Arnold Kling  

Videoconferencing and Health Care

Tell Me the Difference Between... Cato and the Kochs, Take 3...

Scott Gottlieb writes,

A patient recently asked me why doctors don't spend more time communicating over email or by videoconferencing.

There's a simple answer: Medicare hasn't created a billing code for these services.

I would love to stand up and cheer. But I think this is not a good example. If email and videoconferencing are what doctors and patients want, then we should see it in widespread use in the sectors of the health care system that are not tied to fee-for-service: HMO's; concierge medicine; Canada; etc.

Look, I absolutely agree that third-party payment systems, including Medicare and private health insurance (or what I call insulation) are dysfunctional. They may be particularly dysfunctional with regard to cost-saving innovation.

However, in the particular case of videoconferencing, I think the problem is that this is still perceived as bleeding-edge technology. I brought this up during the video conference with Hal Varian and Nick Schulz. Hal and I remember the 1990's, when corporations first connected to the Internet, and managers dealt with email by having their secretaries print it out for them. They were wary of the new technology and unwilling to really dive into it. That is where most people are with videoconferencing right now.

When that changes (assuming it does), a lot of habits will change. People will spend less time going to and from meetings. Instead, they will hop from meeting to meeting with a click of a button, sitting at their computers. This will save a lot of time.

Yes, I know that videoconferencing is not a perfect substitute for face-to-face. But on some margin, it is more cost-effective. And I think what is holding it back the most is lack of comfort with its use. People aren't using it very much because they think it is bleeding-age, and they think it is bleeding-edge because people aren't using it much. If this analysis is correct, then the situation will tip rapidly. The evolution away from printed-out email took only a couple years.

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COMMENTS (13 to date)
drobviousso writes:

HIPPA, according to my doc.

V writes:

I have to use videoconferences for work a significant amount. They are usually far inferior than face-to-face meetings (even accounting for the expense and hassle of travel) due to a variety of factors (e.g., lack of reliability, delay, no body language reads, artificial setting, etc.).

Email is a perfectly adequate substitute for the type of meeting that VC's do well and so I don't see how they can catch on without a significant change in quality.

I can imagine physicians not wanting to use them for exactly the same reasons...

Glen Smith writes:


I'd have to agree. I don't even work in a field where human touch is required to make good diagnosis of a problem and I don't like video conferencing in most cases. Even if you need more synchronous communications, texting or voice communications fill that role well are more than adequate. Pretty much the only time a VC provides better services is when I need a white board or want to provide that "class room" feeling and face to face is not an option.

Kevin writes:

I've had a few meetings in full-size Cisco telepresence rooms, and it's every bit as good as face to face. I think the key is the full-size HD display, directional sound, and lack of latency in the stream. When those things are widely available and affordable, videoconferencing will boom.

Andy writes:

Malpractice, liability, accountability, and litigious patients will also limit the desire to use any technology that leaves digital trails. If I were an attorney representing medical professionals, I would probably advise them from communicating via email or videoconferencing extensively.

Bob Knaus writes:

Medical videoconferencing is in widespread use within America's prison systems, and has been for several years. I've written summaries of the benefits as a management consultant.

The usual justifications are reduced travel costs and increased security. There are probably a couple more unspoken ones (almost always are in the ciminal justice arena) and I would say overall it's a widely adopted and non-controversial improvement to the treatment of prisoners within the last decade.

blsdaniel writes:

The first comment got it right. Just today, in fact, I asked my doctor if I could email her results she wanted instead of doing a phone call. Sorry, she said, HIPP won't allow it.

Joe Cushing writes:

I think the quoted section of your post nailed it about email and I think V in the comments above, nailed it when it comes to video conferencing. HIPPA is also a concern but whether it's medicare or HIPPA, it's government standing in the way of innovation towards email.

Bill Nichols writes:

I had a similar experience to blsdaniel. Faxing a prescription is OK (who has a fax anymore?) scanning and e-mailing, they are not permitted to do. There are a lot of privacy and electronic record regulations. Even if something is not prohibited, most will stay within the box to avoid problems.

Videoconferencing is still bleeding edge for most users. We typically spend 10 to 15 minutes of every meeting just getting the computer equipment sorted out. Skype has gotten a lot more reliable over the past year and is on the verge of making a lot of more expensive systems obsolete. However, connection bandwidth, reliability and resolution vary.

Dave Schuler writes:

Another factor in the U. S.: many if not most states restrict prescription authority on telemedicine.

David C writes:

The problem is HIPAA laws vary by state. blsdaniel and Bill Nichols seem to both be in very restrictive states. A lot of states have laws where all electronic communication is considered to be verbal, which makes things easy.

David C writes:

Woops! Wrote that wrong. HIPAA is a federal law, and it permits everything being described above, but there are a bunch of other related state laws that can cause those restrictions.

Dr. John writes:

Lack of reimbursement IS a BIG issue, along with other issues (regulatory, licensing, etc).

I am a Kaiser Permanente physician and we ARE incorporating secure email and other alternative approaches. A reason it works for us is that KP doctors are salaried. Thus, if I can answer a question by email in 5 minutes and eliminate a 10 minute office visit, I have decreased the "cost" of that encounter by 50%, a benefit to the organization. (In practice it allows me to spend more time with other patients.)

Also note that this email also decreased the "cost" to the patient including travel, parking, time, time off work, etc.

If I were in private practice that email would not be reimbursed and my income for that 5 minutes would be $0. Thus, I would have no incentive to adopt email or other non-reimbursed activities. I could use email as a "loss leader", but not as a significant part of my practice.

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