Hi Tech House Calls by the Rural Doc
Reach out and Touch Your Patient
The smart phone buzzed gently alongside the physician’s coffee mug alerting him that it was time to send an appointment reminder to his elderly patient’s daughter. A click of the mouse and a reminder email is sent. Another click opens Quicken to show his outstanding accounts receivable with Medicaid. A finger swipe brings up the accountant’s telephone number, a tap and the call is being placed. While on hold the doctor clicks his email, where his Google Alerts tell him of the latest research with several medications he’s thinking of prescribing.
Is this a concierge practice physician in Los Angeles? Is he a medical director of a large clinic in Manhattan? No, it’s a seventy-year old physician1 in a rural area of Hawaii’s remote island of Moloka’i.
The remote house call may be a quaint idea to someone in the states, but for many working in healthcare in remote areas where it can take hours to reach a patient, it’s a future that results in higher quality care. With the decline of primary care physicians, remote house calls may become a necessity in underserved rural areas. Here’s what you should know.
The Rural Doctor
The rural doctor is on his own. There are no colleagues nearby. Patients come because the doctor is close and he takes insurance, Medicaid or Medicare. More likely than not, the doctor has been in the same place treating the second or third generation of families. These doctors range in age from their late 50s’ to their 70’s or even 80’s. This is a typical primary care physician in a rural area.
Specialists are also rare. The few that are in the area are close to the hospitals and their schedules are booked months in advance. For patients in rural areas, the healthcare culture is different. The doctor’s office often consists simply of the doctor and nurse (or assistant). Even if there is a second doctor in the practice and the staff is larger, these primary care doctor’s offices are often closed on the weekend. Patients go to the emergency room of the closest hospital for care on the weekends. That’s expensive care.
The Affordable Care Act is helping
The Affordable Care Act is pushing technology into these rural primary care physician offices by offering financial incentives for implementing electronic health records (EHRs) in their practice. The patient data from the primary care doctor is central to the purpose of sharing patient information digitally across healthcare organizations to improve care. Without the PCP’s patient history, the hospitalists and specialists must attempt to re-create the history by asking the patient again for the information from the PCP, usually by fax. They often have to repeat tests because the results are not available.
Health information exchange (HIE) allows connected PCPs and clinics to share their data from their EHRs with hospitals and specialists. This avoids repeating lab tests and procedures with the bonus of having the information on medications prescribed by the PCP without having to rely on the patient’s memory or a bag of pill bottles that she brings in. The HIE would notify the patient’s PCP that she was in the hospital and needs a follow-up visit. The HIE digitally provides all the information about the patient’s care to the PCP.
PCP’s are increasingly being rewarded by health insurance companies to improve quality of care. For most primary care physicians, this means paying more attention to the chronic care patients. The biggest patient target groups are those with diabetes, heart conditions, and hypertension. Here’s where technology can help put money into the pockets of PCPs. Identification of these patients is not the problem, it’s keeping track of their last visit and lab tests. Improving the quality of care means seeing these patients on a regular basis as a preventive measure as well as making sure they are taking their medications and monitoring their own blood sugar in the case of diabetics. A practice or clinic needs to reach out to patients and remind them to come for a checkup and have tests done.
In a rural area, there are a myriad of logistical problems to overcome in addition to the psychological ones. Common obstacles:
- Patients forget – no matter how hard they try, some cannot remember without human or non-human assistance. Elderly patients are more prone to forget. My uncle who is 95 and lives in a retirement facility and is very healthy by most measures. He is lucky and takes only one or two medications. But he forgot to take his medicine for the first time a few weeks ago. At that age, it meant he ended up in the hospital.
- Transportation – getting to the doctor’s office if you can’t drive yourself means you rely on other people and their schedule. They may need to wait and then drive the patient home.
- Not sick – patients who feel fine don’t want to go in for a checkup or they postpone it.
Engaging the patient is key to getting past the obstacles. The more information a patient has about their condition and how to take care of himself, the more likely it is that he will do what’s necessary to stay healthy. Technology can help by making it easier to communicate.
Take Advantage of Technology that is Available Today
Use Mobile Apps. Today is the age of the app. Over 60 percent of U.S. adults own mobile smart devices – cell phone or tablet. There are apps for everything including ones that can help patients track their blood pressure, blood sugar, weight, and other health measures. This data can be shared with doctors automatically or manually so that there is a continuous recording and large deviations alert doctors to contact patients. Studies have shown that patients are more likely to follow orders from doctors. PCPs should be armed with a host of apps that they can recommend to their patients.
Text Patients. People read texts more often that emails. The big advantage – a practice or clinic does not need to have a web site in order to text. They are short and to the point and no need to scroll through all of the inbox to get to a message. Texts can also be tailored to groups of patients. Doctors can use texts as notification for:
- scheduling an appointment with doctor (especially useful following discharge from a hospital)
- appointment reminder
- medication refills
- preventive – get a flu shot
- education – good foods, exercise
- lab test reminder
- Happy notes – exercise, positive thoughts
- Local public health news – food recalls, outbreaks, fitness events
Communicate with Email. Many of the EHRs offer secure emails so that patients can email questions to their doctors. This helps solidify and enhance the doctor – patient relationship. It can also increase efficiency because some questions can be handled offline. The challenge is that email is for non-urgent questions. Auto-replies must be used to direct the sender to the appropriate facility for urgent or emergency care.
Over 60 percent of PCPs have implemented EHRs in a rural area, and there are simple ways to communicate with patients. Communication shows patients that doctors care about them even when they don’t see them.
Information helps patients take better care of their health. The result is higher quality of care and better health in rural areas with a little help from technology.
1 This physician is fictitious.