Starting Points: Medicine

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May 30, 2010

Healing by 2-Way Video - The Rise of Telemedicine

Michael Stravato for The New York Times

Dr. Jerry Jones uses two-way video at his home in Houston to consult with a patient across town. Dr. Jones is under contract to NuPhysicia, one of the new telemedicine companies.

By MILT FREUDENHEIM

ONE day last summer, Charlie Martin felt a sharp pain in his lower back. But he couldn’t jump into his car and rush to the doctor’s office or the emergency room: Mr. Martin, a crane operator, was working on an oil rig in the South China Sea off Malaysia.

He could, though, get in touch with a doctor thousands of miles away, via two-way video. Using an electronic stethoscope that a paramedic on the rig held in place, Dr. Oscar W. Boultinghouse, an emergency medicine physician in Houston, listened to Mr. Martin’s heart.

“The extreme pain strongly suggested a kidney stone,” Dr. Boultinghouse said later. A urinalysis on the rig confirmed the diagnosis, and Mr. Martin flew to his home in Mississippi for treatment.

Mr. Martin, 32, is now back at work on the same rig, the Courageous, leased by Shell Oil. He says he is grateful he could discuss his pain by video with the doctor. “It’s a lot better than trying to describe it on a phone,” Mr. Martin says.

Dr. Boultinghouse and two colleagues — Michael J. Davis and Glenn G. Hammack— run NuPhysicia, a start-up company they spun out from the University of Texas in 2007 that specializes in face-to-face telemedicine, connecting doctors and patients by two-way video.

Spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry. A fifth of Americans live in places where primary care physicians are scarce, according to government statistics. That need is converging with advances that include lower costs for video-conferencing equipment, more high-speed communications links by satellite, and greater ability to work securely and dependably over the Internet.

“The technology has improved to the point where the experience of both the doctor and patient are close to the same as in-person visits, and in some cases better,” says Dr. Kaveh Safavi, head of global health care for Cisco Systems, which is supporting trials of its own high-definition video version of telemedicine in California, Colorado and New Mexico.

The interactive telemedicine business has been growing by almost 10 percent annually, to more than $500 million in revenue in North America this year, according to Datamonitor, the market research firm. It is part of the $3.9 billion telemedicine category that includes monitoring devices in homes and hundreds of health care applications for smartphones.

Christine Chang, a health care technology analyst at Datamonitor’s Ovum unit, says telemedicine will allow doctors to take better care of larger numbers of patients. “Some patients will be seen by teleconferencing, some will send questions by e-mail, others will be monitored” using digitized data on symptoms or indicators like glucose levels, she says.

Eventually, she predicts, “one patient a day might come into a doctor’s office, in person.”

Although telemedicine has been around for years, it is gaining traction as never before. Medicare, Medicaid and other government health programs have been reimbursing doctors and hospitals that provide care remotely to rural and underserved areas. Now a growing number of big insurance companies, like the UnitedHealth Group and several Blue Cross plans, are starting to market interactive video to large employers. The new federal health care law provides $1 billion a year to study telemedicine and other innovations.

Michael Stravato for The New York Times

From thousands of miles away, Dr. Oscar Boultinghouse checks the eye of a patient.

With the expansion of reimbursement, Americans are on the brink of “a gold rush of new investment in telemedicine,” says Dr. Bernard A. Harris Jr., managing partner at Vesalius Ventures, a venture capital firm based in Houston. He has worked on telemedicine projects since he helped build medical systems for NASA during his days as an astronaut in the 1990s.

Face-to-face telemedicine technology can be as elaborate as a high-definition video system, like Cisco’s, that can cost up to hundreds of thousands of dollars. Or it can be as simple as the Webcams available on many laptops.

NuPhysicia uses equipment in the middle of that range — standard videoconferencing hookups made by Polycom, a video conferencing company based in Pleasanton, Calif. Analysts say the setup may cost $30,000 to $45,000 at the patient’s end — with a suitcase or cart containing scopes and other special equipment — plus a setup for the doctor that costs far less.

Telemedicine has its skeptics. State regulators at the Texas Medical Board have raised concerns that doctors might miss an opportunity to pick up subtle medical indicators when they cannot touch a patient. And while it does not oppose telemedicine, the American Academy of Family Physicians says patients should keep in contact with a primary physician who can keep tabs on their health needs, whether in the virtual or the real world.

“Telemedicine can improve access to care in remote sites and rural areas,” says Dr. Lori J. Heim, the academy’s president. “But not all visits will take place between a patient and their primary-care doctor.”

Dr. Boultinghouse dismisses such concerns. “In today’s world, the physical exam plays less and less of a role,” he says. “We live in the age of imaging.”

ON the rig Courageous, Mr. Martin is part of a crew of 100. Travis G. Fitts Jr., vice president for human resources, health, safety and environment at Scorpion Offshore, which owns the rig, says that examining a worker via two-way video can be far cheaper in a remote location than flying him to a hospital by helicopter at $10,000 a trip.

Some rigs have saved $500,000 or more a year, according to NuPhysicia, which has contracts with 19 oil rigs around the world, including one off Iraq. Dr. Boultinghouse says the Deepwater Horizon drilling disaster in the Gulf of Mexico may slow or block new drilling in United States waters, driving the rigs to more remote locations and adding to demand for telemedicine.

NuPhysicia also offers video medical services to land-based employers with 500 or more workers at a site. The camera connection is an alternative to an employer’s on-site clinics, typically staffed by a nurse or a physician assistant.

Mustang Cat, a Houston-based distributor that sells and services Caterpillar tractors and other earth-moving equipment, signed on with NuPhysicia last year. “We’ve seen the benefit, ” says Kurt Hanson, general counsel at Mustang, a family-owned company. Instead of taking a half-day or more off to consult a doctor, workers can get medical advice on the company’s premises.

NuPhysicia’s business grew out of work that its founders did for the state of Texas. Mr. Hammack, NuPhysicia’s president, is a former assistant vice president of the University of Texas Medical Branch at Galveston, where he led development of the state’s pioneering telemedicine program in state prisons from the mid-1990s to 2007. Dr. Davis is a cardiologist.

Working with Dr. Boultinghouse, Dr. Davis and other university doctors conducted more than 600,000 video visits with inmates. Significant improvement was seen in inmates’ health, including measures of blood pressure and cholesterol, according to a 2004 report on the system in the Journal of the American Medical Association.

In March, California officials released a report they had ordered from NuPhysicia with a plan for making over their state’s prison health care. The makeover would build on the Texas example by expanding existing telemedicine and electronic medical record systems and putting the University of California in charge.

California spends more than $40 a day per inmate for health care, including expenses for guards who accompany them on visits to outside doctors. NuPhysicia says that this cost is more than four times the rate in Texas and Georgia, and almost triple that of New Jersey, where telemedicine is used for mental health care and some medical specialties.

“Telemedicine makes total sense in prisons,” says Christopher Kosseff, a senior vice president and head of correctional health care at the University of Medicine and Dentistry of New Jersey. “It’s a wonderful way of providing ready access to specialty health care while maintaining public safety.”

Georgia state prisons save an average of $500 in transportation costs and officers’ pay each time a prisoner can be treated by telemedicine, says Dr. Edward Bailey, medical director of Georgia correctional health care.

With data supplied by the California Department of Corrections and Rehabilitation, which commissioned the report, NuPhysicia says the recommendations could save the state $1.2 billion a year in prisoners’ health care costs.

Gov. Arnold Schwarzenegger wants the university regents and the State Legislature to approve the prison health makeover. After lawsuits on behalf of inmates, federal courts appointed a receiver in 2006 to run prison medical services. (The state now runs dental and mental health services, with court monitoring.) Officials hope that by putting university doctors in charge of prison health, they can persuade the courts to return control to the state.

“We’re going to use the best technology in the world to solve one of our worst problems — the key is telemedicine,” the governor said.

WITHOUT the blessing of insurers, telemedicine could never gain traction in the broader population. But many of the nation’s biggest insurers are showing growing interest in reimbursing doctors for face-to-face video consulting.

Starting in June, the UnitedHealth Group plans to reimburse doctors at Centura Health, a Colorado hospital system, for using Cisco advanced video to serve UnitedHealth’s members at several clinics. And the insurer plans a national rollout of telemedicine programs, including video-equipped booths in retail clinics in pharmacies and big-box stores, as well as in clinics at large companies.

“The tide is turning on reimbursement,” says Dr. James Woodburn, vice president and medical director for telehealth at UnitedHealth.

Both UnitedHealth and WellPoint, which owns 14 Blue Cross plans, are trying lower-cost Internet Webcam technology, available on many off-the-shelf laptops, as well as advanced video.

UnitedHealth and Blue Cross plans in Hawaii, Minnesota and western New York are using a Webcam service provided by American Well, a company based in Boston. And large self-insured employers like Delta Air Lines and Medtronic, a Blue Cross Blue Shield customer in Minneapolis, are beginning to sign up.

Delta will offer Webcam consultations with UnitedHealth’s doctor network to more than 10,000 Minnesota plan members on July 1, says Lynn Zonakis, Delta’s managing director of health strategy and resources. Within 18 months, Webcam access will be offered nationally to more than 100,000 Delta plan members.

Dr. Roy Schoenberg, C.E.O. of American Well, says his Webcam service is “in a completely different domain” than Cisco’s or Polycom’s. “Over the last two years, we are beginning to see a side branch of telemedicine that some call online care,” he says. “It connects doctors with patients at home or in their workplace.”

Doctors “are not going to pay hundreds of thousands of dollars for equipment, so we have to rely on lower tech,” he adds. The medical records are stored on secure Web servers behind multiple firewalls, and the servers are audited twice a year by I.B.M. and other outside computer security companies, Dr. Schoenberg says.

In Hawaii, more than 2,000 Blue Cross plan members used Webcams to consult doctors last year, says Laura Lott, a spokeswoman for the Hawaii Medical Service Association. Minnesota Blue Cross and Blue Shield started a similar Webcam service across the state last November.

Doctors who use the higher-tech video conferencing technology say that Webcam images are less clear, and that Webcams cannot accommodate electronic scopes or provide the zoom-in features available in video conferencing. “If they are not using commercial-grade video conferencing gear, the quality will be much lower,” says Vanessa L. McLaughlin, a telemedicine consultant in Vancouver, Wash.

Last month, Charlie Martin, the crane operator, was back in the infirmary of the Courageous for an eye checkup. In Houston, his face filled the big screen in NuPhysicia’s office.

After an exchange of greetings, Chris Derrick, the paramedic on the oil rig, attached an ophthalmological scanner to a scope, pointed it at Mr. Martin’s eye, and zoomed in.

“Freeze that,” Dr. Boultinghouse ordered, as a close-up of the eye loomed on the screen. “His eyes have been bothering him. It may be from the wind up there on the crane.”

Apr 14, 2010

U.S. Faces Shortage of Doctors - WSJ.com

As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years

By SUZANNE SATALINE And SHIRLEY S. WANG

Getty Images

First-year resident Dr. Rachel Seay, third from left, circumcises a newborn in George Washington University Hospital's delivery wing on March 12.

The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors.

Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.

That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.

The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.

The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.

A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.

Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.

Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.

But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.

There are about 110,000 resident positions in the U.S., according to the AAMC. Teaching hospitals rely heavily on Medicare funding to pay for these slots. In 1997, Congress imposed a cap on funding for medical residencies, which hospitals say has increasingly hurt their ability to expand the number of positions.

Medicare pays $9.1 billion a year to teaching hospitals, which goes toward resident salaries and direct teaching costs, as well as the higher operating costs associated with teaching hospitals, which tend to see the sickest and most costly patients.

Doctors' groups and medical schools had hoped that the new health-care law, passed in March, would increase the number of funded residency slots, but such a provision didn't make it into the final bill.

"It will probably take 10 years to even make a dent into the number of doctors that we need out there," said Atul Grover, the AAMC's chief advocacy officer.

While doctors trained in other countries could theoretically help the primary-care shortage, they hit the same bottleneck with resident slots, because they must still complete a U.S. residency in order to get a license to practice medicine independently in the U.S. In the 2010 class of residents, some 13% of slots are filled by non-U.S. citizens who completed medical school outside the U.S.

One provision in the law attempts to address residencies. Since some residency slots go unfilled each year, the law will pool the funding for unused slots and redistribute it to other institutions, with the majority of these slots going to primary-care or general-surgery residencies. The slot redistribution, in effect, will create additional residencies, because previously unfilled positions will now be used, according to the Centers for Medicare and Medicaid Services.

Some efforts by educators are focused on boosting the number of primary-care doctors. The University of Arkansas for Medical Sciences anticipates the state will need 350 more primary-care doctors in the next five years. So it raised its class size by 24 students last year, beyond the 150 previous annual admissions.

In addition, the university opened a satellite medical campus in Fayetteville to give six third-year students additional clinical-training opportunities, said Richard Wheeler, executive associate dean for academic affairs. The school asks students to commit to entering rural medicine, and the school has 73 people in the program.

"We've tried to make sure the attitude of students going into primary care has changed," said Dr. Wheeler. "To make sure primary care is a respected specialty to go into."

Montefiore Medical Center, the university hospital for Albert Einstein College of Medicine in New York, has 1,220 residency slots. Since the 1970s, Montefiore has encouraged residents to work a few days a week in community clinics in New York's Bronx borough, where about 64 Montefiore residents a year care for pregnant women, deliver children and provide vaccines. There has been a slight increase in the number of residents who ask to join the program, said Peter Selwyn, chairman of Montefiore's department of family and social medicine.

One is Justin Sanders, a 2007 graduate of the University of Vermont College of Medicine who is a second-year resident at Montefiore. In recent weeks, he has been caring for children he helped deliver. He said more doctors are needed in his area, but acknowledged that "primary-care residencies are not in the sexier end. A lot of these [specialty] fields are a lot sexier to students with high debt burdens."

Jan 27, 2010

The Radiation Boom - As Technology Surges, Radiation Safeguards Lag

Image by IndyDina with Mr. Wonderful via Flickr

By WALT BOGDANICH

In New Jersey, 36 cancer patients at a veterans hospital in East Orange were overradiated — and 20 more received substandard treatment — by a medical team that lacked experience in using a machine that generated high-powered beams of radiation. The mistakes, which have not been publicly reported, continued for months because the hospital had no system in place to catch the errors.

In Louisiana, Landreaux A. Donaldson received 38 straight overdoses of radiation, each nearly twice the prescribed amount, while undergoing treatment for prostate cancer. He was treated with a machine so new that the hospital made a miscalculation even with training instructors still on site.

In Texas, George Garst now wears two external bags — one for urine and one for fecal matter — because of severe radiation injuries he suffered after a medical physicist who said he was overworked failed to detect a mistake. The overdose was never reported to the authorities because rules did not require it.

These mistakes and the failure of hospitals to quickly identify them offer a rare look into the vulnerability of patient safeguards at a time when increasingly complex, computer-controlled devices are fundamentally changing medical radiation, delivering higher doses in less time with greater precision than ever before.

Serious radiation injuries are still infrequent, and the new equipment is undeniably successful in diagnosing and fighting disease. But the technology introduces its own risks: it has created new avenues for error in software and operation, and those mistakes can be more difficult to detect. As a result, a single error that becomes embedded in a treatment plan can be repeated in multiple radiation sessions.

Image via Wikipedia

Many of these mistakes could have been caught had basic checking protocols been followed, accident reports show. But there is also a growing realization among those who work with this new technology that some safety procedures are outdated.

“Scientific societies haven’t been able to keep up with the rapid pace of technical improvements,” said Jeffrey F. Williamson, a professor of radiation oncology, who leads the medical physics division at the Massey Cancer Center at Virginia Commonwealth University in Richmond.

Hospitals, too, are lagging, sometimes failing to provide the necessary financial support to operate the sophisticated devices safely, according to accident reports and medical physicists, who set up and monitor radiological devices. And manufacturers sometimes sell machines before all the software bugs are identified and removed, records show.

At a 2007 conference on radiation safety, medical physicists went so far as to warn that radiation oncology “does indeed face a crisis.” The gap between advancing technology and outdated safety protocols leaves “physicists and radiation oncologists without a clear strategy for maintaining the quality and safety of treatment,” the group reported.

Image via Wikipedia

Government regulators have been slow to respond. Radiation accidents are chronically underreported, and a patchwork of laws to protect patients from harm are weak or unevenly applied, creating an environment where the new technology has outpaced its oversight, where hospitals that violate safety rules, injure patients and fail to report mistakes often face little or no punishment, The New York Times has found.

In this largely unregulated marketplace, manufacturers compete by offering the latest in technology, with only a cursory review by the government, and hospitals buy the equipment to lure patients and treat them more quickly. Radiation-generating machines are so ubiquitous that used ones are even sold on eBay.

“Vendors are selling to anyone,” said Eric E. Klein, a medical physicist and professor of radiation oncology at Washington University in St. Louis. “New technologies were coming into the clinics without people thinking through from Step 1 to Step 112 to make sure everything is going to be done right.”

A national testing service recently found unacceptable variations in doses delivered by a now common form of machine-generated radiation called Intensity Modulated Radiation Therapy, or I.M.R.T. To help institutions achieve more consistency, an association of medical physicists issued new I.M.R.T. guidelines in November.

The problems also extend to equipment used to diagnose disease.

More than 300 patients in four hospitals — and possibly many more — were overradiated by powerful CT scans used to detect strokes, government health officials announced late last year. The overdoses were first discovered at Cedars-Sinai Medical Center, a major Los Angeles hospital, where 260 patients received up to eight times as much radiation as intended.

Those errors continued for 18 months and were detected only after patients started losing their hair. The federal Food and Drug Administration is still struggling to understand and untangle the physics underlying the flawed protocols. The F.D.A. has issued a nationwide alert for hospitals to be especially careful when using CT scans on possible stroke victims.

Although the overdoses at Cedars-Sinai were displayed on computer screens, technicians administering the scans did not notice. In New York City, technologists who also did not watch their treatment computers contributed to two devastating radiation injuries documented in an article in The Times on Sunday.

The incidents not only highlight the peril of placing too much trust in computers, they also raise questions about the training and oversight of medical physicists and radiation therapists.

Despite the pivotal role medical physicists play in ensuring patient safety, at least 16 states and the District of Columbia do not require licensing or registration. “States can be either very tough or very lax,” said Dr. Paul E. Wallner, a director of the American Board of Radiology.

Eight states allow technologists to perform medical imaging other than mammographies with no credentials or educational requirements.

In those states, said Robert Pizzutiello, a medical physicist in New York who is part of a movement to license all medical physicists, “you could drive a truck in the morning and operate an X-ray in the afternoon.”

Turmoil at the V.A.

Frederick Stein, an Army veteran from New Jersey, was already suffering from a delayed diagnosis of laryngeal cancer when he began radiation treatments in late September 2006 at the Veterans Affairs Medical Center in East Orange. Within weeks of starting radiotherapy, his sore throat worsened and a rash appeared along with other skin problems, according to Mr. Stein’s family.

Swallowing became more difficult, causing him to lose weight. His skin eruptions worsened. Mr. Stein’s pain became so severe, he needed an injection of morphine. More painkillers followed. The hospital stopped chemotherapy, figuring it was causing his problems. But his condition continued to deteriorate.

If Mr. Stein’s skin damage was a mystery to his doctors, two therapists — Alisha High and Lorraine Raymond — had already concluded that he was being overradiated. Ms. High was so concerned that in December 2006 she refused to administer the radiation, records show. The next day, Ms. Raymond expressed her concerns as well.

The protest did not go over well. Their supervisor, Kirk Krickmier, admonished them for questioning doctors and the physics department, and later that month, both therapists were fired by the agency that had placed them in the veterans’ hospital, Rosato Associates, according to a lawsuit Ms. High and Ms. Raymond filed against Rosato.

Mr. Stein died of cancer in 2008 at age 71, but not before the hospital admitted that he had been overradiated. His wife, Eileen Stein, said the botched radiation treatments had shortened his life. “Oh, it was just awful,” Ms. Stein said in an interview. “They cooked him something terrible. He suffered awful.”

Ms. High and Ms. Raymond declined to be interviewed for this article. Steven Menaker, a lawyer who represented Rosato Associates, said his client disputed their account of why they left the hospital. Mr. Krickmier declined to be interviewed about the case, which has been settled.

It turned out that Mr. Stein was not the only victim. Having learned of the therapists’ complaints on Dec. 20, 2006, hospital administrators tracked them down a month later and interviewed them, according to Veterans Affairs. A week later, the director of the East Orange facility, Kenneth H. Mizrach, ordered the radiotherapy unit to stop accepting new patients, pending a full investigation.

That investigation found that of 160 cases reviewed, 56 patients were treated incorrectly for cancer of the prostate, head and neck, lung, breast and two other malignancies. Thirty-six had been overradiated and 20 more subjected to “errors in technique,” the hospital said. Although the patients were informed, the findings had not been publicly revealed until The Times uncovered them.

According to a confidential report by the American College of Radiology, which had been brought in to study the situation, the hospital’s radiotherapy unit was out of control: medical personnel lacked the training and knowledge to safely administer I.M.R.T. treatments, quality control was virtually nonexistent, vital safety procedures were performed by unqualified employees, and patients had little or no follow-up.

“Discontinuation of I.M.R.T. treatment is STRONGLY recommended until additional training is obtained by all staff including the physicians,” the college said. The reviewers reminded the hospital that the new technology was “VERY labor intensive, and requires not just sophisticated hardware and software, but a lot more training.”

The college said medical personnel were “really pushing the envelope of tolerances” and that nonphysicians were apparently approving — in the physician’s name — certain steps in the treatment process.

Investigators found that without proper follow-up, there was no way for the hospital to know whether its cancer treatments were successful or whether there were complications. In addition, the college of radiology found no evidence of peer review, quality assurance meetings, outcome studies or mortality and morbidity (known as M&M) conferences, where doctors meet to review cases.

“Several charts reviewed indicated that treatment had been discontinued or at least interrupted by a patient’s worsening condition, or in a few cases death, but there was no M&M review of these issues,” the report said. A spokeswoman for the V.A. said most of the affected patients suffered no apparent harm.

The unit remains closed; it is expected to reopen soon with all new personnel and equipment. “It took a long time to get here — three years in the making,” Mr. Mizrach said. “Without question, this was a dark part of this medical center, but I would hate this to be a defining moment of what this institution is about.”

Checks and Errors

When inspectors from the Radiological Physics Center, a federally financed testing service, arrived at the Moffitt Cancer Center in Tampa, Fla., in 2005, they uncovered something alarming: a miscalibrated machine that overradiated 77 brain cancer patients by 50 percent in 2004 and 2005.

A new linear accelerator had been set up incorrectly, and the hospital’s routine checks could not detect the error because they merely confirmed that the output had not changed from the first day.

“Errors of this magnitude are very rare,” said Geoffrey S. Ibbott, director of the physics center. But the center’s tests have shown that inaccuracies in the delivery of machine-generated radiation are not uncommon.

Dr. Ibbott’s group also reported in 2008 that among hospitals seeking admission into clinical trials, nearly 30 percent failed to accurately irradiate an object, called a phantom, that mimicked the human head and neck. The hospitals were all using I.M.R.T., which shapes and varies the intensity of radiation beams to more accurately attack the tumor, while sparing healthy tissue.

“This is a sobering statistic, especially considering that this is a sample of those institutions that felt confident enough in their I.M.R.T. planning and delivery process to apply for credentialing and presumably expected to pass,” said a task group investigating I.M.R.T. guidelines for the American Association of Physicists in Medicine.

The group’s report, published in November, said the failure rate “strongly suggests” that some clinics had not adequately performed the initial tests to make sure their equipment was set up correctly.

“Errors like the one at Moffitt, and other errors that we have detected at other facilities, would be much less likely to have occurred if, every time a new piece of radiation therapy equipment were installed, there was some sort of independent check of the type that we do,” Dr. Ibbott said in an interview last year. “If we had gone to Moffitt eight months earlier, perhaps none of those patients would have received the higher dose.”

Another set of tests from 2000 to 2008 found that 15 percent to 20 percent of hospitals using linear accelerators in clinical trials had at least one radiation beam outside the acceptable range.

“We haven’t been sufficiently outspoken about this, although we are now in the process of correcting that,” said Dr. Ibbott, whose group is based at the M. D. Anderson Cancer Center in Houston.

Hospitals sometimes embrace new technologies before medical personnel can agree on how best to use them.

James Deye, a program director in radiation research at the National Cancer Institute, watched with concern as the popularity of I.M.R.T. exploded before there were national standards. Dr. Deye said he established minimum I.M.R.T. guidelines for institutions wishing to participate in cancer trials. “The community was going along merrily and happily without those guidelines,” he said.

Dr. Ibbott’s testing service can help clinics improve the performance of their linear accelerators if they are in clinical trials. Operators not in trials can pay to have their units tested by a sister group of the Physics Center. Even so, many do not.

“There are clearly places that don’t avail themselves of the service, even though it is well known and very affordable,” Dr. Ibbott said. “I guess they don’t want someone else checking them for some reason.”

In radiotherapy, eschewing an outside, independent review is a calculated gamble.

“If you radiate a person wrong, there’s no repeat — you can’t say, ‘Let’s forget about that one and do it correct next time,’ ” said George X. Ding, a medical physicist at the Vanderbilt Center for Radiation Oncology in Nashville. “It’s not like you do a measurement of a phantom and it went wrong and you can do it again.”

Steeper Learning Curve

Last fall, in the vast exhibition hall at McCormick Place in Chicago, dozens of companies from around the world displayed their latest radiological weapons in the war on cancer.

“That’s our newest linear accelerator,” said Hans-Jörg Freyer of Siemens Healthcare, standing in front of his company’s Artiste model, which combines imaging with therapy. Sophisticated, yet easy to use, it is capable of treating 80 patients a day, Mr. Freyer said.

Dee Mathieson, of the Swedish company Elekta, said imaging technology in their linear accelerator improved accuracy. “What has changed is the software that allows us to unleash some of these new techniques,” Ms. Mathieson said.

Over the last two decades, the industry has developed generations of machines, each designed to more precisely attack tumors, allowing doctors to administer higher doses of radiation with less risk to healthy tissue.

Linear accelerators once used radioactive beams crudely shaped as blocks or rectangles. Since tumors do not grow in straight lines, healthy tissue was sometimes irradiated along with the cancer. To minimize collateral damage, technicians manually inserted blocks and filters, a task later taken over by computers.

Computers eventually were able to produce three-dimensional images of tumors — a major advancement — and linear accelerators used software that contoured beams to conform to the shape of the tumor. The next step, I.M.R.T., allowed doctors to more precisely tailor the shape and intensity of the beams. The latest generation of machines, which were on display at McCormick Place, incorporates sophisticated imaging.

The F.D.A. waved these advancements through with little review on the grounds that they just extended existing technology. But there are dissenters. “It’s so much more than that,” said Dr. Deye, the National Cancer Institute official. “The issues surrounding advanced technologies are far-reaching.”

Even if the devices work as intended, hospitals face a steep learning curve.

In 2005, when Landreaux A. Donaldson underwent therapy for prostate cancer at Mary Bird Perkins Cancer Center in Baton Rouge, La., the linear accelerator was so new the vendor’s training instructors were still in the hospital, records show. The accelerator delivered radiation in a radically different way, emitting tiny beams of radiation from many points on a spiral encircling the patient.

In treating Mr. Donaldson, the hospital used the wrong type of CT treatment scan for the machine, prompting medical personnel to compensate by doing what is called “a work around” — a departure from established procedure. But because they were unfamiliar with the treatment planning software, they made a miscalculation that affected all 38 treatments, stretching over two months, according to state records and a lawsuit filed by Mr. Donaldson.

The next year, Mr. Donaldson began experiencing stomach ulcers, anemia and urethral stricture, which required surgery. He also underwent hyperbaric oxygen treatments, where pure pressurized oxygen is used to promote healing. Neither the hospital nor Mr. Donaldson would comment on the lawsuit, which has been settled.

As therapies become more complex, there is more to check — sometimes too much, say some medical physicists.

“When it exceeds certain levels of complexity, there is not enough time and not enough resources to check the behavior of a complicated device to every possible, conceivable kind of input,” said Dr. Williamson, the medical physicist from Virginia.

As the person most responsible for ensuring that an optimal radiation dose is delivered safely, the medical physicist must make sure that new machines are set up properly; that daily warm-up checks are carried out, along with more extensive monthly and annual evaluations; and that individual treatments are administered as prescribed.

Computers can provide only so much help. In the past, they checked the work of radiotherapists, but now therapists check the computers, said Howard I. Amols, chief of clinical physics at Memorial Sloan-Kettering Cancer Center in New York.

The problem, Dr. Amols said, is that computers are better at checking humans than humans are at checking computers. “The responsibility on Day 1 to make everything right is much more important than it used to be,” he said. “We are still grappling with how we do that.”

Hospitals sometimes aggravate the problem, buying new technology without adding the employees needed to operate it safely, according to a report issued on a 2007 conference sponsored by two radiological associations and the National Cancer Institute.

And hospitals complain that manufacturers sometimes release new equipment with software that is poorly designed, contains glitches or lacks fail-safe features, records show.

Northwest Medical Physics Equipment in Everett, Wash., had to release seven software patches to fix its image-guided radiation treatments, according to a December 2007 warning letter from the F.D.A. Hospitals reported that the company’s flawed software caused several cancer patients to receive incorrect treatment, government records show.

In another case, an unnamed medical facility told federal officials in 2008 that Philips Healthcare made treatment planning software with an obscure, automatic default setting, causing a patient with tonsil cancer to be mistakenly irradiated 31 times in the optic nerve. “The default occurred without the knowledge of the physician or techs,” the facility said, according to F.D.A. records.

In a statement, Peter Reimer of Philips Healthcare said its software functioned as intended and that operator error caused the mistake.

Patchwork of Regulation

When George Garst was treated in 2004 for prostate cancer at Christus Spohn Hospital in Corpus Christi, Tex., his caregivers were subject to the following regulations:

The first half of his radiation treatment — external beam therapy — was overseen by the state radiological division operating under one set of rules. The second half of his treatment — radioactive seeds — was subject to a second set of rules established by the Nuclear Regulatory Commission, except that the commission passed its responsibility on to the state, which must follow some, but not all, of the commission’s rules. In any case, the second rules differ from the first.

State radiology officials have no enforcement power to punish a clinic if it botched the first half of a procedure like Mr. Garst’s, but they can for the second half. If any radiation equipment failed to work properly, resulting in a serious injury, that must be reported to the federal Food and Drug Administration, the manufacturer and the state.

As it turned out, Mr. Garst was overdosed and seriously injured, destroying his ability to urinate and move his bowels normally. Before two external bags were attached to collect his waste, Mr. Garst’s urine leaked into his rectum because a fistula had developed. He had so many infections, his doctors had to keep trying new antibiotics to replace those that no longer worked.

“He was very, very sick from all this,” said Dr. Norbert C. Brehm, one the doctors who treated Mr. Garst after the accident. “He was not sleeping. He had a feeling of worthlessness, hopelessness, appetite disturbance, mood swings.”

And yet, until The Times began investigating Mr. Garst’s injuries, no one in government — not Texas, not the Nuclear Regulatory Commission — was even aware of his overdose or of his devastating injuries.

The state and the commission initially told The Times that they had no jurisdiction in the case since neither the first nor second treatment was by itself an overdose, even though in combination they were. Despite their mandate to protect patients from radiation mistakes, the state and federal government said in essence that Mr. Garst was someone else’s problem.

Had regulators investigated, they would have found reasons for concern.

The medical physicist later said he had been overworked, rarely taking a day off, and that he had complained to hospital officials about staffing issues. Mr. Garst’s radiation oncologist failed to prescribe a dosage for the implanted radioactive seeds, and the actual dose ended up being too high, according to a lawsuit filed by Mr. Garst. The physicist then failed to catch the mistake. The oncologist also implanted seeds too close to Mr. Garst’s rectum, the physicist delayed performing a post-implant analysis, and the oncologist failed to promptly report the overdose to the patient’s doctor.

Mr. Garst said he did not learn of his overdose until about a year later.

In response to inquiries by The Times, the Nuclear Regulatory Commission said the state had opened an investigation into Mr. Garst’s care. “They’re going to look at why the licensee didn’t report it — was there a deficiency in their procedures or training?” said James G. Luehman, a deputy director in the commission.

Last week, Texas reported that its investigation had found no violations of state radiation regulations. The hospital declined to comment on the case, which has been settled.

Mr. Garst said that medically, he was at a dead end. “They couldn’t really do anything for me because I’m so burned up,” he said.

Last year, health officials in eight states sent a letter to Congress asking for a more rational way to regulate radiation. “There is no national program charged with the protection of the public from all radiation sources,” the letter stated. “Federal agencies pressure the states, most of which have comprehensive radiation programs, to provide protection from certain sources of radiation while ignoring other sources.”

Kirksey Whatley, director of the Alabama Office of Radiation Control, said radioactive materials, which are overseen by the N.R.C., received most of the government’s attention, while the much more common machine-generated radiation was largely unregulated by the federal government.

Thirteen states, including California, do not require that errors involving linear accelerators be reported to state health officials. Texas requires that they be reported, but has no enforcement authority to punish anyone. New York rarely fines radiotherapy units for substandard care, while Florida frequently does.

Part of the problem is that hospitals may skimp on quality assurance because, depending on the state, it is voluntary, medical physicists say.

Jared W. Thompson, an Arkansas radiation official, said he mostly worried about diagnostic radiation. “There are no limits about what can be done, how it can be used, when it is considered unsafe,” Mr. Thompson said.

There are no guarantees, Mr. Whatley said, that radiological devices have been inspected and that its operators are properly trained and qualified. Depending on the state, he added, “you may get two to three times more of the radiation you need.”

Even when overdoses occur, some medical practitioners are reluctant to publicly disclose them. An N.R.C. advisory group underscored that point when in 2005 it recommended that the agency adopt the “industry standard” when responding to a radiation error, called a medical event, or M.E. “Keeping M.E. reports, or at least the licensee’s identity out of the public record, is probably the single most useful improvement N.R.C. could make in this regard,” the advisory committee urged.

The commission rejected that recommendation.

Responding to Mistakes

Under Ohio law, Akron General Hospital was obliged to file a detailed written report no later than 15 days after it overdosed Myra Jean Garman, 76, a breast cancer patient, with high-dose radioactive seeds.

Instead, Akron General waited five months, records show.

Just two months before Mrs. Garman’s accident, at the same hospital, another patient was overdosed with 111 radioactive seeds that were too powerful. When the Ohio Bureau of Radiation Protection inspected the facility, it found that the hospital’s radiation safety officer was not even aware of the accident. Nor did the hospital’s radiation safety committee discuss the overdose when it met for its regular meeting, state regulators said.

Mrs. Garman’s accident occurred in September 2006, when she received twice her prescribed dose five separate times because a physicist had “entered an incorrect magnification factor into the treatment planning computer,” according to state regulators.

Five months later, she complained of severe pain, and doctors discovered that she had broken ribs, a known side effect of her type of overdose. Mrs. Garman’s daughter, Joyce Lilya, said her mother, who had walked two miles daily before the procedure, could now barely walk two blocks.

Even though her cancer did not reappear, a year after the overdose, Mrs. Garman ended up in intensive care with breathing troubles. No cause could be determined, her daughter said.

A month later, Mrs. Garman took an overdose of Tylenol, tied a plastic bag around her head and killed herself. “I was really trying, but it was too much for me,” she said in a note. “Let me go!!! Please.”

Ms. Lilya said she and her family were stunned, calling her mother a “positive person” who would never hurt herself even though her husband had died several months earlier. Seeking reasons for her mother’s suicide, Ms. Lilya began searching the Internet and reached out with dozens of calls and e-mail messages to professional groups and government agencies.

Only then, she said, did she learn of the radiation overdose. Much to her surprise, the state had cited the hospital only for failing to promptly report the mistake to state authorities. There was no fine. And while Mrs. Garman’s medical records show that she had asked for a written account of her overdose, the hospital could produce no such document nor was one in her medical file.

James Gosky, a spokesman for Akron General, said in a recent interview that Mrs. Garman had been informed of her overdose.

Still, Ms. Lilya said, “none of this made any sense.” So she kept pressing — without success — for a more thorough investigation of her mother’s accident.

In a conference call last summer, she said Lance D. Himes, assistant counsel for the Ohio Department of Health, explained part of the department’s enforcement philosophy.

“He told me they don’t get into assessing penalties because that is what malpractice is for,” she said.

A spokesman for the state said Mr. Himes denied making that statement. And in October 2007, the state did fine the hospital $4,000 for other infractions — but not for Mrs. Garman’s overdose.

Ms. Lilya said her investigation had taught her much about how hospitals respond when they make a mistake. “It has been a long and tragic journey for my family,” she said, And, she added, “No one was held accountable.”

Reporting was contributed by Simon Akam, Renee Feltz, Andrew Lehren, Kristina Rebelo and Rebecca R. Ruiz.

Jan 21, 2010

Hospitals: Radical Cost Surgery

Image by cobalt123 via Flickr

A hospital that slashes costs—and delivers high-quality care as it innovates? Yes, it exists

By Catherine Arnst

Walk into most hospitals, and you'll see patients scattered about the halls on gurneys or wheelchairs. They're waiting to be moved from intensive care to a standard ward, or to an X-ray room, or to physical therapy. Each journey adds to the patient's discomfort and increases the risk of infections and other complications. Tally up a single patient's migrations over 24 hours, and they may consume as much as half a day of staff time.

Walk into Providence Regional Medical Center, in Everett, Wash., and you will see a hospital trying something different: It brings the equipment to the patient. In 2003, Providence opened one of the few "single stay" wards in the nation. After heart surgery, cardiac patients remain in one room throughout their recovery; only the gear and staff are in motion. As the patient's condition stabilizes, the beeping machines of intensive care are removed and physical therapy equipment is added. Testing gear is wheeled to the patient, not the other way around. Patient satisfaction with the "single stay" ward has soared, and the average length of a hospital stay has dropped by a day or more.

This is just one of many changes—some radical, many quite small—that have enabled Providence Regional to join a special subset of American hospitals: those that do not lose money on Medicare patients.

Almost 60% of U.S. hospitals report losing 20 cents on the dollar for every elderly patient that comes through their doors. They make up the difference by charging the under-65s a far higher fee. But Providence breaks even on the elderly, even though Medicare pays about $1,000 less per enrollee in the hospital's region than the national average. The hospital accomplishes this feat while winning a doctor's satchel full of national awards for top-notch care, placing it among the elite 5% of all U.S. hospitals.

High quality at a low price. Every other industry strives for that combination, but a hospital that does both is all too rare. Providence and its cost-efficient brethren demonstrate that quality care can be delivered at an affordable price, provided hospitals can be persuaded to rethink decades-old practices.

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The crazy world of hospital economics does not offer a lot of incentives to change. Both Medicare and private insurers reimburse on a piecework basis—known as fee-for-service—that encourages hospitals to treat more, prescribe more, and test more. Economists refer to this arrangement as a "value-blind" payment system since no premium is paid for quality.

Consequently, hospitals have no financial motivation to invest in productivity-enhancing computer technology, management experts, or efficiency research—and by and large, they don't. Columbia University economist Frank Lichtenberg calculates that productivity growth for the hospital industry has increased at less than half the rate of the general economy.

There are no proposals in either the House or Senate reform bill to scrap the fee-for-service system. As a result, the Congressional Budget Office expects the legislation to do little to halt the medical inflation that has pushed health-care spending to 16.2% of the gross domestic product. Because hospitals are among the largest employers in many congressional districts, their political clout protects them from reforms that would cause any real financial pain.

But even under a value-blind system, there are ways to "bend the cost curve," an oft-stated goal of President Barack Obama. The nonprofit Institute for Healthcare Improvement last year identified 70 regions around the country, out of a total of 306, where high-quality care is delivered at a reasonable cost. One of those regions is Everett, home of Providence Regional.

Providence is the only hospital in this coastal city of 98,000 people located 20 miles north of Seattle. It is the third-largest hospital in Washington, with two campuses serving 25,000 overnight patients a year, and operates the second-busiest emergency room in the state. It's building a $500 million, 368-bed tower, due to open next year, that will double its capacity.

What sets Providence apart from its peers is not size or location but its ability to operate within a Medicare-designated budget. The majority of U.S. hospitals have the market power to demand higher reimbursements from private insurers to make up for what they see as insufficient payments by Medicare. Because of a wave of consolidation in the 1990s, when more than 900 hospitals merged (including the two medical centers that created Providence Regional), some 90% of the U.S. population that lives in metropolitan areas is now served by just one or two hospital networks. "Hospitals simply don't need to be efficient," says Dr. Robert A. Berenson, a leading health-care economist and member of MedPAC, an independent agency that advises Congress on Medicare. "They are able to get payment differentials from the private sector of 30% to 35% over what Medicare pays." In some markets, it's 50% to 100%, he says.

Providence doesn't have enough private payers to engage in such fee-shifting. Forty percent of its annual revenues come from Medicare, and an additional 13% from Medicaid. Commercial insurers account for only 39%. Dependence on Medicare has forced it to focus on taking costs out of its operation rather than maximizing revenues.

To get those savings, the hospital tries to standardize best practices whenever possible. "There is a tremendous variation in medical delivery that is not quality driven," complains Dr. James Brevig, director of cardiac surgery at Providence. Doctors and nurses are often reluctant to analyze and change their methods because it would mean revamping long-accepted treatments or routines. As a result, says Brevig, "there are no standards in hospitals. Why is that? It's crazy. No other industry is like this."

Providence took a different path after picketing by workers nine years ago reflected a shattered morale. A new administration decided to attack the internal staff divisions and foster collaboration among doctors, nurses, and administrators. Everyone is encouraged to contribute ideas on driving down costs and improving patient outcomes. "I'm eligible for retirement, and under the prior leadership I would have left," says pediatric nurse Kathy Elder, a 34-year veteran of Providence. "They were very hierarchical, very closed. There was a lack of trust all around."

The current CEO, 48-year-old David T. Brooks, a fast-talking Detroit native, took over two years ago. He says the administration is open to suggestions from any and all staffers. "We have scorecards for everything around here, which measure both quality and efficiency. If all we had were great clinical outcomes but costs kept rising, that just wouldn't be good enough."

The staff embraced the challenge to innovate. The nursing team came up with the idea of checking on patients every two hours without waiting for a call button, to see if they need help walking to the bathroom or moving about their rooms. Ten percent of fatal falls by the elderly in the U.S. occur in hospitals. This one change at Providence reduced falls by 25%, according to chief nursing officer Kim Williams. "We believe we'll see more improvement over the next six months."

CONTROVERSIAL PRACTITIONERS

One of the bigger changes at Providence, implemented in 2003, is to place the day-to-day care of almost all its inpatients in the hands of hospitalists, a new type of doctor that has emerged in the last decade. Unlike primary care physicians, who usually visit their patients only early in the morning or late at night, hospitalists are available around the clock, checking that medications are administered properly, chart orders followed, and infection risks minimized. About 37% of Medicare inpatients are attended by hospitalists nationwide, and several studies have associated their use with better outcomes. Providence has also published data showing that infections, lengths of stay, and surgical complications have dropped since starting its own program.

But hospitalists are still controversial in many communities, because primary care physicians are wary of giving up control of their patients, along with their share of inpatient fees. Dr. Joanne C. Roberts, one of the first hospitalists at Providence, has not seen this conflict in Everett, possibly because most of the hospitalists and primary care doctors are associates at one large medical practice, Everett Clinic. That's not true everywhere, she says. "In another community where I worked, independent doctors were pretty hostile. Everyone was trying to grab part of the money. That just doesn't happen here."

The lack of hostility could be because Washington attracts people who appreciate the region's quality of life. The ocean on one side of Everett and the Cascade Mountains on the other are their own kind of bonus. "It helps that most doctors don't move to the Seattle area just to get rich," says Dr. William M. Wisbeck, a radiation oncologist at Providence.

It also helps that Providence has no competition nearby. "We don't have to engage in a medical arms race," says Dr. Lawrence M. Schecter, chief medical officer. Instead, a 20-member Value Analysis Committee consisting of doctors, nurses, and administrators scrutinizes every proposal for a major equipment purchase to determine if it is warranted in terms of patient need, rather than to keep up with the competition or to increase billings.

Providence's savings efforts don't stop at the hospital doors. It offers financial training courses to the 800 independent doctors affiliated with the hospital in an effort to get them thinking about cost efficiencies. That's no easy task, however, since savings don't necessarily flow into their pockets. Cutting back on unnecessary services may be better for the bill payer, but it lowers the income of doctors and hospitals.

Thus there is no national rush to imitate Providence's strategies. The Centers for Medicaid & Medicare Services, which administers Medicare, tries to encourage fiscal restraint through its reimbursement rates, but hospitals consistently argue that these rates are too low. MedPAC estimates seem to support this position—it calculates that hospital Medicare margins were -7.2% in 2009. But overall operating margins are far more robust. Thanks to income from private insurers, the nation's 5,000 nonprofit hospitals had a median operating margin of 8.4% in the second quarter of 2009, according to a Thomson Reuters (TRI) analysis. Health insurers, by comparison, had a median margin of less than 4%.

Brooks says Providence's 2009 operating margins were 6%, despite its heavy dependence on Medicare. Reaching that level is a challenge. As the only major hospital in a fast-growing county, Providence must provide every kind of medical service. Thus its lucrative cardiology unit and high-tech cancer centers are offset by an obstetrics ward that delivers 4,000 babies a year. The hospital loses money on almost every one of those births. Providence also has to absorb some $16 million in unpaid bills each year, more than any other Washington hospital except a public facility in Seattle.

Charity care fulfills a moral mission at Providence that sometimes trumps economics. The hospital is owned by the Sisters of Providence, a Canadian order of Catholic nuns founded in 1843 to minister to the poor. "Everything we do has to uphold our core values," says Brooks. "Our mission doesn't end with our business goals."

DOING PENANCE

But business goals and social mandates do sometimes align. To make life easier for dying patients, Providence opened a hospice in 2003 that offers palliative treatments. Patients tend to express relief when offered the option of hospice over hospital care, says Dr. Roberts, the hospitalist who helped start the program. She recalls one day last fall when the palliative care staff was asked to consult on two patients who, between them, had been admitted 35 times to the hospital within 12 months. "As a result of calm discussions with patients and families regarding their goals for their own care and future, both were referred to hospice," she says. Roberts estimates that Medicare saves an average of $3,120 on patients who choose hospice over drastic interventions.

Providence also seeks to soften contentious encounters among doctors and patients by doing penance for errors. The hospital set up an independent panel to investigate medical mistakes, disclose its findings to the patient, and voluntarily offer a financial award if warranted. As a result, Providence has only two malpractice suits pending, compared with an average of 12 to 14 at other hospitals of similar size.

When Providence can't find standard medical practices, it innovates. That was the case with blood transfusions. Cardiac and orthopedic surgeons realized a few years ago that there was no widely accepted data on the optimal amount of blood to give patients during surgery, despite the $240 cost per bag. Dr. Brevig started looking around and found several studies that correlated greater transfusion volumes with longer patient stays and higher infection rates.

He was particularly surprised that transfusion rates varied greatly from hospital to hospital, regardless of the patient's status. "The variations were related to the culture of the hospital, not the decisions of the doctor," he says. Brevig set out to create a low-transfusion culture at Providence. He got surgeons to slow down because speedy operations cause more blood loss. Settings were changed on heart bypass machines to save blood, and the hospital hired a blood conservation coordinator. In a study of 2,531 operations at Providence, Brevig reported that the incidence of transfusions was reduced to just 18% in 2007, from 43% in 2003, while the average patient stay was reduced by half a day. The changes have saved Providence an estimated $4.5 million.

Brevig has been proselytizing for his plasma practices at medical meetings, but to little avail. Only some 200 U.S. hospitals have a blood conservation program. Since patients are billed the cost of the plasma, doctors aren't motivated to change their habits.

There is also the fear that cutbacks on services will lead to accusations of rationing. Dr. Donald Berwick, president of the Institute for Healthcare Improvement and a longtime campaigner for better, safer hospitals, says this attitude must be revamped. In a recent speech he called on hospitals to reduce costs by 10% over the next three years without harming care. In almost every case, he noted, fewer interventions and adherence to standards lead to better medical outcomes. "Doctors and patients alike need to realize that the best health care is the very least health care that we need," he said. "The best hospital bed is empty, not full."

Dec 21, 2009

The Virtual Visit May Expand Access to Doctors

By CLAIRE CAIN MILLER

SAN FRANCISCO — Americans could soon be able to see a doctor without getting out of bed, in a modern-day version of the house call that takes place over the Web.

Image by leoncillo sabino via Flickr

OptumHealth, a division of UnitedHealth Group, the nation’s largest health insurer, plans to offer NowClinic, a service that connects patients and doctors using video chat, nationwide next year. It is introducing it state by state, starting with Texas, but not without resistance from state medical associations.

OptumHealth believes NowClinic will improve health care by ameliorating some of the stresses on the system today, like wasted time dealing with appointments and insurance claims, a shortage of primary care physicians and limited access to care for many patients.

But some doctors worry that the quality of care that patients receive will suffer if physicians neglect one of the most basic elements of health care: a physical exam.

“This is a pale imitation of a doctor visit,” said David Himmelstein, a primary care doctor and associate professor at Harvard Medical School. “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.’ ”

Others, including Rashid Bashshur, director of telemedicine at the University of Michigan Health System, say online medicine is a less expensive way of providing routine care.

Image by Ben Dodson via Flickr

“The argument that you need the ‘laying on of hands’ to practice medicine is an old and tired argument that simply has no credibility,” he said. “There are two constants in medicine: change and resistance to change.”

Christopher Crow, a family physician in Plano, Tex., who used the system during its test period, said, “NowClinic gives you the ability to have that gut feel if something is wrong, in tone or facial expression or body language, that you have when you walk in the door with a patient.”

Many patients who do not have primary care physicians nearby use the emergency room for routine problems. Wait times for patients needing immediate attention have increased 40 percent, in part because of overcrowding, according to a study by Harvard Medical School and Cambridge Health Alliance.

In Texas, 180 counties do not have enough physicians, 70 percent of patients cannot obtain a same-day visit with their primary care doctor, and 79 percent of emergency room visits are for routine problems, according to OptumHealth.

“We are, through this technology, replenishing the pool of physicians and making them available to patients,” said Roy Schoenberg, chief executive of American Well, which created the system that OptumHealth is using.

For $45, anyone in Texas can use NowClinic, whether or not they are insured, by visiting NowClinic.com. Doctors hold 10-minute appointments and can file prescriptions, except for controlled substances. Eventually they will be able to view patients’ medical histories if they are available.

The introduction of NowClinic will be the first time that online care has been available nationwide, regardless of insurance coverage.

American Well’s service is also available to patients in Hawaii and Minnesota, through Blue Cross Blue Shield, and to some members of the military seeking mental health care, through TriWest Healthcare Alliance.

Some hospitals and technology companies provide similar services on a smaller scale, including Cisco, the networking equipment maker, which uses its videoconferencing technology to remotely connect employees with doctors. It is working with UnitedHealth Group to offer the service more broadly.

The service has encountered resistance in states where it is already available. Texas law requires that before doctors consult with patients or prescribe medicine online or over the phone, they form a relationship through means like a physical examination.

The Texas Medical Board, which regulates doctors in the state, is evaluating its telemedicine policies in light of new technologies. But Mari Robinson, executive director of the board, said that an online or telephone exam was inadequate if doctors and patients had not met in person and was “not allowed under our rules.”

After American Well’s service began in Hawaii last year, lawmakers passed legislation that allowed doctors and patients to establish a relationship online, though the Hawaii Medical Association opposed the bill.

“From our perspective, we still are a little bit concerned that a relationship can be established online with no prior relationship,” said April Troutman Donahue, the association’s executive director.

American Well and OptumHealth predict that health care professionals will adapt. “This is new technology, so you have a lot of code written that doesn’t take these medical technologies into account,” said Rob Webb, chief executive of OptumHealth Care Solutions.

Many patients seem ready to embrace the new technology. In a recent study, a Harvard research team at Beth Israel Deaconess Medical Center found that patients were comfortable with computers playing a central role in their health care and expected that the Web would substitute for face-to-face doctor visits for routine health problems.