Telemedicine in practiceAustin doctor sees benefit in virtual caregiving

Published November 2017

Health information technology (health IT) is a promising approach for tackling the health care challenges of Texas’ booming population, physician shortages and under- or unserved rural residents. Telemedicine, telehealth and telemonitoring programs, along with new health IT legislation, are discussed in a recent Fiscal Notes story.

Line Items talked with Dr. Thomas J. Kim, an Austin internist and psychiatrist and member of the Texas Medical Association’s Council on Legislation who has used telemedicine for 12 years. What began as a moonlighting job while training later became Kim’s fellowship research project: improving the delivery of telemedicine services to incarcerated juveniles. Today, he supports a number of different “vulnerable” populations, including the incarcerated, elderly, military personnel, people struggling with substance dependence and disaster victims.

LI: Do you have your own practice?

I spend about half of my time caring for patients where I primarily work as a telehealth psychiatrist. There’s a subtle distinction between the terms telemedicine and telehealth; I prefer the slightly more inclusive term telehealth. Because I’m also an internist, I am fortunate to [be able to] offer comprehensive, collaborative care strategies for all my patients.

The other half of my time is spent on consulting and advocacy work, where I’m hired to build or improve strategies for telehealth programs and solutions. Most recently, I’ve joined tech startup Medici in developing an app dedicated to redefining the doctor/patient relationship.

LI: What challenges does our state face in providing medical care for Texans?

Texas struggles with the same challenges as other states, primarily access to care. While that’s mostly relevant to those on lower rungs of the socioeconomic ladder, even those on higher rungs are continually frustrated by how poorly our healthcare system works.

It’s overly complicated. We have a three-party transaction [doctors, patients and payers] where the objectives and incentives are misaligned. As a result, we have doctors in the wrong places and payment models that create impossible decisions for everyone involved. For example, too many people have to choose between buying health insurance or feeding their kids. We have doctors who, despite their interest, struggle with the fact that Medicaid [patients] cost them money and threaten their ability to keep the lights on. These situations lead to choices that cost all of us dearly.

My hope, in some small measure, is to assist in overcoming these challenges with telehealth.

LI: When you say doctors are in the wrong places, what do you mean?

Many people have to drive three hours to see a psychiatrist, for example. And despite lots of conversations about doctor shortages and the need for more doctors, I don’t yet know that it’s an issue of numbers. What I do know is that they’re in the wrong places.

Doctors tend to gravitate to urban centers like everybody else. Rural areas tend to hold very little attraction for most every healthcare provider, including nurse practitioners, physician assistants and others.

Because we have too few doctors in some places and too many in others, I suspect this contributes to the record high levels of professional burnout we are seeing. More and more, I notice a disturbing trend of doctors exiting clinical practice [prematurely], and it troubles me greatly. If this trend continues, we will definitely have a shortage of doctors, magnifying our care delivery challenges even more.

LI: Do you see telemedicine as helping with that burnout?

I do. I’m biased, but some of the value telehealth offers is the ability for doctors to practice on their own terms. For me, I’m incredibly fortunate to be able to control the amount of time I spend on work based on my interests or opportunities.

I have a five-second commute from my coffee machine to my desk and, on any given day, I can care for an incarcerated juvenile in Louisiana or an active-duty Army specialist in Killeen, or find ways to support my peers through Medici. When it’s time to punch out, I can immediately help my son with homework or crush him in a game of Exploding Kittens.

LI: How is the passage of S.B. 1107 in the last session going to change Texas’ medical landscape?

S.B. 1107 makes it clear that telehealth care is health care. As such, it should be held to the same guidelines and standards as conventional health care. In the broadest terms, telemedicine is a means to [provide] a service rather than something independent or peripheral to our care system.

As a doctor who’s spent years developing skill in delivering telehealth care, S.B. 1107 doesn’t change my life at all. Following the passage of S.B. 1107, my enthusiasm and excitement has only grown; telehealth now holds the interest of a much larger audience. [It] unlocks an untold amount of opportunity in Texas.

I’m often asked how to properly establish a therapeutic relationship at a distance, but that question misses a much larger opportunity. If telehealth is a skill to be mastered, every healthcare provider stands to benefit from mastering it. These providers have already established therapeutic relationships, and telehealth offers the potential to expand and enhance how they care for their patients.

LI: What economic impact will these new laws have?

Economic impact speaks to utilization, cost and outcomes — and the many competing forces driving these issues.

Because the floodgates have opened a bit, I anticipate seeing more telehealth usage. There will likely be an early spike in pure telehealth service offerings that can be easily packaged as a covered benefit. In time, this will be followed by doctors finding ways to include telehealth encounters in their clinical practices.

The interesting thing to note about this predicted trend relates to cost and outcomes. Pure telehealth service offerings are responding to overwhelming need and are constructing payment models to support their continued growth — new ways to pay for new services. Conventional providers offering telehealth as part of their services just want to be reimbursed as they ordinarily are, the same pay for the same service. Over time, the initial spike in service costs from telehealth services likely will settle down as more services through telehealth rise.   

Both conventional and telehealth pathways have the potential to improve our collective health and wellness, but I suggest focusing on conventional care models that integrate telehealth services. By supporting these care models to improve timeliness, responsiveness, efficiency, reach and satisfaction, I believe we have a real chance at improving the basic health status of our society. With this foundation, pure telehealth service offerings can and will improve our health status even more.

Given that we currently spend far too many healthcare dollars for very little in return, I’m hopeful that, as our health care system evolves to integrate telehealth solutions in meaningful ways, we will better deliver the right provider with the right information at the right time. FN