Health systems expanding digital access to doctors

Regional health systems are expanding what they predict will be the next frontier in treatment: telemedicine, a form of remote care where doctors interact with patients via a phone, tablet or other devices with a camera.

Remote visits can range from having a physician check a sore throat with a flashlight on a patient's smartphone, to routine post-operation checkups, where a doctor directs a subject to push parts of their body and asks for feedback on pain levels. 

Telemedicine also often entails emergency care, where doctors at a central station assist nurses and staff at other facilities with stroke, psychiatric and intensive care patients via high-definition monitors and cameras, speeding diagnosis in fields where either specialists are in short supply, or time is critical to a better outcome. Often the doctor is "wheeled in" on a wired table  at a patient's bedside. 

Investments in telemedicine are being used to launch remote urgent-care services, in which doctors remotely examine patients who don't want to wait for an appointment when they don't feel well, and make follow-up appointments less time-consuming. 

Area hospitals are also expanding their remote stroke care networks, since studies have shown that getting the proper  help 15 minutes faster can make the difference in whether a patient will be able to move and talk again.

Health systems such as Northwell Health and Catholic Health Services are also pushing deeper into remote psychiatric services, because local and national shortages of psychiatrists have made it difficult to staff emergency rooms around the clock.

“Telehealth in general is the new reality, it is the new normal,” said Dr. Paul Testa, chief medical information officer at Manhattan-based NYU Langone Health. “Technology will continue to change how we deliver health care, and how patients expect to receive it.”

Insurers are taking notice and have started to include remote “visits” in coverage plans, according to a Kaiser Family Foundation survey compiled in October.

About 74 percent of large companies with at least 1,000 employees offer the benefit, compared to only 27 percent in 2015.

Nationally, some employers also provide financial incentive for insurance enrollees who use telemedicine instead of more expensive personal visits with doctors, Kaiser found, adding that 26 percent of firms offering health benefits with 50 or more workers have such an incentive in 2018, compared to 14 percent in 2016. The incentives include lower deductibles and copays.

Still, many patients have been slow to use the services, according to Kaiser, which found that while telemedicine visits rose 46 percent to 429,000 in 2016, fewer than 1 percent of patients with telemedicine benefits used them.

“We’ve been talking about the growth of telemedicine for a long time,” said Matthew Rae, senior health policy analyst at Kaiser. “Technology is getting to where, perhaps, we will see increases. But we have a long way to go when less than 1 percent of us are using it. Many patients are most comfortable seeing a doctor” at the office.

Two large New York City-based health systems with a large Long Island presence, see urgent care as one way to entice patients into using their doctors and services.

NYU Langone started in September 2017 delivering urgent care through video visits. Patients can access NYU’s Virtual Urgent Care service either through an NYU Langone Health app on their smartphone or tablet, or by using a computer connected to the internet. Doctors might examine a throat or stuffy nose or have a patient check her fever. 

NYU Langone doctors in Manhattan see about 25 urgent-care patients remotely each day, Testa said. Service is available 7 a.m. to 11 p.m. weekdays and 8 a.m. to 8 p.m. on weekends.

Mount Sinai Health System offers tele-urgent care to its employees and expects to launch the service for its patients in 2019.

New Hyde Park-based Northwell Health has not launched a remote version of urgent care. A spokesman said it would need to clear several hurdles before doing so.

Northwell, the largest private employer in the state (68,000 employees), operates a network of 50 urgent-care centers in New York with GoHealth Urgent Care, an Atlanta-based group that partners with health systems nationwide. 

Northwell executives said it would work with GoHealth should it decide to provide remote urgent care.

Northwell said inconsistent state laws  are another challenge. For example, care is defined as where the patient is at the time of the visit, and a provider has to be licensed in that state to provide care.

“Telehealth breaks down the barriers of time and distance, crossing state lines with relative ease, said Patrick McCarthy, a director for telehealth services at Northwell Health. “This creates a challenge for telehealth as we try to ensure that our physicians are properly licensed to deliver care to our patients no matter where they are located.”

Iris Berman, vice president of telehealth services at Northwell, said the health system is lobbying for uniform laws.

Berman also said that remote urgent care is not usually compensated as much as regular visits. “A doctor shouldn’t be paid less for the same service,” she said.

Insurance payments also weigh on the urgent-care business at other health systems. Dr. Abe Warshaw, senior vice president of access services at Mount Sinai, said, “The insurance aspect of remote urgent care is a work in progress, and we want to be careful with the rollout until this is sorted out.” 

Health systems launching tele-urgent care services are competing directly with insurers offering their own product, often at a lower cost to patients.

In New York, Emblem Health, which insures more than 3 million people in the metropolitan area, offers Teledoc, which gives patients “24/7 access to doctors by phone or video” via a mobile app. UnitedHealth Group offers a similar virtual service for $40 or less per visit. The insurers contract out their urgent-care services to third parties.

NYU Langone said it has reached contract agreements with four insurers to cover remote urgent-care visits: UnitedHealth, Cigna, Aetna, and Blue Cross Blue Shield. Patients covered by these carriers pay only their office visit copay, and NYU Langone bills their insurance company for the remaining balance.

A patient without one of those insurers would be charged $126.

Health systems are also hiring psychiatrists and neurologists to offer remote care at emergency rooms. Hospital representatives said hiring them remotely is one solution to the shortage of mental health care on Long Island.

Catholic Health Services has added 10 psychiatrists in the last two years and has trained about 15 psychiatrists to offer overnight emergency room care at all its hospitals, said Dr. Ronald Brenner, chief of the behavioral health services line at CHS. The initiative is part of a pilot program launched less than two years ago by the state Office of Mental Health. Northwell is also a participant.

“The shortage is a big problem, and it gets worse as you move to the east on Long Island,” Brenner said, adding that a psychiatrist sits in a CHS hospital every Friday, Saturday and Sunday from 6 p.m. to 7 a.m. and handles patients in need of behavioral care who are serviced by any of the system’s emergency rooms.

“Each emergency room has high-definition equipment that’s rolled out to a patient,” Brenner said. “The service has cut some wait times from as much as 12 hours to two hours.”

CHS, which has seen about 500 patients since the pilot launched, hopes to expand the services next year, but “it costs money, and we need to find the finances to do this,” Brenner said.

Costs include equipment, hiring staff and getting credentials at each of CHS’ six hospitals.

Northwell’s emergency telepsychiatry program, based at Northwell facilities in Syosset and Manhattan, provides mental health coverage for emergency departments at 15 of the health system's metropolitan area hospitals. Those services include a 24/7 multidisciplinary team of staff psychiatrists, nurse practitioners, social workers and mental health counselors who provide 350 consults per month, on average, with the goal of reducing wait times.

“It has reduced wait times by over 90 percent,” said Dr. Jonathan Merson, the program’s medical director and an associate vice president at Northwell’s Behavioral Health Service Line. “Most patients are seen in less than an hour and almost half experienced waits less than 30 minutes thanks to telepsychiatry.”

Stony Brook Medicine’s Department of Psychiatry is recruiting psychiatrists to provide outpatient services to the East End, said Dr. Kimberly Noel, Stony Brook Medicine’s telehealth director.

Good Samaritan Hospital Medical Center in West Islip, which treats about 500 stroke patients annually, recently invested in a remote stroke-care system. A neurologist is wheeled, via screen, directly to a patient’s bedside. About 10 neurologists have been trained to support the system, which will launch this month, said Dr. Kimon Bekelis, chairman of neuro-interventional services at CHS.

“This will make a significant impact on outcomes,” Bekelis said.

A UCLA study shows for every 15-minute-faster interval of treatment, stroke sufferers were 2 percent more likely to go home, while walking at the time of discharge was 4 percent more likely.

Bekelis added that paramedics have been trained to recognize stroke characteristics in patients because “pre-notification matters. When the patient hits the door, we are ready.” 

Northwell Health’s telestroke program, begun as a pilot initiative five years ago, has since been mainstreamed as the new standard of care throughout the health system. It is already widely available, and every acute-care emergency room — 14 Northwell facilities in all — will have access to it by next year.

Northwell’s telestroke team makes a stroke neurologist available 24/7 in cases where that wasn’t previously possible and has treated more than 1,100 patients through the first 11 months of the year. That caseload is expected to double in the next year, Berman said.

Cardiologists, gastroenterologists, endocrinologists, primary-care physicians and surgeons at many health systems are also increasingly leaning on remote visits.

“We look at telehealth as part of our standard business offerings, and for some patients it makes life much easier,” said Dr. Bruce Darrow, chief medical information officer at Mount Sinai Health System and a cardiologist in Manhattan. “Why should a patient take a half-day off work, travel an hour by subway to the Upper East Side to have a five-minute conversation with me as part of a follow up appointment? In some cases we can check in via video, and it’s just as effective.”

Also, Stony Brook Medicine is operating a randomized trial where family and internal medicine patients receive kits as part of their post-hospitalization care. The kits include a touch-screen tablet, blood pressure monitor, pulse oximeter and scale.

Stony Brook said that 90 percent of patients have successfully adhered to medication and program adherence.