Northwest Health Spring 2011

Medicine in the Virtual World

Electronic tools are stretching how and where medical care happens. More and more, that care is happening outside the walls of the doctor's office.

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Last summer, Bellevue resident Abby Adams experienced several instances of nausea and aching arms while running — a form of exercise she's enjoyed for many years.

Although the symptoms went away when she stopped exercising, they were worrisome. So on a Sunday evening, she decided to describe them to her doctor, Patricia Boiko, MD, via a MyGroupHealth secure e-mail.

Dr. Boiko, whose practice is at Group Health Medical Centers Factoria clinic, was at home on a Monday morning checking her Group Health e-mail, when she found the message from Adams.

"I knew that Abby — a longtime patient of mine — wasn't a complainer, and I knew her medical history. When I read her symptoms, I really wanted her checked out that day. So I asked my clinic partner, Lisa Baker, DO, to follow up."

Adams recalls: "After Dr. Boiko read my e-mail, things went on a fast track. I had an immediate appointment and an EKG. Dr. Boiko and Dr. Baker then consulted with a cardiologist."

That phone consultation was especially effective since Adams' medical records were available electronically — as they are for all Group Health Medical Centers patients. This allowed Drs. Boiko and Baker, and cardiologist Simeon Rubenstein, MD, to review her EKG results together, even though the doctors weren't in the same building. Dr. Rubenstein suggested a second EKG and stress test that took place Tuesday at our Urgent Care Center in Bellevue. As a result of that test, her doctors ordered an angiogram on Thursday. When it confirmed a blockage in a coronary artery, Adams was scheduled the same day for a procedure to insert a stent to open the blockage.

A few months later, she's back to running, and grateful for the easy communication with her doctor and the seamless care that she experienced, indicative of the new world of virtual medicine at Group Health.

The Evolution of Virtual Medicine

Virtual medicine (sometimes called telehealth or telemedicine), is a term that describes care that uses technology to exchange medical information between two parties, usually at different locations, with the goal of improving health.

At Group Health, this practice can be traced back to the 1970s when Group Health launched the nation's first consulting nurse service, connecting patients with nursing advice via the telephone. Beginning in 2001, Group Health made it possible for patients who get their care with Group Health Medical Centers to communicate with their doctors and medical team members via secure e-mail messaging. Patients access this by signing up for MyGroupHealth personal online services.

Secure e-mail has been very popular with patients. "We have probably the highest usage by patients of any large medical system," says Gwen O'Keefe, MD, chief medical informatics officer for Group Health. Along with the convenience and quick access to doctors, studies have shown that some patients — about 5 percent to 6 percent — would not have sought care for a medical condition without e-mail. "Sometimes it's an issue that the patient doesn't feel comfortable talking about in person," says Dr. O'Keefe.

Around the same time that e-mail messaging was launched at Group Health Medical Centers, patients' medical records were being converted into an electronic clinical information system known as Epic. All new patient information was then entered into this electronic medical record.

Recently, Group Health has joined other health care organizations that use the same electronic medical record, becoming part of a network that allows a patient's medical records to be shared by providers in different care systems. In Washington state, the participating organizations currently include The Everett Clinic, Swedish Medical Center, and MultiCare. Joining this network allows Group Health members and their health care teams — even those that aren't within the Group Health Medical Centers system — to share important health care information.

Within Group Health Medical Centers, the electronic medical record has significantly changed the way primary care doctors and specialists work together, since it's easily accessible to all clinicians involved in a patient's care. It's led to a form of virtual medicine called the virtual consultation.

More and more frequently at Group Health Medical Centers, rather than sending a patient for an office visit with a specialist, the primary care doctor serves as the conduit between specialist and patient via the virtual consult. "The electronic medical record is key to allowing the kinds of care that we could never envision before," says neurologist Tim Scearce, MD, an enthusiastic proponent of virtual consulting. "These consults bring the specialist to the family doctor, sometimes even when the patient is still in the examination room."

While Group Health is not alone in exploring the world of virtual medicine — which also includes phone appointments — Group Health Medical Centers is uniquely positioned to take advantage of it because of the integration of care and coverage. Unlike the fee-for-service medical world, doctors with Group Health Medical Centers don't bill for each service. They're paid a salary, and don't need to worry about how to bill a patient for answering an e-mail, talking on the phone, or doing a virtual consultation.

How Virtual Consulting Works

"In the old days, if I had fairly simple questions that needed consultation with specialists, I would page them or write a paper memo or call their staff and ask for a call back," says Travis Abbott, MD, who practices at our Capitol Hill Campus in Seattle. "Often, we'd play telephone tag for days. Now, I'll e-mail my question, and get an answer in a half day or a day."

He recalls what it used to be like, only a few years ago, when he needed a consult with an orthopedist over a patient's broken bone. "I'd have to send the X-ray by messenger or taxi, or send the patient to see the specialist, or try to describe what the fracture looked like over the phone. Now, I just ask the orthopedist to pull up the electronic version of the X-ray at the same time I'm looking at it. It saves a lot of time, and I can tell the patient right away what's going to happen."

Dr. O'Keefe agrees: "The important difference is that both doctors have a complete view into the patient's medical record. You can make better recommendations when you're both operating from the same body of knowledge."

For patients, virtual consults also mean they don't have the inconvenience of going to another appointment, making another copay, taking time off from work, or arranging for child care.

Another benefit is that after a virtual consultation, if a specialist recommends the patient come in for a visit, that visit can be scheduled quickly. "We can expedite scheduling for patients who clearly need to be seen by the specialist," says Dr. Scearce.

What's Next?

Newspapers, magazines, and Web sites are full of anecdotal stories about new possibilities for virtual medicine. There are stories of patients who snap cell phone photos that they send to their doctors for a diagnosis; other patients are using smart phone applications to help them lose weight or monitor their glucose levels.

The greatest value of many of these new technologies is that they extend a patient's involvement with their medical care outside the walls of the doctor's office, says James Ralston, MD, an associate investigator at Group Health Research Institute. The heart of Dr. Ralston's research involves looking at how health care could be redesigned to better meet the needs and preferences of people living with chronic conditions.

Some of his research has shown that using e-mail and electronic medical records can help people with diabetes better manage their disease. One research study demonstrated that patients with high blood pressure saw their levels drop when they took their blood pressure at home and sent results every two weeks to a pharmacist via secure messaging. The pharmacists were able to adjust medication as appropriate. Other research is looking at whether mobile phones can help patients with diabetes control their blood sugar.

"We can proactively engage patients in ways that we never have before," says Dr. Ralston of some of the new technology. "The number of patient encounters that are happening outside the doctor's office is growing," he says.

Dr. Ralston says that the use of mobile devices — including cell phones, smart phones, and hand-held computers — for health care applications is rapidly evolving and is likely to have a significant impact on patient health. "Preliminary studies suggest that bringing health services to the mobile phone will help meet patient needs," he says.

These devices may help doctors reach patients who don't often use e-mail to contact their physicians, and who may only go to the doctor when a medical emergency arises. These include people with lower incomes and some minority groups. Dr. Ralston is hopeful that mobile devices can be harnessed to improve the health care of these populations.

Dr. O'Keefe sees the smart phone world as both a challenge and an opportunity. Improving health is the opportunity, but the challenge is to be sure that when Group Health invests in these technologies, there is a tangible gain. "How do we focus on investments and resources that use members' dues in the most effective ways, with the most benefits to health?"

Any new information technology worth the investment must pay off in delivering better health care or a better health care experience. "We don't want to chase something just because it's 'cool,'" says Dr. O'Keefe. "It has to have a good benefit."

A Timeline: Virtual Medicine at Group Health Medical Centers

  • 1970: Group Health launches the nation's first phone-based consulting nurse service.
  • 1999: Group Health Medical Centers begins developing Web services, including patient-provider secure messaging and online pharmacy refills via MyGroupHealth.
  • 2001-2002: Group Health implements secure online communication in primary care, including patient-provider e-mail and an online prescription refill service at all of its medical centers.
  • 2003: Group Health implements Epic, an electronic system of storing patient information, accessible to all clinicians at Group Health Medical Centers. Specialty physicians begin using secure e-mail messaging with patients.
  • 2008: Picture Archiving and Communication system debuts, allowing X-rays, CT scans, MRIs, ultrasounds, and other images to be shared electronically.
  • 2010: Virtual consults become part of the electronic patient medical record.
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