Continuity of Care in Telemedicine

I recently treated a critically ill patient in my ER who presented late in the evening with profound weakness, vomiting, abdominal pain, and polyuria. The classic acetone smell when I walked into the room, along with his rapid breathing told me he was in diabetic ketoacidosis, a life-threatening condition. This young man is a type 1 diabetic dependent on daily insulin injections to stay alive. He had run out of his insulin two weeks before and being the holidays, he experienced barrier after barrier in trying to gain access to his medications.

After he was stabilized I asked him why he had run out of his insulin? He told me he’d moved to the area for a job earlier in the fall and his insurance didn’t kick in until Jan. 1 but his employer allowed him to buy into an access plan with one of the national telemedicine companies for $26 per month, to be deducted from his paycheck. It turns out, he had initiated an encounter with a doctor on this platform who was willing to refill his insulin, for which the patient was very thankful. When he showed up to the pharmacy however, he learned the doctor had phoned in a version of insulin that didn’t have a generic version and would cost “hundreds of dollars,” making it financially out of reach for him.

He then initiated several new encounters on the service, but none of the physicians he connected with were willing to prescribe insulin. Each doctor said he would need to establish a relationship with a primary care physician or go to the ER, presumably because prescribing insulin is a potentially risky move for a doctor with no ability to follow up with a patient.

Ultimately, with health insurance out of reach until the new year, the patient allowed himself to get sicker, presumably in hope that he’d be able to make it until Jan. 1 when the financial hit wouldn’t be so great. The situation, of course, didn’t turn out as hoped, and ended with the patient admitted to the ICU that night.

Context: Most national telemedicine companies staff physicians in a similar manner to the way Uber staffs drivers. The idea is that a visit is not unlike a ride with Uber: when it’s over, it’s over. Any one of thousands of registered providers may log into the system and the company connects patients with these doctors for a consult. Where the model breaks with Uber is that most national telemedicine companies have a specific policy built into their algorithm that does not allow a patient to connect with the same doctor twice; “We do not want to establish a relationship with the patients,” said Dr. Tim Howard, a senior medical director for Teladoc in a hearing before the Texas Medical Board in 2015. Lack of continuity and lack of relationship, in many physicians’ minds, equals bad medicine.

As we saw with the patient above, lack of continuity in service and reciprocity (or accountability) among physicians results in bad clinical outcomes. At CirrusMD, we’re building patient-facing solutions for communication with physicians and staff within integrated delivery networks. Our solutions are about more than isolated encounters, they’re about ongoing communications.

Doctors have always taken care of patients remotely. Most people at one point or another have spoken with a physician on the phone or via email, usually in the context of an ongoing relationship. What the leading national telemedicine companies have built up are isolated transactions that aren’t integrated into a patient’s care delivery network and are never relationship-based. At CirrusMD, we are working to enhance relationships between patients and their home health system by setting up an environment for ongoing communications. For example, with teams of doctors working together, our integrated care delivery partners are directing as many as 10 percent of remote encounters to follow up on the CirrusMD platform for ease of communication, and the better practice of medicine.

To learn more about what we’re building around interdisciplinary care, AI assisted workflows, provider-to-provider and provider-to-patient communications, and how all this is transforming medical care delivery email us at info@cirrusmd.com.

Blake McKinney, MD

I'm the Co-Founder and Chief Medical Officer of CirrusMD.

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