Here are key takeaways from an episode of Kentucky Health that examines the rising use of telemedicine in Kentucky. Host Dr. Wayne Tuckson welcomed Dr. William Thornbury, MD, medical director and CEO of Medical Associates Clinic in Glasgow and board chair of the Kentucky Medical Association.
Creating a Groundbreaking Telemedicine Model in Kentucky
“Telemedicine is a term we use for communication or delivery of health care using digital means,” Thornbury says. “That could be my computer to your computer, it could be a mobile app in a smartphone, and it could also be voice over the Internet.”
The practice of telemedicine has become more popular this century due to ongoing advances in technology, and host Dr. Tuckson’s brother Dr. Reed Tuckson was a leading proponent of the discipline while serving as the president of the American Telemedicine Association several years ago (he appeared on Kentucky Health to discuss telemedicine in 2015). During COVID-19, telemedicine proved to be a lifeline for many patients as they accessed care from home in order to both protect their own health and limit attendance at overwhelmed hospitals and clinics.
Thornbury became involved in telemedicine early in his practice through a connection at the University of Kentucky College of Engineering and through one of his mentors at the Mayo Clinic who was an innovator in the field. At UK, he learned about a systems program utilized by Toyota that utilized a streamlined workflow, and decided to apply that to his mentor’s early telemedicine model and create his own service.
He struggled early, especially with efficiency and timekeeping using early-generation cell phones. “But at about that time, they developed the iPhone, and I said that if we could put mobile health and digitize that and make that telemedicine, then you could live what I call the promise of Barbara Starfield’s medical home model.” That medical home model, developed by the late Johns Hopkins physician, calculated that patient-centered primary care not only results in better health results but is also cost-effective.
After three years of practice, he and his staff compiled research on their own telemedicine model. Their research found that effective care was administered 98 percent of the time once patients were educated on how to use the remote technology. “We’ve shared our research over the last decade not only with people around this country but with people around the world as well. It took me to the White House,” he says.
While Thornbury shared his findings with health care administrators in the Trump administration, around the same time, then-Gov. Matt Bevin signed into law Senate Bill 112, which imposed parity in telemedicine for Kentucky’s Medicaid program, managed care organizations (MCOs), and commercial health insurance plans. This measure will help offset upfront costs to providers of when they transition to telemedicine by ensuring that reimbursement for services will be the same as for in-person care.
“We banked on payment parity, we banked on requiring our insurers in Kentucky and MCOs and Medicaid to pay dollar for dollar – what we are doing is we’re going to invest,” he says. He credits leadership in both legislative bodies and former Gov. Bevin for passing Senate Bill 112 and says that doing so gave Kentucky an advantage over other states when the COVID-19 pandemic forced many providers to move online.
Streamlining Care to Help Both Patient and Provider
For Thornbury, the first principle of telemedicine is to use technology that will allow each specific patient and his or her medical concern be addressed promptly, efficiently, and successfully. For patients with minor problems, care can be provided via smartphone – he gives an example of a patient with poison ivy who sends in a picture of the plant and the affected skin, and gets a prescription ordered and filled in the same “e-visit.” More complicated problems might require a video chat, he adds, and as expected, in-person visits are still required for diagnostic tests and surgeries.
“It depends on what your needs are,” he says. “If you’re doing something like behavioral health, psychology, education, maybe physical or occupational medicine, you probably need very high video content. But if I’m calling you about an adjustment in your thyroid medicine and we’ve been doing this three years together, probably [a phone call] is enough.”
Thornbury envisions telemedicine to continue evolving as new technologies are applied. One of his goals is to improve the integration of electronic medical records (EMTs) into telemedicine, so a physician can access a patient’s entire medical history through digitized records and call up any that are needed during a remote e-visit. He admits that the possibility of a standard EMT-telemedicine model adopted by the entire U.S. health care industry is still a long way away, due in part by a lack of oversight and regulation years ago when the technology was just emerging.
Security issues are another ongoing concern, says Thornbury. “It’s a challenge – that is its own specialized field,” he says. “For everything the white knight does, the black knight tries to do two more. In my own mind, I always think we’ll have difficulty (with security) until we move to a blockchain based technology.” Blockchain technologies utilize an advanced level of encryption in recording information that make it very difficult, if not impossible, to hack or cheat the system.
Thornbury adds, “The information that we always give our patients is, look, if it’s something extremely private – come into the clinic, let’s just do it person to person. If it’s that private, let’s not take the chance that the information can be breached, no matter how great the technology is.”
One important goal for the future of telemedicine, especially in Kentucky, is to increase broadband Internet capacity in what is still a largely rural state. Thornbury says that a report published in the January 2020 issue of the Journal of the American Medical Association (JAMA) showed that there is a gap in access to technology that affects persons in minority groups, women, older people, and those who earn lower incomes.
“There’s a literacy problem, but more importantly, there’s a broadband problem,” he says. “Do we have to have broadband? Well, there are definitely places where it will be necessary, and it may be necessary on a national basis to have a separate broadband for health care. There’s a lot of discussion about that.” He supports the Kentucky Wired program to bring broadband to rural areas of the commonwealth but acknowledges that “the last mile takes a lot of time” to complete.
Thornbury tells viewers interested in accessing care through telemedicine to first make sure that they already have a good relationship with their primary care doctor. If they do, he recommends working with the physician to determine how to best use telemedicine for their specific health care needs and home environment.
“And remember the golden rules of telemedicine,” he says. “Number one: do you as a patient think that this [medical issue] is something directly simple that we can handle on the phone? Number two: could care wait a day if it had to wait a day? And number three: give your health provider a couple of hours to get back with you. If you do that, our study said you’re going to get excellent outcomes, you’re going to lower the costs, and 98 percent of those cases were able to be taken care of and weren’t diverted to somewhere else.”