Sunday, December 27, 2009

The Ethics of Virtual Medical Visits

OptumHealth, a division of UnitedHealthGroup, will soon be offering a web-based platform for connecting patients and doctors by video. When the largest health insurer enters the E-visit space we know a change is coming. The Optum program will roll out in Texas in 2010.

I think virtual visits are a great step forward. But I'm chastened by this critique in the article about Optum:
"This is a pale imitation of a doctor visit. It’s basically saying, ‘We’re going to give up any pretense of examining the patient and most of the nonverbal clues that doctors use.'"
If the quote were anonymous I might have dismissed it as fuddy-duddyism. But it's from Dr. David Himmelstein, a friend, a superb primary care physician, a brilliant policy researcher, and co-founder of Physicians for a National Health Program (PNHP - the single payer advocacy group) - the opposite of a fuddy-duddy!

Experience with E-care is just beginning to emerge. In January, the Hawaii Medical Service Association (HMSA - Hawaii's Blue Cross Blue Shield) began offering 24/7 access via telephone and the web to physicians in its network who sign up to provide the service. Hawaii is a natural place to start, since for a number of patients, seeing a doctor in person would require flying to another island. If I were a primary care physician in Hawaii, I'd sign up to do it!

The infrastructure is provided by American Well, a Boston-based company that provides secure infrastructure for web visits, automated billing, and care coordination. The technologies involved aren't new, but packaging them to create tools easy for patients and clinicians to use is a valuable step forward.

I write about Optum and American Well on an ethics site becuse the fundamental step of trying to meet "constructive," "health promoting" patient preferences evinces an ethical focus on patient and public values. Even in my dark ages psychiatry practice I had patients who were VERY grateful for the opportunity to use email to monitor and manage the medications we were using, or to use email to discuss issues we had initially opened up in the office. And when email served my patients' needs it was a win/win tool, since I could access it from home at times that were convenient for me as well.

David Himmelstein is absolutely correct in noting the ways in which E-visits fall short of what an expert physician can transact in the office. But there is a segment of the public that places more value on convenience and timeliness than on a high quality in-person relationship. I have less of a sense of the pros and cons of E-visits for this segment, but it's an experiment worth conducting, on the hypothesis that E-access is better than no access!

(More information on the HMSA program is available from a Fortune article here and a Business Week article here.


Grand Central Office Space said...

As long as the patient can be treated, then I see no reason why a physician could set up an appointment virtually. The same rules apply to subleasing office space at fractional times. This way the leaser can recoup some of their losses while the new tenant can come and go as they please (based on their specific contract) and conduct business at smaller prices/month.

Jim Sabin said...

Dear Grand Central Office Space -

Thank you for your comment. I infer that you are in the office rental business.

What you say made me realize that a virtual appointment involves creation of a new office space. Patients can be in their homes and physicians can likewise be in their own homes. In place of the cost to the physician for creating an office space and to the patient for getting there, new costs are created - for the IT infrastructure that allows the virtual visit.

In my own experience of psychiatry practice I did at one point sublet an office for 2 1/2 days per week from the primary tenant who paid the full rental. This was an advantageous arrangement for both of us. Until I read your comment I hadn't thought of the supplier of IT infrastructure as an analogue of "rental agent," but that's really accurate.

In my view the best use of virtual visits is as a supplement to an in-person care relationship. But the technology will have implications for the real estate business. Two clinicians who might otherwise have leased two separate offices might share one office and conduct practice from home on the other days.

This will be a dynamic area, interesting to follow!