Employers looking to reduce health care costs increasingly are offering plans that include e-visits and telemedicine appointments as well as/instead of in-person doctor office visits. Online video or login portal physician visits are cheaper and more convenient for physicians and patients as well. Yet new research results question whether e-visits offer the same kind of care for patients.
The telemedicine model has the advantage of allowing patients to "be seen when you want as quickly as you want," says CEO of STAT Doctors Alan Roga, who points out that telemedicine is particularly attractive in a society that loves instant gratification as much as Americans do. He also considers telehealth benefits a great "turnkey solution for the employer," coming at no cost to them while providing the most accessible kind of care.
Perhaps the strongest case to be made for telemedicine is its potential to keep non-life-threatening ailments out of emergency rooms and prompt care centers. The average cost of an ER visit hit $1,381 last year.
"ER visits have gone up 40% since 1996," Dr. Roga says. "It's not because ERs are doing such a great job; it's not because they don't; [it's that] these people have nowhere else to go."
He continues: "Out of 136 million ER visits [in 2009], at least 20% can be treated virtually. And about 70% of what goes through an urgent care center or primary care doctor can be treated through telehealth as well."
Roga says, "We've got to come up with ways to improve access while focusing on quality and cost-reduction, and that's what the technology allows." He added that the participant response to telemedical services is overwhelmingly positive, with 91% to 98% approval ratings.
E-visits vs. office visits
A new study, however, published this year in JAMA Internal Medicine, indicates there could be treatment differences when a patient is seen in person versus an e-visit. While follow-up rates were comparable, physicians in e-visits did order different care.
University of Pittsburgh and RAND Corporation researchers examined all office visits and e-visits for treatment of two common ailments, sinusitis and urinary tract infection, for 63 internal medicine and family practice physicians. All part of four primary care practices in the Pittsburg area, the physicians had 5,165 in-person and e-visits for sinusitis and 2,954 for UTI, between Jan. 1, 2010 and May 1, 2011.
Laboratory tests related to sinusitis were rare in either type of visit, but doctors were far more likely to order UTI-related lab work for office visits (51%) than for e-consultations (8%). However, for both conditions, physicians were more likely to prescribe an antibiotic to a patient they had not seen in person.
For sinusitis, 99% of telemedicine patients were given an oral antibiotic, compared to 94% of office patients. UTI patients had a far greater discrepancy: 99% of e-visits also ended in a prescription antibiotic, but only 49% of face-to-face visits did.
"The antibiotic prescribed at either type of visit was equally likely to be guideline recommended," reads the report.
Doctors were less likely to call for preventive care in e-visits for either condition.
Again, follow-up rates were steady across the board. "Follow-up rates," Dr. Ateev Mehrotra hastens to point out along with his fellow researchers, "are a rough proxy for misdiagnosis or treatment failure. The lack of difference will therefore be reassuring to patients and physicians."
So, the first piece of good news is e-patients appear to suffer no worse quality of care. The second piece of good news is that "the lower reimbursement rates" for e-visits "outweigh the increase in prescriptions" for a net gain from using the service.
"Our data support the idea that e-visits could lower health care spending," Mehrotra says. "In total, the estimated cost of UTI visits was $74 for e-visits, compared with $93 for office visits."
On its own though, the high prescription rate is troubling, and not just because providers would want to guarantee participants the same care through telemedicine. The study authors had a theory about the gap, though an untested one.
"When physicians cannot directly examine the patient, physicians may use a 'conservative' approach and order antibiotics," they write. "The high antibiotic prescribing rate for sinusitis for both e-visits and office visits is also a concern given the unclear benefit of antibiotic therapy for sinusitis."
The biggest risk, of course, is that overprescription of antibiotic can lead to drug-resistant strains of infection. If telemedicine patients are more or less automatically given antibiotics (as they were for both sinusitis and urinary tract infections), a population that uses e-visits exclusively or an overwhelming majority of the time could develop far more dangerous bacteria.
The study authors do note that "there are several key limitations of our analyses" and "as small samples in an observational study, they should be interpreted cautiously."
What constitutes an e-visit?
Roga, looking at the research, draws a firm line between video feed or vocal telemedicine and "more of an electronic chat and email" interaction.
"They are analyzing what is essentially an electronic communication between a patient and primary care doctor rather than a live, real-time interaction," Roga says. "So, it sounds like patients logged in, they answered some questions, information was sent to the doctors, they made a note and replied to the patient via a portal. This was not a live e-visit the way STAT Doctors or a lot of the industry would define it."
He clarifies that "e-visits are better served with a live encounter, rather than a questionnaire or email communication ... E-visits and the telehealth space are really progressing toward live interactions between doctors and patients, supported by technology. I think that's [an] important point of the study that may or may not have affected the outcomes."
Roga added that he'd like to see a study compare live tele-interactions against in-person visits for prescriptions rates and other treatment results.
Teleheath is a new, growing field and, as health visits shift away from the "brick-and-mortar," it will need to be well-understood.
Still, Mehrotra says, "overprescribing of antibiotics is a concern in our society" that should raise alarms due to "concerns of drug-resistance and unnecessary side effects," no matter the vehicle of their prescription.
"Either the patients who select this option are much more likely to have disease and/or physicians are taking a conservative approach," Mehrotra tells EBN. "I think many employers are focused on e-visits and telemedicine as a mechanism to improve productivity, because of less time off of work. I think we need to evaluate these new options and compare them to existing options."
Research at a glance
University of Pittsburgh and RAND Corporation researchers examined all office visits and e-visits treating sinusitis and urinary tract infections for 63 internal medicine and family practice physicians.
Physicians saw 5,165 in-person and e-visits for sinusitis, and 2,954 for UTI, between Jan. 1, 2010 and May 1, 2011.
Doctors were far more likely to order UTI-related lab work at office visits (51%) than at e-visits (8%).
For both sinusitis and UTI, physicians were more likely to prescribe an antibiotic to a patient during e-visits. A full 99% of sinusitis e-visit patients were given an oral antibiotic, compared to 94% of office patients. Among UTI patients, 99% of e-visits also ended in a prescription antibiotic, compared to 49% of office visits.
