2. Doctor-Patient Interaction and
the Physical Exam
Medical School- taught medical history and full medical exam
Diagnosis should be narrowed down to 1-2 problems after the
history 85% of time
Exam and testing solidify the diagnosis
Many fields of medicine lend themselves largely to the history
Cognitive fields- neurology, psychiatry
Primary care follow-ups
ER care- non surgical orthopedics
Realized quickly in my practice that I examined about 25% of
my return patients and they were driving 4-6 hours to see me
Gas costing many more than the visit itself
Problem that needed a solution
3. Future Exam
Point now where technology allows us to often do
remote exams, same proficiency many cases
History 100% of the time
Standard of excellence the same
Stethoscope, otoscope, opthalmoscope
Imaging
Even performing surgeries remotely with robots
Military
Technology advances making it preferable by patients
Patient demand and technology will drive this industry
4. Where Will Future Generation
Seek Care?
Where will people access information and expertise
in the future?
How long will they want to wait?
How far will they be willing to travel?
How will they travel?
5.
6. Future of Medicine
Estimate that we will be short 150,000 physicians in the
next 10 yrs
Primary care- rural and urban
Specialists rural
Volume driven- critical # of patients in an area to keep
physician busy
Varies per specialty
Georgia- 159 counties
65 have no pediatrician
68 have no Ob/Gyn
1/3 of the state’s docs will retire in next 10 yrs
7. Future
Excellence in healthcare is driven by pattern recognition
Seeing the same thing over and over
Can’t train enough MD’s to make up for the shortage
NP’s, PA’s, and other para-professionals
Quick solution
Faster to train
Won’t be enough
Will take even longer for pattern recognition
Will not be trained in specialty and subspecialty care
Do we accept substandard delivery of care or find
another solution?
Medico-legal implications!
8. Future
Specialty care will not go away
Driven by advancing, complicated knowledge in
different fields of medicine
Has become too complicated for primary care alone
As mentioned, too complex for even some specialists
Complex evaluations and management of disease
Life threatening diseases
Life threatening treatments
Complex monitoring
Multidisciplinary teams
9. Neurology
13K in the USA
Many are academic- see few patients
Estimated need - 20K by 2010
New trained = those who retire
Neurologists function as PCP’s
Need more as more function as PCP’s
ACA allows patients to designate specialists as their
PCP
Those with complex, chronic disease
10. Neurology
Neurologists as subspecialists
MS example
Treatment became ultra-specialized
Effective treatments, life threatening complications
Care centralized
Concussion care will follow the same path
Scarcity of providers trained, complex evaluations, life
altering risks to inappropriate management
Legal implications
As evaluations becomes more complex in certain centers,
leads to increased liability for others
Standard of care
11. Future Healthcare
Battlefield
Technology will allow us to bring pattern
recognition and experience to the provider
Bring to 1000 people vs train 1000 people
Clinical Judgment
Human, not computer quality
Patterns, voices, experience
True vs false symptoms, complaints
Science will make disease management more complex,
not less
12. Future Healthcare
Battlefield
Will allow for increased access and decreased cost
Transportation
Nursing home, schools, offices
Safety- patients unstable
Prison
Savings
Gas
Time off work
Reach anywhere where there is a broadband access
Georgia- most “wired” medical state
Makes sense under any healthcare model
ACO, HMO
Private insurance
Self pay/HSA
13. Not a new problem
Georgia MS (multiple sclerosis) example:
MS Center of Atlanta
Patients from 23/50 states
118/159 counties
Complex disease
Neurologists/specialists send for subspecialty care
Rural patients diagnosed 1.5 years later
Delay diagnosis leads to increased disability
Avg rural patient drives 103 miles for care
Gas, loss work
14. Challenges In Extending MS Care Outside Metro
Atlanta…
Original MSCA Plan for Expanding MS Care :
Develop brick and mortar sites that would be staffed by local neurologists and
primary care physicians
Current Satellite Location:
• Weekly Office and Infusion presence in
Villa Rica on the Tanner Medical Campus
• Costly, ongoing operational expenses that would limit the
number of satellite facilities
• Because of extensive federal regulations, rigid
professional services agreements are necessary
between the local physician and the MS Center. These
PSA’s limit availability of local physicians and restrict
changes that reflect patient volume.
• Limited number of neurologists that have
available time for lengthy and reoccurring MS
office visits
• Patient apprehension to a new physician
for their long-term care
Hurdles to expansion of long-term care at satellite location
15. Solutions for MS Care Through Georgia
Telehealth…..
For the MS Patient:
Local physician versus a physician office that is an extended
distance away
More available locations for ongoing MS care
Continued long term-care with the neurologist that developed their
MS treatment program
Real time evaluation by a MS specialist when disease relapses or
flare-ups occur.
Elimination of travel expense and time as a barrier to ongoing care
For the Rural Physician:
• Greater flexibility in the use of staff and
resources for administering long-term MS care
• Limited investment and reoccurring costs in the
treatment of patients with MS
• MS specialist available to assist in the
comprehensive treatment of the MS patient
For the MS Center:
• Greater flexibility in the use of staff and
resources for administering long-term MS
care
• Limited investment and reoccurring costs
in the treatment of patients with MS
• A solution that aligns with the MS Center’s
mission to extend long-term, ongoing care
to a medically under-served population.
16. SCI Model
Increased education
Digital
Certification process
Spoke clinics
Training on site personel
Baseline testing
Evaluation and management
Appropriate disposition
History, examination, imaging, testing presented through
telemedicine
Follow up care
Telemedicine outside 25 mile radius
From schools
17. Model Challenges
Challenges
Initial evaluation
Comfort- patient and provider
Experience
Lies in education and comfort with sites
Laws regarding establishment of legal doctor-patient
relationship
License, state based
Concerns for nationalizing license
Payment systems
FFS
Global
Technology Access
18. Solutions
Regional networks
SCI/MS regional centers covering 5-10 states
License laws
States- easier access to telemed license in state
Not national
State Fed laws
Payments
Care establishments
Home/Office/Medical Office
19. Summary
We have a problem
Cost, access, expansion of knowledge
Will NEVER have enough experienced healthcare
providers physically located in all locations
Not a new problem, but solution has become easier
Technology and patient demand will deliver state-of-
the-art specialty care to all areas at a fraction of the
cost
