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Tony Mira, Chairman and Chief Executive Officer of MiraMed

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Telemedicine in Anesthesia: Perioperative Medicine’s Newest Disruptor?

​Summary: The use of telemedicine to streamline care, reduce costs without compromising quality, and enhance patient satisfaction and engagement among a highly technology-connected population of healthcare consumers shows promise in the delivery of perioperative services. We offer highlights of a presentation on telemedicine in anesthesia at ANESTHESIOLOGY® 2018 in San Francisco.

Telemedicine—the use of technology to deliver healthcare, health education or health information from a distance—is altering the healthcare paradigm. And, as shown in a session at ANESTHESIOLOGY® 2018 in San Francisco, it's beginning to take off in perioperative medicine as well.

The rapid aging of the United States population, the rising prevalence of chronic diseases, a shortage of healthcare professionals, particularly in rural areas, the need for more affordable treatment options to contain healthcare costs and improvements in telecommunication infrastructure are all joining to drive telemedicine's growth. Globally, the telehealth market is predicted to reach $19.5 billion by 2025, according to Transparency Market Research. A report by Business Insider suggests that 2018 could be the tipping point for the telehealth market, with the proliferation of mobile technology spurring adoption.

Recognizing the constellation of forces, the Centers for Medicare and Medicaid Services (CMS) has included several amendments in the proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program designed to improve reimbursements for remote patient monitoring (RPM) and telehealth programs.

The AMA has introduced new codes in the 2019 Current Procedural Terminology (CPT®) code set that would allow physicians to bill for some RPM services and internet consultations. Acceptance of the new codes by CMS in the 2019 Physician Fee Schedule "would signal a landmark shift to better support physicians participating in patient population health and care coordination services that can be a significant part of a digital solution for improving the overall quality of medical care," AMA President Barbara L. McAneny, MD, said.

Also fueling telemedicine's growth is the rise of a new type of healthcare consumer, said Nirav V. Kamdar, MD, MPP, in his presentation at the ASA meeting. This is a highly technology-connected healthcare consumer with expectations for "just-in-time" medical care that echoes the immediacy and convenience of the overnight Amazon Prime deliveries and Uber or Lyft rides that are a routine part of their lives.

"When they want goods or a service, they essentially want it now," said Dr. Kamdar, who is director of quality in the department of anesthesiology and perioperative medicine at Ronald Reagan UCLA Medical Center. "This is a consumer who's going to access the healthcare marketplace with a lot more frequency in the next 20 years, and we need to prepare for that," he said, citing data from the Pew Research Center showing mobile phone penetration in the 18- to 49-year age bracket of 90 percent.

Dr. Kamdar noted that the U.S. leads developed nations in the administrative costs associated with healthcare, making these costs "a prime target for disruption. The current argument about disruptive technologies is that the technology itself gives us a platform to actually bring down some of our costs and bend the cost curve in healthcare. In the realm of telemedicine, we have clear opportunities to make use of that possibility for disruption."

Dr. Kamdar and his anesthesia colleagues at UCLA have begun exploring some of these opportunities in the perioperative space. The group employs an informatics-driven data screen, or smart screen, to help triage patients. This kind of tool can be used to triage patients to: 1) a virtual preoperative visit using a video conferencing tool; 2) an in-person visit at the clinic; or 3) for healthy patients, a bypass of these preoperative visits directly to the operating room. "From there [the smart screen], we determine what they might need in order to optimize their care in the OR," he said.

The UCLA group has completed 250 preoperative evaluations in which patients log in from a tablet, computer or cell phone at home that connects to the electronic medical record. They undergo a comprehensive 30-minute history and evaluation (including documentation time) that includes an examination of neck mobility and the airway. Anesthesiologists can take photos of the patient's airway and embed them directly into the chart.

The group connects patients who have Bluetooth-enabled devices to "patient-entered flow sheets" that capture data remotely and upload it into the chart so that it can be viewed directly from afar. So far, 97 percent of patients have reported that they were satisfied or very satisfied with their telemedicine experiences, and 87 percent reported a preference for the remote versus in-person consultation. "Saving time is a huge correlation to the patient experience," reported Dr. Kamdar, noting that the group has saved more than 8,000 one-way driving miles for patients around the Los Angeles area and throughout California with remote technology. "That can make a huge difference in people's lives," he said.

The UCLA group also has used a variety of consumer-based monitoring tools to improve assessments of functional status and optimize preoperative care. One 66-year-old patient with ischemic cardiomyopathy who presented with severe fluid overload was given a Bluetooth-enabled scale to measure his weight daily before being scheduled for elective total knee replacement surgery. His digital scale sent reports of his weight via patient-entered flow sheets connected with the EMR. The team sent the patient to his local cardiologist immediately after the virtual visit for titration of his diuretics. He was scheduled for surgery when remote monitoring of his weight showed that it had returned to his dry weight.

Dr. Kamdar noted the remaining hurdles facing telemedicine, including the ongoing "paradox" of inadequate reimbursement for telemedicine services in primary care and the specialties, including anesthesia. He said the few billing codes for 30-minute remote consultations are reserved primarily for patients in rural areas. The reimbursement strategies of Medicaid programs differ by state, requiring clinicians to research reimbursement parameters individually. And ongoing controversy surrounding proper E&M billing for anesthesiologists in the preoperative space continues to cloud the reimbursement picture.

Telemedicine also faces a host of regulatory, legal and compliance issues. "The marketplace is bringing things to consumers at a much faster rate, and the obligation we have as clinicians is to know the validity and safety of that data and how we're going to deal with having responsibility for that data—for example, if a patient is bradycardic and 300 miles away."

Despite these hurdles, "the future in terms of telemedicine and using machine learning to aid clinicians in their decision-making capacity can be quite fruitful," Dr. Kamdar said. "It's the 'human/AI care team' going forward."

Is your practice using telemedicine? Please share your experiences.

With best wishes,

Tony Mira
President and CEO

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