How telehealth can bring back the intimacy of house calls

Like many physicians, I entered medicine with a desire to care for patients in an engaged and collaborative fashion, not shuttle them through the exam room and out the door. After finishing my residency in family medicine in the 1990s and working in a few different clinical settings to start out, I found myself at a hospital-owned clinic, where the culture of “feeding the mothership” prevailed and accomplishments were measured almost exclusively by RVUs. My job satisfaction was low as I wasn’t engaging with patients in more fulfilling and impactful ways.

So in 2006, I joined a physician service that provided on-call, personalized urgent medical care in patients’ preferred setting: their home.

Delivering house calls is neither cheap nor particularly efficient. House calls had dwindled from 10 percent of patient encounters in 1950 to 1 percent of patient encounters by 1980. However, by targeting unnecessary costly ER visits and replacing them with a house call, employers saw value in selectively bringing back the house call, offering me an opportunity.

In switching to the house call model, I was able to spend uninterrupted time with patients, getting to know them beyond just their presenting symptom or problematic body system. I was typically with a patient in the home for 30 to 60 minutes, engaging with them not only during the traditional history and physical elements of the visit, but also while registering them, taking vital signs, running a lab test or giving a breathing treatment. I did all this on their turf and had insight into their lives. With that insight and time to build rapport and engage in shared decision making and patient education, I felt like I was contributing to their health beyond just the prescription or lab result in hand when they left a 10-minute clinic visit. While the individual visits were great, I also spent too much time sitting in traffic between house calls and recognized that only a select segment of the population had access to this type of care. New tools were needed to offer the “high-touch” house call approach to more patients in a viable, efficient model.

Our house call business was growing but also bumping up against the limits of geography and healthcare economics. Simultaneously a new breed of mobile apps and telemedicine programs were popping up that connected patients to clinicians for the urgent care issues we were doing via house calls. By 2009, our company transitioned to the virtual direct-to-consumer care model which eventually led to being acquired by a leading telehealth provider in 2017. My practice has now almost exclusively migrated to the virtual setting.

At first, I was a bit skeptical practicing telemedicine. Would I be able to align my holistic approach to treating the whole patient with the utilization of something as seemingly impersonal as a technology platform? In the year we switched from homes to screens, DTC telehealth was a potentially cost-efficient but largely untested model, one that few patients and physicians had experienced. But the feedback from so many patients that they felt far more engaged during the virtual house call then they had in their clinic visits helped confirm the sentiment from the other side of the doctor-patient relationship.

Although we experienced a few blips, mostly end-user communication technology issues, our organization gradually grew its team of virtual DTC physicians and nurse practitioners. We developed our own best practices by adapting clinic-based guidelines to the virtual setting. We hired more providers who value the emphasis on patient engagement, and we scaled the “high-touch” approach to virtual care and avoided the risks of quick, transactional direct-to-consumer telehealth (DTC) visits that technology can also facilitate.

Today I oversee a team of virtual DTC healthcare providers who are committed to providing high-quality patient care on demand, but without making patients feel rushed. In the era of FaceTime, patients are used to screens, and much more comfortable with video conversations. Unsurprisingly, there were reported 1.25 million direct-to-consumer telehealth visits in 2015, as a Health Affairs brief noted, and that number is expected to rise.

Still, I often get asked what I do to make the experience of telehealth more intimate, or house call-like. From my experience, the best virtual DTC service offers patients a high degree of availability — such as evenings and weekends — but also by being “present”— listening closely to the patient, carefully observing the patient, and avoiding competing distractions. The best virtual-based physicians are comfortable with the video interface and can put their patients at ease by smiling and asking questions in a friendly, unassuming demeanor. Lastly, a provider needs to recognize the limits of virtual medicine, as there are still so many situations a patient needs an in-person physical exam or lab test.

When outsourcing “dial-a-doc” virtual DTC services, medical groups must also ensure the said service only hires high-quality clinicians.

As we continue to move forward, focusing on value and quality, we need to think of telehealth as a platform by which physicians and patients can engage in a mutually fulfilling manner drawing from the richness of old-fashioned house calls to meet the triple aims of today.

Robert Bernstein is a family physician and vice-president of clinical affairs, Avizia.

Image credit: Shutterstock.com

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