Seattle Paves the Way in Telemedicine

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This article appears in print in the April 2019 issue, as part of the Top Doctors cover story. Click here to subscribe.

For most weeks during the past several years, Cindy Kahler and her daughter Hadassah, now 10, spent from six to seven hours on the road traveling from their home in Cashmere to a one-hour appointment with the specialists at Seattle Children’s Autism Center. There, Danielle Dolezal, Ph.D., a child psychologist and director of the hospital’s pediatric feeding program, and other specialists worked with mother and daughter on complex treatments that help make it possible for Hadassah—who is autistic and has several medical conditions, including a feeding disorder—to eat more easily at home and at school.

The drive took a toll on the family and made treatment more difficult. Two of Kahler’s other children, who are homeschooled and close to Hadassah’s age, usually came along. Sometimes Hadassah needed feeding or changing on the way. The result? “By the time this young lady got here after hours in a car seat, she engaged in significant challenging behavior,” says Dolezal. “Mom would say, ‘She’s not like this if we don’t have to drive this far.’”

Dolezal works with children who struggle with feeding disorders, and like many other specialists at Seattle Children’s, her skills are rare, in demand and hard to find outside a major city. Luckily, a pilot program is allowing patients like Hadassah to be treated by specialists like Dolezal without leaving home.

Hadassah’s family enrolled in the new program a little more than a year ago. It allows Seattle Children’s autism specialists to extend care into patients’ homes—and sometimes schools or other locations—using technology. At appointment time, Kahler and her daughter sit at their kitchen table. They click a hyperlink on their computer, and within moments they are engaged in a videoconference with Dolezal, who is seated at her desk in her Seattle Children’s office. “It’s a secure connection, they click on it, and—voilà—we’re together,” says Dolezal.

The program also means that the doctor can manage care differently, checking in with her patient at regular scheduled mealtimes, coaching families and kids, and “actually developing more precise treatments because the child is in their natural setting,” Dolezal says.

“It has been such a huge blessing to me,” says Kahler.

The pilot program is one of three at Seattle Children’s (the other two are in psychiatry and sleep medicine) that are examples of a larger movement in health care to connect patients and health care providers remotely via digital and communication technologies. This type of care is usually referred to as telemedicine or telehealth. As Mark Derchuen Lo, M.D., director of telehealth and digital health at Seattle’s Children’s Hospital, explains, it’s a way for the hospital to provide care for more kids, in more places.

“As our region grows and the number of children and the complexity of their needs grow, we’ve realized that we can’t just remain within our own four walls; we have to have the ability to virtually care for our patients beyond them,” says Lo.

Many patients are already familiar with basic telehealth options, such as communicating with providers over secure e-mail. But the trend is expanding to include real-time videoconferencing, apps, remote monitoring for patients and more.

So far, some research suggests that this shift can lead to more equitable care, because many patients reached by telehealth programs are using it not as a replacement for other types of care, but to gain access to any care at all. This may be because they are in remote locations or because they don’t have a primary care doctor. Many are turning to commercial “virtual visit” companies for a flat-fee consultation to diagnose and potentially treat minor illnesses, such as the common cold, pink eye and urinary tract infections, connecting on FaceTime, texting or another remote option. Virginia Mason, for example, advertises a flat-rate $35 consultation, no insurance required, through its Virtual Care Clinic.

Telehealth also can save time, and usually money, for patients. In fact, the program that the Kahlers are enrolled in, which began in April 2018, had saved patients and families more than 50,000 miles in travel by the end of 2018, according to Lo. “We’ve been really happy we’ve been able to show these savings to families,” he says. Lo believes telemedicine that extends to patients’ homes is likely to increase. “It’s sort of a new version of the house call—but it’s virtual.”

Other telehealth options are already taking hold. For example, the American Telemedicine Association says nearly 1 million Americans are currently using remote cardiac monitors for chronic conditions such as heart failure. Through the Department of Veterans Affairs (VA), approximately 12 percent of veterans received care via VA’s telehealth services in fiscal year 2016, amounting to 2.17 million telehealth “episodes of care.” (Forty-five percent of those veterans lived in rural areas.)

In the Seattle area, some providers are dipping their toes into the telemedicine pool, while others have jumped in.

“Telehealth has been a fundamental part of the way Kaiser Permanente cares for our members and the communities they live in for many years,” says Chris Cable, M.D., senior medical director for Kaiser Permanente Washington. (Local Kaiser clinics previously were Group Health clinics; Kaiser purchased Group Health in 2017.) One of Kaiser’s most popular telemedicine tools, teledermatology, gives patients the option of having a photo taken of their skin issue during their primary care visit. The photo is then reviewed by a specialist in dermatology, frequently on the same day. It often means that patient can avoid scheduling a separate visit to a dermatologist.

Kaiser launched two new telehealth tools in 2018: One, E-consults, allows specialists to provide consultation at the request of a patient’s primary care provider using the patient’s shared electronic medical record. The specialist then gives advice directly to the patient via a secure online message, thus allowing a patient to avoid an in-person visit. Another, Care Chat, is a real-time text-based tool that allows patients to connect directly with a Kaiser Permanente clinician. “Care Chat has been our most satisfying telehealth tool,” says Cable, because members get a quick response and real-time interaction between 6 a.m. and 10 p.m. daily. Kaiser Permanente plans to broaden Care Chat to a 24/7 service this year.

At Seattle Cancer Care Alliance (SCCA), an app called Caresi was rolled out as a pilot program in February 2016, and gradually, was made available to all patients over the two years that followed. Caresi provides patients with access to their lab results, appointments, information about their disease and other data. Using the app, providers can survey patients about how they are feeling, emotionally and physically, as they go through treatment. The patients’ responses go to a nurse, and extra support services are provided as needed. “It’s just another type of care,” says Debbie Berg, customer engagement manager for digital health at SCCA. Berg helped design the app, which was inspired in part by her own experience as a cancer patient. “We’re doing this because collecting this information and surveying these patients increases their survival and decreases their emergency room visits and in-patient stays,” according to their data, says Berg. “We’re trying to get ahead of issues and jump on symptoms before they become worse.” So far, more than 5,100 patients have signed up for the app.

Like Seattle Children’s, SCCA has also introduced physician-patient videoconferencing. One SCCA pilot program connects possible bone-marrow-transplant patients in Hawaii and their providers to specialists in Seattle. The videoconference allows a physician to virtually “meet” the patient to help determine if that person is a potential candidate for the procedure and is interested in the procedure. In the past, potential candidates had to fly to Seattle for an initial screening visit.

Yet despite innovations in this area of health care, telehealth is growing slowly. One stumbling block is the cost and resources required to upgrade health providers’ technological systems to allow for virtual care; another is laws that restrict telemedicine billing in many states. Washington state is considered progressive in this regard, and is working to create legislative policy that supports and encourages the use of telehealth. For example, as of the fall of 2018, and following guidelines issued by the Centers for Medicare and Medicaid Services (CMS), providers are now allowed to bill for virtual visits in a patient’s home, like the one for Kahler and her daughter.

There are limitations, as well, though there isn’t agreement on what they are both because the definition of telehealth is broad and because technologies are evolving. One obvious restriction is that “you cannot reach through and touch a patient,” says Jennie Crews, M.D., a medical oncologist at SCCA. For her, that means she can’t palpate a lymph node or an abdomen to feel for swelling or a lump without an in-person visit.

For Dolezal of Seattle Children’s, in-person visits seem indispensable, particularly at the start of treatment. “There is something about meeting a family and developing a rapport,” she says, “being able to interact live before you start developing telemedicine interventions.” Part of the research at Seattle Children’s is looking at whether telemedicine interventions are changing care in ways that make that care less effective.

Other limitations or drawbacks of telehealth may appear over time, as research gives a clearer picture of differences in outcomes for patients who substitute telemedicine for in-person care.

But some see additional uses for telehealth. It could improve preventive care, says Cable of Kaiser Permanente. “In the future, I would like to see telehealth move from a reactive experience which is only initiated by our members to more of a proactive outreach, where we can detect health problems before they become more serious and intervene much earlier.” For example, he says, simple devices that can measure a patient’s daily weight, blood pressure and sleep pattern have been shown to predict hospital admissions for congestive heart failure. “By using more extensive home monitoring tools, we can identify those warning signs and reach out to our mem-bers before they become truly ill,” he says.

“Our job in health care is to greet our patients in different places,” says SCCA’s Berg. “We have to come up with new and innovative ways to reach our patients where they are.”