Save Billions in Health Care

Save Billions in Healthcare

I have been AAFP (American Academy of Family Practice) board certified since 1982 and after practicing Emergency Medicine for 10 years, attained in ABEM (American Board of Emergency Medicine) from 1992 to 2002. I worked a variety of places, including Tripler Army Medical Center, Waianae Coast comprehensive health center ER, Kahuku hospital and KVMH (Kauai Veterans Memorial hospital) in Waimea on Kauai. I was intensively involved in all aspects of emergency, ICU, medical-surgical floor, obstetrical care. In the small community hospital (KVMH) where I did most of my work, I also frequently assisted in surgery and delivered many babies. I was familiar with the recovery room, Xray department, Laboratory and physical therapy. In other words, I was intimately involved in all aspects of hospital care.

As a surfing afficiano, I was motivated to put to use the latest available wireless communication gear available from the very start, around 1983, prior to the cell phone revolution. During the 24 hour emergency call for KVMH (Kauai Veterans Memorial Hospital), our 50 bed community hospital serving around 20,000 people of rural west Kauai, ER doctors carried 2 radios and a pager during the day while they were driving or at their clinic. One radio was MedCom (the radio that ambulances used to call the hospital ER or emergency physician) and the other radio was Local Government (the radio that police dispatch used to call the poice, fire department and ambulance to respond to emergencies). The fire trucks would frequently respond to medical emergency 5-15 minutes before the ambulance because their stations were closer and areas of responsibity smaller than the EMS (emergency medical service) units.

I was not always hospital based while on call in that my office was 6-8 minutes fast drive to the ER. The police all knew my jeep and when they heard a call on the same radio, knew that I was tearing down the highway for a legitmate reason. On the Westside, there was no need for lights and siren, a few flashes of my brights and people would think:

"There goes Dr Spear."

When I arrived 6-10 minutes before the MICT (medical emergency care technitions who are like ICU/ER nurses that can work in the field) and EMTs (emergency medical technicians), invariably the firemen where greatly relieved when a medically sophisticated professional was there to take over the patient(s).

Since 2003 I have added tele-medicine to my practice by bringing the communicaiton directly to the patient, not just other medical paraprofessionals. To my knowlege, am a pioneer in this technique. I also have had some legal consequences of being on that forefront of tele-medical pain practice which I can address in another correspondence at your request.

I have also had a great deal of experience with musculoskeletal pain and addiction management, areas that are know to be the highest utilizers of outpatient primary care visits, by some estimates up to 30% of outpatient visits. implementing my remote tele-medical methodology in this large population alone can manifest enormous savings immediately. In addition, my extensive experience with tele-medical diagnosis and treatment places me an unique position to teach other physicians, residents and medical students how to provide these type of services.

HMSA, the Hawaii Blue Cross/Blue shield provider has implemented a similar, web based doctor service. The difference that the program we will design will be that it is not run by a private insurer, hence can apply across the board. I have expanded the idea and made it more complementary to exsisting care, facilitating, expediting and triaging medical problems. As you may know, much of primary care involves us taking on the role of gatekeeper.

The "tele-medical consultation" is done in advance of the first office visit. To be less controversial, deleting the treatment aspect and taking the role of medical advisor, guide and most importantly Health Tutor does not take business away from traditional doctors. It is complementary, much like a physician assistant and more because it is a doctor, a second opinion to begin with. A patient's informed decision requires time consuming education of variable length. The scope of medicine is so broad that even a medically sophisticated lay person is daunted, despite internet searching for treatment options.

My plan begins with a comprehensive "Sherlock Holmes" history by phone or webcam that through fax or email, which becomes a part of medical record of the accepting primary care or subspecialty acceptin physican. Interestingly, I have found that is easier and more complete if accomplished by using purely audio communication as a analog hardline telephone or even an intercom when I am at my office (cell phones and webcams work but digital signal may not impart voice inflection and cadence as well). Face to face interviewing leads to distractions or intuitive leaps by the doctor to treatment that leave a patient's understanding of their condition in the dust.

Time consuming explanations of diagnostic or treatment rationales necessitating physical presence in the office leads to more time away from family, physician disenchantment due to overhead costs eating up money and burnout. Home office work has been instituted by many industries, why not primary healthcare on a large scale? This turns conventional medical dogma on its head. Furthermore, the physical exam almost becomes optional or at least deferred until laboratory testing or imaging studies are done. The decisions are most often historical and diagnostic studies which can be immediately arranged in advance leave the physical exam as confirmatory, particularly if the patient is put through some well explained self examination during or before their tele-medicine visit.

The result is a treatment, test or prescription clinical trial being started with a patient who has an in depth understanding of their particular problem. My tele-patients universally tell me that they have received more comprehensive explanations than their regular, office based doctors. As my PROM (problem oriented medical record) professors who were the progenitors of this system in the 1970's and their application of the use of SOAP (subjective, objective, assessment, plan) notations now the standard of medical practice, said, "great history taking is 85% of good medicine." Emory, where I attended medical school, was THE pioneer and implementor in this methodology, as 3rd year students, we were the guinea pigs.

As a Health Tutor and/or Personal Health Guide my role would involve bringing people to a higher degree of medical sophistication, far beyond just random web based information searching. The physician calling or web cam pool could be a "cubicle farm" of US trained MD's in Houston, Cleveland, SF or Denver or they could be a virtual pool of doctors at home or on their cell phones. The last would certainly curtail physician disenchantment and burnout.

This would involve, yet not be limited to:

1. Exploring 3rd party payor options and strategies at the time of initial consultation. How to fight the HMO wars. Whether it is appropriate and how to apply and receive benefits from workman's comp, welfare, SSI or medical retirement.

2. Picking the right doctor, (Can your problem be handled locally?) and if not how to get into the best tertiary care. Plus, how to avoid local medical ethical/political faux pas, so eventually, you will be well received back to your PCP (primary care Dr).

3. Explaining your condition to a health care provider (not his receptionist) in a medically succinct way, possible over the phone. This includes what to say on his/her voicemail so as to get a timely response from the PCP.

4. Setting medical diagnostic goals and reaching them in a timely and efficient, cost saving manner and without redundancy (including labs) by knowing what to ask for and more importantly taking the time to explain to patients the rationale for ordering the testing, with a relaxed question and answer period that is usually not afforded people in the setting of a busy medical office.

5. Setting medical treatment goals, attaining them quickly (having already been informed of and had time to consider the risk/benefit ratios before seeing tertiary care) and efficiently. Having a medical knock list of a staged treatment plan so that tertiary care is used more appropriately including providing direct phone contact information to the appropriate entity to expedite care.

I have no alternative care, holistic, medical economic drum to beat. Although I do take a holistic integrative approach to allopathic medical care starting with nutrition and lifestyle complementary treatments, including alternative options such as acupuncture, manipulation, and naturopathic modalities as indicated. The foundation is straight old blood and guts, pharmaceutical, allopathic (a.k.a. Mayo Clinic type), AMA accepted medicine.

Primarily this is a format to train the public on utilization for the highest good with the most efficient allocation of resources which will naturally address the primary care shortage that was alluded to in the President's ABC interview with Tim Johnson MD aired on the 7/15/09 nightly news.