With all of the regulatory initiatives facing physicians, Ronald Dixon, MD, set out to find a way to increase clinicians’ efficiency without sacrificing quality of care.

“Every single thing we are asked to do in outpatient practice takes additional time,” says the medical director at Massachusetts General Hospital (MGH) Beacon Hill Internal Medicine Associates, and director of the Virtual Practice Pilot at MGH. From Meaningful Use to quality reporting, Dixon says he and other clinicians are feeling the pressure.

Enter virtual visits. Dixon spent years researching alternative forms of patient care and found asynchronous visits to be the best methodology. In asynchronous visits the patient and physician don’t have to be scheduled and available at the same time, but can exchange and review information when they each have time. He looked into video consultations but found that patients had to have the technology and often there were technological glitches so it took longer than traditional visits. “That’s what led us to say there has to be a better way. We think the backbone of virtual care should be asynchronous delivery.”

There wasn’t technology available, however, to conduct asynchronous care. “There was nothing available to allow us to manage our patients that needed it most.” Acute conditions such as flu or GTI aren’t difficult to manage but “we needed to manage chronic conditions—the things that really take up most of my office visits.” The chronic condition patients who typically have 4 or 5 visits a year are the ones Dixon believed could be offloaded to the virtual space.

Virtual visits offer a fivefold increase in efficiency, Dixon says. When he reads notes from a patient and responds, it takes an average of 3.6 minutes compared to 18 minutes for an in-office visit when factoring in taking vital signs, asking the patient questions and recording answers by hand and then in electronic notes. All of those steps are built into the virtual visit platform plus it “eliminates variability and increases the validity of the evaluation.”

Patients answer condition-specific questions in a secure website and then the physician reviews the answers within one day and communicates the next steps through the website. “The key point here,” says Dixon, “is that we’re not just talking about check-in visits. We are making the same types of decisions made in the office. We are trying to move care away from the office whether it’s to increase medication or order a referral, lab or radiology test.”

With just a few clicks, the note is entered into the record and the physician’s response becomes part of that note. The system creates documentation that supports clinician responses and the patient receives the decision and instructions. The billing is generated as well. “All the extra stuff I do when the patient is there is all taken care of by technology. That’s the beauty of it. The clinician still makes the decision.”

Dixon’s practice prescribes patients with a blood pressure cuff and they input their readings. His research has shown that the process is very effective and cheap.

Preparing to go virtual

Once Dixon developed a system, he brought in John Schmucker, an independent consultant, to expand the operations. “Now that we had something developed and piloted, I really wanted to implement it and potentially scale the system. That’s when I brought John in to help with the spread and scale of this innovation.”

Patients were more than ready for virtual visits, Dixon reports, because they were already using a portal to request refills and schedule appointments.

The goal, Schmucker explains, was to move heavy office users to virtual care and engage high emergency department and hospital users in the nonhospital setting. For lower level users, “we wanted to encourage appropriate virtual and office visits to improve their routine care and prevention. Could we move these lower level visits to the virtual world to free up time to see sicker patients?”

Dixon bet they could and in January 2013 moved to full day-to-day use of virtual visits. The practice has reaped cost savings by preventing some lower level visits. Meanwhile, chronic care patients are more likely to agree to check-in visits that can make a big difference in their outcomes, Schmucker says.

Patients weren’t being asked to try a new provider or new technology plus the practice “realized that a patient’s condition isn’t necessarily the most important thing in his or her life at any given time. These visits take that into account,” Schmucker says.

Clinicians, the institution and payers were another story, however. “It has taken a long time to get most of the involved parties on board,” Dixon says.

Physicians are “completely overwhelmed and drowning in administrative duties,” so they weren’t even interested in hearing about yet another new thing to try. “We tried to highlight that this is a clinical tool designed to take as little time as possible to complete the documentation.” He also put the focus on an opportunity to care more efficiently for patients they already know.

“We want to manage them in a way that’s more modern and better for them. We feel we might produce a win-win because it’s more convenient. It can actually save you time,” Dixon told them. “It’s designed to take as little time as possible to complete documentation.” Once the clinicians gave it a try, the system was very well adopted. “It’s been a challenge just to get into the mindspace of clinicians but once they start doing it, they get it.”

“A huge piece of the success is creating a system that can be easily rolled out to primary care providers and specialists,” says Schmucker. “We’re not asking them to make a large investment.” The system is rolled out as software-as-a-service and practices can go live in a matter of weeks and 45 minutes of physician training.

Dixon says the overall institution “typically is not interested in significant change but became interested because the payment model has gradually changed. That was a big lever.” The sense, he says, was that the practice could decrease the overall number of visits and potentially improve the quality of care at the same time. “That was the institutional impetus to consider this.”

But, while it’s great to have that impetus to decrease costs and improve quality, “there has to be a mechanism for value to the clinician.” Payers, Dixon said, feared that virtual visits might just add cost into the system.

Partners HealthCare has roughly 500,000 lives under some sort of risk contract, notes Schmucker. The question is how to keep these people who are basically well from progressing to needing more care and more expensive care. “This is broader than just treating illness. Payers are now compensating on a risk-adjusted panel size but how can you grow a panel without the tools to do it? Virtual visits are a way to help manage growth.” Physicians using virtual visits receive one-third extra compensation as an incentive to overcome the barrier.

The results

It’s too early for solid numbers on cost trends but “we’re getting evidence that virtual visits are at least as good, and might be trending toward being better, for conditions such as high blood pressure.” Patients are not being triaged at “some foreign call center—these are patients the physicians know which allows for some of the stickiness of this mode,” says Dixon.

Another benefit has been some evidence that depression patients might be more willing to share their true thoughts with the technology. As part of the practice’s depression questionnaire, there is a question about whether the patient is having suicidal thoughts. If the patient says yes, the clinician is notified with a text message right away. “We have noted over the past year that approximately 15 patients have admitted to suicidal thoughts that we didn’t know about,” Dixon says. “They were willing to admit that when using the technology so we were able to intensity their treatment.”

Virtual visits are now in eight MGH clinics with more coming online. They’ve been able to add modules and workflows for more acute illnesses—there are now more than 1,800 visits completed in the first clinic. Content has been built for specific areas and Dixon says he’s seeing very high satisfaction scores from both clinicians and patients.

Dixon says the hard work to get to this point has been worth it. “If I had a chronic condition, this is how I would want to be managed. I want an accurate diagnosis but then I don’t want to go into the office every three to four months if it’s not absolutely necessary. Yet I would still like to be managed by someone who knows me.”

More and more patients (and their clinicians) seem to agree.