1. Telemedicine:
Healthcare Paradigm Shift
Douglas Stuart, MD
MS Center of Atlanta
Peachtree Neurological Clinic

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?

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