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News Roundup: November 4, 2016

Extreme Home Makeover — The Role of Intensive Home Health Care

Published by The New England Journal of Medicine
By Luis Ticona, M.D., M.P.P., and Kevin A. Schulman, M.D.
November 4, 2016

In 2010, the department of health in Victoria, Australia, announced the construction of a 500-bed hospital without bricks and mortar. This “virtual hospital” has 33,000 admissions each year, accounting for almost 5% of all acute care bed-days in the state of Victoria and adding much-needed hospital-bed capacity.1 The Australian health system has since expanded this program to reduce the strain on available hospital beds in other regions as well, while avoiding capital expenditures and preserving the quality of care. What incredible technological advance permitted achievement of these impressive results? Home visits.

Intensive home health care services as an alternative to hospitalization are becoming a standard option in many health systems around the world, perhaps most notably the United Kingdom, France, New Zealand, and Australia. These health systems deploy multidisciplinary home health care teams after emergency department evaluation and diagnosis, outpatient evaluation, or an ultra-brief hospital stay to provide acute care services, comparable to hospital-level care, in the patient’s home rather than a hospital. They bundle existing services, including physician oversight and backup, nurse visits for ongoing evaluation and delivery of interventions, home infusion technology and pharmacy resources, telehealth interactions, point-of-care testing, and home health aide services to create comprehensive, customized programs of intensive care at home. Indeed, it’s the existence of these technologies and the growth of the skilled-nursing workforce that enable the creation of such service lines.

Clinical conditions that appear amenable to these services as a substitute for hospitalization include exacerbations of heart failure or chronic obstructive pulmonary disease, stable pulmonary embolism or deep-vein thrombosis, pneumonia, and skin or soft-tissue infections such as cellulitis.

Since many of these programs have existed for more than a decade, there are evaluation data available for review. A 2009 meta-analysis revealed effects including increased patient satisfaction, reduced use of antipsychotic drugs in patients with dementia, reductions in lower urinary tract and bowel complications, reduced costs, and a significant difference in 6-month mortality (hazard ratio, 0.62; 95% confidence interval [CI], 0.45 to 0.87; P=0.005).2 Although that analysis did not show a significant decrease in the rate of readmission (hazard ratio, 1.49; 95% CI, 0.96 to 2.33), a subsequent meta-analysis did (odds ratio, 0.76; 95% CI, 0.60 to 0.97; P=0.02), in addition to showing reduced costs (mean difference, $1,567; 95% CI, $1,065 to $2,070; P<0.001).3 For single-payer health care systems, blurring the line between inpatient and outpatient services makes fiscal sense if good outcomes and patient-satisfaction levels are preserved, especially if a system must choose between investments in additional hospital beds and in technology and services for intensive home care.

Since initial feasibility studies were conducted in Medicare managed care and Veterans Affairs (VA) sites in the early 2000s, the United States has seen limited uptake or development of intensive home health care programs designed to avert hospitalizations. Current programs include Presbyterian Healthcare at Home in Albuquerque, New Mexico; VA intensive home health care services offered at 11 sites; and offerings from Cedars–Sinai Medical Center in Los Angeles and the Kaiser Permanente Riverside Medical Center in Riverside, California.

Published reports on Presbyterian Healthcare’s experiences are favorable. Costs of care for patients in the Healthcare at Home program were 19% lower than those for a matched cohort, and although 30-day postepisode hospital-utilization rates were similar, patient satisfaction scores were higher.4 Furthermore, 323 of the 348 Medicare Advantage patients who were offered the option chose intensive home health services over acute hospital care. The program’s leaders reported that the development of intensive home health care pathways allowed them to fully explore the array of available home health services, a crucial step in developing a full continuum of community-based care. Rather than using intensive home-based interventions solely as a tool for post–acute care, they recognized the potential for intensive home-based interventions to substitute for costly, facility-based interventions, particularly for frailer or less mobile patients who tended to have high utilization of services.

Some of the component parts of the home-based spectrum already exist. Health systems can align home-based primary care, home-based palliative care, and Programs of All-Inclusive Care for the Elderly (PACE, a program of the Centers for Medicare and Medicaid Services [CMS]) with home-based acute care to create a suite of community-based services. Substituting intensive home health interventions for inpatient care could radically transform home-based care as a vital part of these services.

One risk would be triggering utilization of intensive home care services by patients who may not need them. Indeed, some observers have raised questions, in relation to home-based care in general, about appropriate utilization and substitution of formal (paid) care for informal (unpaid) services, and fears about induced utilization have limited expansion of home care models.5 However, supply-driven demand is not a new phenomenon. We need further research to elucidate the kinds of cases that could be usefully diverted from hospitals to intensive home health care programs. Empirically, we know that there are patients who need frequent but not constant supervision and moderate-intensity technologies such as infusion services and oxygen delivery systems but who are unlikely to need intensive care services, surgeries, or tertiary care services during more routine admissions.

Thus, an important challenge will be to develop robust eligibility criteria for triage into intensive home health care pathways. Patient selection is an issue that needs to be addressed urgently if we are to develop operational solutions using these pathways to reduce avoidable and inappropriate hospital utilization. The experience in Australia illustrates the value that intensive home health services can provide for patients and the broader system.

In health care systems that bear full risk for costs and full responsibility for outcomes, the ability to substitute such services for hospitalization makes sense, given the differences in cost between inpatient care and home care. An emerging model within Medicare Advantage plans is a type of physician practice designed to care for smaller panels of sicker patients with multiple chronic conditions, deploying intensive home health services specifically designed to reduce hospital utilization.

But in general, the lack of financial alignment in our system is an important concern. Fee-for-service systems have little incentive to develop these programs: hospitals stand to lose revenue, outpatient care providers have no incentive to work collaboratively with home care providers, and payers do not want to be burdened with ensuring appropriate utilization of these services. Aiming to address some of these hurdles, CMS has proposed alternative payment models that favor innovative programs such as intensive home health services. It has also awarded an innovation grant to New York’s Icahn School of Medicine at Mount Sinai to explicitly test a “hospital at home” model — a project that may inform a possible bundled-payment approach for Medicare.

Telemonitoring technology, sensors, point-of-care diagnostics, and the increasing use of midlevel health care providers in the home may well be the new face of health care. This vision of the future is challenging not only for infrastructure planning, but also for envisioning our future health care workforce. It portends the development of a new specialty of home intensivists with competencies including informatics of remote-monitoring technology, leadership of multidisciplinary care teams, and the interpersonal skills required for compassionate end-of-life care. It will require a new generation of technologists who can integrate detailed personal, clinical, and sensor data to provide actionable insights to the care team. Finally, it depends on ensuring that allied health professionals acquire these skills concurrently with the physician workforce. In this new world, the quaint house call will get an extreme makeover in the coming decade.

Telemedicine is becoming more widespread

Published by The Baltimore Sun
By Andrea K. McDaniels
November 4, 2016

ded by his wife, Peter Schon wrapped a gray cuff around his upper forearm to take his blood pressure. Within seconds, thanks to wireless technology, his reading popped up on a computer screen in his home near where he sat in a brown leather recliner.

A couple of minutes later, the phone rang. On the other end was a registered nurse from a skilled nursing facility, who had gotten a message that Schon's blood pressure was elevated. She wanted to make sure the Baltimore retiree was feeling okay and to determine if she needed to intervene before his high blood pressure turned into a serious health problem.

Schon, 80, suffers from a variety of illnesses that keep him homebound, but telemedicine enables nurses to monitor him virtually. The technology-driven remote monitoring and treatment has him — as he put it — living in tomorrowland.

He could be right. In just a few years, telemedicine went from a promising, but little-used form of health care thought to be useful mostly in rural areas with few doctors to one that is growing rapidly as the technology improved, insurance coverage expanded and pressure grows to keep people out of hospitals.

Last year, more than 15 million Americans received some kind of virtual medical care, according to the American Telemedicine Association. The trade group expects the number to jump by 30 percent this year. Nearly three-quarters of large companies will offer telemedicine doctor visits as part of their health packages this year, an increase from 48 percent last year.

In a nod to the large role telemedicine soon may play in health care, Johns Hopkins Medicine this summer created the first administrative position and office dedicated to the practice. Among the tasks of the new office is developing policies and guidelines around the use of telemedicine.

"I think the future market for telemedicine — the potential is incredible," said Dr. Ingrid Zimmer-Galler, executive clinical director of JHM Telemedicine. "The market is exploding. Things you would think you can't possibly do from home are absolutely going to become a reality in coming years."

Doctors and nurses across the state are using high-resolution cameras, smartphones and desktop computers to diagnose, treat and monitor patients.

They tout it as a way to better care for patients like Schon who can't easily get to the doctor and say it can help decrease emergency room visits. They also have found that many patients like not having to drive to the doctor's office.

State health officials see telemedicine as key to new reimbursement models that emphasize fewer hospital visits and more preventive care.

"Telehealth has the potential to increase access to care, improve patient outcomes and generate cost savings," said Ben Steffen, executive director of the Maryland Health Care Commission. "Expanded access to telehealth will be an essential element of the new primary care models now being developed in Maryland."

But some wrinkles still need to be worked out for it to become more widespread. Not all doctors and patients are ready to embrace remote treatment. And while private insurance and Medicaid cover telemedicine, doctors say the reimbursement process can be tedious and hard to prove.

"It is very challenging. You have to do it in a special way and meet certain criteria," said Dr. Marc T. Zubrow, vice president of telemedicine at the University of Maryland Medical System. "The companies make you jump through so many hoops."

CareFirst BlueCross BlueShield, the state's largest insurer said it covers telemedicine if it is a face-to-face consultation and includes both video and voice services. In the last year, the insurer created Video Visit, where patients can see a doctor if their primary care physician is unavailable or they need treatment for common conditions or routine follow-up care. CareFirst also has given out $4.2 million to various treatment providers to invest in telemedicine.

UMMS brought in Zubrow in 2012 to launch a telemedicine program for intensive care units. Under the program, UMMS doctors can evaluate patients at 11 other regional hospitals via video camera as needed. The services have been helpful to smaller hospitals who can't keep doctors on staff 24 hours a day.

"Whatever the nursing and medical staff can see, we have the computer capability to see at the same time," Zubrow said. "It's as if we're at the bedside."

UMMS has a variety of other telehealth initiatives and more in the works. For instance, physicians can evaluate patients who show up at smaller emergency rooms around the state to determine if they need to be flown to Baltimore for vascular surgery.

Johns Hopkins is using telemedicine even in its own emergency rooms to examine patients with less urgent needs, so they won't tie up personnel involved in more urgent cases or have to wait long for care. Under the program, a remote doctor works with an on-site nurse to assess patients at specialized carts with a video monitor, stethoscope, otoscope and high resolution camera.

In six months, the program has proved so successful in reducing wait times that Hopkins plans to expand it other hospitals in its system, Zimmer-Galler said. It plans to bring telemedicine to other areas of the hospital in the next year, she added.

Physicians also are starting to use telemedicine in their offices. MedChi, the medical society that represents many of the state's doctors, held a session on the practice in October.

Dr. Michael Randolph, a Baltimore primary care physician, began incorporating telemedicine into his practice a few months ago and has seen 10 to 12 patients remotely. Randolph said it can be more convenient for his patients who may not have enough time for an office visit. He also said it is easy for him to squeeze in consultations between office visits.

But Randolph said doctors still have to worry about liability issues and for now he prefers to use telemedicine for patients with whom he already has relationships.

"Sometimes people are sick and you want to see them," he said. "I tell them, 'You look bad. You need to come in here.'"

Schon, the retiree, started getting telemedicine services two months ago through a program run by Gilchrist Services. The health care company known for its hospice services runs a program for the elderly with either debilitating or terminal illnesses. They used a grant from the Maryland Health Care Commission and work with Lorien At Home to coordinate the care. They have enrolled 15 patients, including Schon, in the program since it started in August.

Ellicott City-based Lorien Health also works with University of Maryland Upper Chesapeake Health to provide telemedicine services for patients at Lorien's three facilities in Harford County. Each of the skilled nursing facilities has a telemedicine room used to examine patients whose condition changes suddenly. Doctors for Upper Chesapeake examine the patient via video in hopes they don't have to come to the emergency room.

Tracie L. Schwoyer-Morgan, lead nurse practitioner for Gilchrist's palliative program, said the program's goal is to better monitor the health of patients

"The idea that we can physically see them without being there gives them some reassurance and comfort, and if we need to really get there, we can," she said.

Schon's wife, Julie Schon, 72, said the service gives her peace of mind.

"I can go to the store and know if something happens there is somebody monitoring him," she said.

House calls coming back for seniors needing care

Published by McKnight's
By Betsy Rust
November 4, 2016

Baby boomers likely recall, in flickering black-and-white, kindly physicians making house calls on television and in the movies. Older Americans may remember real home visits by besuited doctors toting emblematic little black bags containing a stethoscope, sachets of sedatives and sundry medical supplies.

That long-mourned practice is seeing slow revival of sorts, and the trend may accelerate as the population ages, health care economics change and technology advances.

About 3% of doctors made three or more house calls a week in 2013, the most recent year for which data exists; and about 13 percent made what they called regular house calls, compared to only 1% in 1980, according to the American Academy of Family Physicians.
In the Great Depression, however, house calls accounted for 40% of all patient interactions with doctors, according to an article in Clinics in Geriatric Medicine.

The increased personalization that house calls provide is an obvious benefit, as is the extra time the visits afford physicians to spend with patients. Indeed, patients waste 1.2 billion hours in doctors' waiting rooms each year.

Some physicians, to help inform their ongoing care, also prefer seeing how patients live at home.

But the biggest beneficiary may be those in treatment in the senior care health system, as many elderly — particularly those who are frail, sickly or advanced in age — find it difficult or maybe unwise, because of fears of catching or spreading illness, to travel to doctors' offices.
Older seniors are a rapidly growing demographic, too. The number of Americans ages 80 to 84 alone is expected almost to double over the next 15 years, from 5.7 million to 10.5 million.

But house calls aren't just a boon for the convenience-seeking patients. They also push down healthcare costs. For example, a recent three-year primary home care demonstration program for Medicare recipients saved more than $25 million in its first year, according to research published in the Journal of the American Geriatrics Society.

Costs also were $8,477 per person lower, over two years, for home care patients than for similar patients who didn't receive house calls. High cost metrics like hospitalization rates, emergency room admittances and specialist visits were lower by 9, 10 and 23 percent, respectively, among those studied in the research.

Other studies, incidentally, have attributed home care to decreases in mortality rates, increases in patient-filled prescriptions and a slowing of cognitive decline.

House calls also may help lower readmission rates, which hospitals must do to avoid penalties under the Affordable Care Act. They also may encourage hospitals to discharge patients to home healthcare rather than nursing homes, which many, if not most, patients would rather avoid and often don't need.

However, potential barriers exist to the continuing growth of house calls. Critics complain that home visits fragment care to the detriment of patients. Others cite logistical difficulties as well as the longer time doctors spend on patients in home care, noting that this inevitably means that doctors making house calls are likely cutting the number of patients they see, not to mention the amount of revenue they earn.
The biggest problem, however, may be the supply of doctors. A shortfall of 90,000 physicians will exist by 2025, according to the Association of American Medical Colleges.

This shortage will place increasing time pressures on those in the field, obviate the ability to make time-consuming house calls and perhaps prompt more nursing practitioners and physician assistants, whom generally charge less for their services, into making the visits instead.

Insurance may be an issue, too. Most insurers will only reimburse for house calls if a patient cannot or should not travel to a doctor's office.
Still, the benefits are manifold. And given the cost-driven push for more home and community-based services throughout the senior healthcare ecosystem, perhaps house calls will someday turn today's image of impatient patients flipping through old magazines in a crowded physician waiting room into a thankfully, sepia-toned thing of the past.

Lawmakers Should Support PUSH Act

Published by Business West
By Holly Chaffee
November 4, 2016

Across Massachusetts, more than 110,000 senior citizens and individuals with disabilities receive healthcare services in their homes from skilled home-healthcare providers. These services help individuals recover from surgery, recuperate following a hospitalization, or manage a chronic health condition that needs frequent monitoring. Thanks to the Medicare home-health benefit, these patients receive timely, safe, and effective healthcare when they need it most and in the location they prefer — their own homes.

Home healthcare is an incredibly convenient delivery model for healthcare, but it is also far more. Skilled home healthcare has become an essential service that doctors depend upon to ensure their patients experience the best possible outcomes. These days, many doctors even require it before they will discharge a patient home from the hospital. It is also a valuable Medicare benefit that has been shown to save millions of dollars annually in reduced hospital readmissions and nursing-home stays.

Unfortunately, the ongoing availability of this trusted care here in Western Mass. and across the state could soon face incredible challenges. A new pilot program from the Centers for Medicare and Medicaid (CMS) threatens home-healthcare reimbursement as it requires a ‘pre-claim review’ before a patient’s care is approved for coverage by Medicare. Under new guidelines aimed at reducing fraudulent claims, care could be delayed while third-party government contractors — who are not healthcare providers and have never met the patient — review paperwork and decide whether or not care is actually ‘medically necessary.’

The program’s initial implementation in Illinois demonstrated that the pre-claim review demonstration is deeply flawed and should be halted before implemented in the other targeted states, including Massachusetts.

Over the years, Porchlight VNA has been fortunate to provide services to thousands of patients in our community. And our providers unequivocally know that care delays and denials like those seen in Illinois spell disaster for many vulnerable homebound patients who depend on us.

The days following an injury or hospitalization are often the most precarious and are when complications are most likely to occur. Without the readily available, medically necessary home care prescribed by a doctor, a patient is far more likely to experience readmission to the hospital. Oftentimes, this is due to unintended side effects from a new medication, an easily treatable infection which progresses to something far more serious, or even a dangerous fall because of decreased mobility. These are the types of poor healthcare outcomes that Porchlight VNA is vigilant about preventing, but that are certainly destined to increase if pre-claim review for care delays our ability to intervene. Helping local patients stay out of the hospital in their best state of health has always been, and will continue to be, our number-one goal at Porchlight VNA.

Therefore, I strongly urge our local and state lawmakers to stand up for those constituents in need of home health and support legislation to delay CMS’ pre-claim-review demonstration. The Pre-Claim Review Undermines Seniors’ Health (PUSH) Act of 2016, sponsored by Massachusetts state Rep. Jim McGovern, would pause the Medicare demonstration for one year to allow Congress, Medicare, and home-health stakeholders to work together to correct the program’s flaws. This would ensure patient care is not delayed and that individual beneficiaries are not unjustly denied coverage when they need it most.

I hope that residents of the Western Mass. — whether they have ever personally benefited from home-healthcare services or not — will urge our lawmakers to sponsor the PUSH Act. The well-being of our community’s home-health patients depends on it.

Judge signs proclamation recognizing Home Care & Hospice Month in Texas

Published by The Daily Tribune
November 4, 2016

Titus County Judge Brian Lee signed a proclamation on Thursday, recognizing November as Home Care & Hospice Month in Texas. According to officials at Outreach Health Services in Mount Pleasant, the home is fast becoming the center of health care as the preferred choice among elderly, disabled and medically frail Texans. Home care and hospice serves to promote independence and keep families together, officials said.

“Home health care and hospice saves billions of taxypayer dollars by preventing or reducing the use of more expensive nursing home or hospital care options,” said Loretta Griffin of Outreach Health Services. “Treating individuals at home — whether someone who needs care after leaving the hospital, or a senior or individual with disabilities that needs ongoing attendant services at home‚ these services decrease re-hospitalizations and help our friends and neighbors to age safely at home.”

Home Care and Hospice Month highlights the choice most Texans needing care to receive services in their home. Recognizing this is the safest and most cost effective choice, home care is becoming more and more prevalent across the northeast Texas.
“I would also like to take this opportunity to express my appreciation to the thousands of caregivers and personal attendants across the state and the hundreds right here in our county who are providing compassionate care to our most fragile neighbors,” Griffin said. “These in-home caregivers are the unsung heroes of so many who depend on help to stay in their homes”

A Telehealth Primer: 5 Tips to Making the Virtual Visit a Success

Published by mHealth Intelligence
By Eric Wicklund
November 4, 2016

Healthcare providers are finding that the telehealth visit is far different than in-person care, and requires a new skillset for communicating with the patient across a video screen.

Not every doctor can “do” telehealth.

As more and more health systems adopt audio-visual platforms and train their doctors and nurses to use the technology, they’re discovering one little problem: One’s “bedside manner” doesn’t always translate to the video screen.

"You can be a great physician and not be a great telemedicine physician," Randy Parker, CEO of MDLIVE, a Florida-based telehealth provider, said in a 2105 interview. "You need a 'desktop manner.' It's a different level of skill that you never learned in medical school."

Unlike a trip to the doctor’s office or hospital, a video visit is limited to the screen space in a desktop PC, laptop, tablet or even a smartphone. That’s the only window a clinician has in connecting with a patient, establishing a rapport and making a diagnosis. If that connection isn’t made, if a patient doesn’t like what he or she is seeing or hearing, the diagnosis could be wrong.

"There's a whole comfort level and professionalism involved [in telehealth] that many doctors don’t get," says Parker, who estimates that about half of the nation's doctors aren't getting it right. "There's even a dress code, and a way you present yourself" in a video encounter.

Telehealth vendors like MDLive, Teladoc, Doctor on Demand and American Well often spend a lot of time training their clinicians on how to conduct virtual visits. And universities and teaching hospitals are getting into the act as well, offering courses on telehealth presentation that separate the technology from the technique.

In a blog posted in 2014, Bret Larsen, CEO of Phoenix-based eVisit, offers five recommendations for clinicians getting ready to go online:

Address patients by their names. That starts the conversation on a less formal, more personal tone and establishes that this visit isn’t all about numbers. A patient will feel more comfortable – and more open – if his or her first name is used.

Introduce yourself and explain your role. Just as the physician wants to know all about the patient, that patient should know a lot about the physician as well. This improves engagement, making the patient feel more like a contributor to his or her health management. If the patient can’t remember the doctor’s name after the video consult, the connection is lost.

Don’t cut the patient off. Studies have shown that patients take an average of 32 seconds to state their health concerns – yet physicians, on average, cut in after 20 seconds and redirect the conversation. If a patient has a story to tell, let him/her. There may be more in that story to help the diagnosis.

Validate the patient’s concerns. A patient’s concerns are real, and should be given the doctor’s full attention. Even if that patient self-diagnosed after a trip to the Internet and is wrong, the symptoms are still there. Hear the patient’s story, then gently turn the conversation toward the right diagnosis without being dismissive or condescending.

Don’t be afraid to admit you need help. Patients may expect that a doctor will know what needs to be known to make a diagnosis, but that’s not always true. It’s better to admit that you need to do some research or consult with a specialist. They’ll appreciate the honesty and will feel more confident in the end result.

Some physicians have had a hard time adjusting to virtual care because the dynamics of the doctor-patient relationship are changed. With an in-person consult, the doctor is more in charge, an authority figure in his or her own environment. But with telehealth, that doctor is stepping into the patient’s environment.

"The whole concept that has changed is patient satisfaction," says Parker. "It's customer service, something they may never have thought of before, but it's big now. Consumers have more money in the game. It may be more than just a small co-pay, more like a high deductible, so they want to make sure they get it right."

Some organizations are only now realizing that telehealth is a whole different ball game, and one to which clinicians may need help adapting.

At this year’s annual meeting, the American Medical Association amended its policies to recommend that medical students and residents train to use telemedicine – part of a contentious, years-long debate over how doctors should use telehealth and how it might affect the doctor-patient relationship. The AMA is working with more than 30 of the nation’s medical schools to make sure tomorrow’s clinicians know how to use the technology.

"The vast majority of medical students are not being taught how to use technologies such as telemedicine or electronic health records during medical school and residency,” Robert M Wah, MD, the AMA’s immediate past president, announced in a press release. “As innovation in care delivery and technology continue to transform healthcare, we must ensure that our current and future physicians have the tools and resources they need to provide the best possible care for their patients. In particular, exposure to and evidence-based instruction in telemedicine's capabilities and limitations at all levels of physician education will be essential to harnessing its potential."

But proficiency with telehealth goes far beyond knowing which buttons to push. And some who have been in the industry for a while believe proper online care won’t be learned in a school.

“[This] isn't necessarily something that can be taught," says Ryan McQuaid, CEO of PlushCare. It requires a certain kind of innate skill to project over a video screen or through an e-mail/text encounter, not unlike acting.

"You have to be outgoing, and comfortable with technology," McQuaid says. "Certainly there are doctors out there who are amazing physicians when dealing in person with a patient, but they just don't do well" in a telehealth setting.

"You can't just connect with anyone," adds HealthTap CEO Ron Gutman,noting that online care might be more quality-intensive than in-person care because of the challenges of dealing with a patient in a different location. "You have to understand the dynamic."

Abraham Verghese, of the Stanford University School of Medicine, says an online doctor needs to make the encounter personal.

“A very important, I would say ministerial, function of being a physician is to be attentive, is to be present, is to listen to that story, is to locate the symptoms on that person of that patient, not on some screen, not on some lab result, but on them,” he said during a 2015 PBS Newshour interview.