on to an iPhone the other day. And we have seen ultrasound transducers that plug into iPhones. A lot of home health devices will start to be integrated. Those smart watches are probably going to be very important one day. Of course, that’s a new kind of practice – not exactly emergency medicine anymore. But it’s going to be a very interesting thing as time goes on, as the technology changes.

Let’s say the next phase of telemedicine involves a lot more video contact with the patients, looking at vitals and tests in real time. What kind of pitfalls do you foresee?

I think telemedicine can be too easy. It’s easy to just call and get prescriptions and refills. And maybe there’s a deeper problem going on. So I think you’d have to be very careful with people who say, “I’m just calling up for a med refill.” They think that they know exactly what the problem is, but it’s been going on for a while. That little something is going to turn into something else if a doctor isn’t paying attention.

A seasoned emergency doc looks at a patient from across the room and says, “That person is sick.” And you don’t have that ability over the phone. Then if it’s a mother talking about their child that’s even further removed. And people do try to call you for their husbands or their almost-adult sons. And then you have to say: “I really would like to talk to them a little bit, just to see what they sound like.”

Another problem is that people call in because they want to have something specific. They have a pretty clear idea of what they think they want, so you’re just getting highly filtered information sometimes. So those are things you have to be careful of. We can’t take the place of their primary physician or an urgent care doc if there’s any possibility of it turning into a problem. I think as ER docs, we know that things can turn into a real problem. So you just have to document very well. You’re being the shortstop, and it would be unwise to overstep that limited role.

“...it can be too easy. It’s easy to just call and get prescriptions and refills. And maybe there’s a deeper problem going on. So I think you’d have to be very careful with people who say, “I’m just calling up for a med refill”. They think that they know exactly what the problem is, but it’s been going on for a while. That little something is going to turn into something else if a doctor isn’t paying attention.”

Has phone-based telemedicine given you a more acute sense of hearing when it comes to clinical gestalt?

Well, if the patient’s talking and has any shortness of breath, I can pick that kind of stuff up, but you don’t want to practice medicine that way over the phone. Things have to get pretty bad before you can hear them on the phone . . . and then it gets very silent of course.

How hard of a transition was this, clinically, for you as an emergency physician?

In the ER, we typically assume that people are sick. It’s a small subset of the population who has made the effort to come out and wait in the ED to be seen. We see a snake under every rock. In telemedicine, it’s almost like being out in the broad population as a whole. They’ve got a runny nose and they know they have a runny nose. It’s not a big deal for them. So you do have to keep your spidey senses tingling, but you also have to realize that this really is primary care for very basic, simple things. So that’s not the easiest transition for us. But I think that our emergency medicine experience makes us very good at this in a lot of ways.

It’s definitely different. And you know, there’s plenty of us that have seen tens of thousands of patients. And it’s kind of neat to do something a little bit different for a while. It’s a way of kind of shifting gears a little bit. I think it’s a perfectly viable thing.

Have you gotten any odd or more extreme calls?

You mean like heavy breathing? No. Just like in the emergency department or anywhere else, you get people and you wonder exactly what they were thinking. Somebody had a chief complaint of tachycardia. Or chest pain. It’s very hard to say anything to them other than, “You probably need to be seen, like pretty soon!” It’s like there’s a 90 percent chance that it’s nothing. But we can’t see thousands of patients and then let ten percent of them have an actual heart attack.

Final question. So the patient (or their insurer) pays about $50 for this service. Is it worth it?

Yes. People need that reassurance sometimes, and a quick fix for a simple problem. We have made access to health care so hard, even when they have a primary care doc. I call it delusions of system continuity. And I would like to think that emergency physicians would be uniquely qualified, using good judgment about anything that’s even remotely complicated or dangerous. That’s kind of what we do.

This article originally appeared in Issue 15 of Emergency Physicians International.

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