We have had an increasing demand for our services from people who are from greater and greater distances. Headache specialty services are rare and seems to become more rare (with two major headache practices in Seattle closing). I’ve worked in other practices that do long distance medicine, such as Mayo Clinic, but there we did things differently. We wrote out a long plan of recommendations and the patient took those home for their referring provider to manage. I don’t think that system works very well, unless the patient is stable and doing well and I don’t think PCPs like working out of someone’s plan.
I have been trying to come up with ways that we could do this better. One idea is virtual visits. This is using a telephone or actual visual communication through Skype or other services. This would allow us to reach patients from far away and save them the trip to Anacortes or Bellingham. While this might sound like a good idea, it is met with many challenges.
First of all is the physical exam. It is rare that something shows up on the neurological exam or the vital signs that’s important. But it does happen. About a year and a half ago a patient was sent to me with headaches. She had seen her PCP and even a neurologist about nine months earlier. She had a normal brain CT scan. By the time I saw her, her headaches were still bad. But during the exam I noticed that she had a particular, but subtle, change in her walking. I ordered an MRI based on that finding. She indeed turned out to have a brain tumor (benign) but it was compressing part of the brain where spinal fluid drains. This was causing a back pressure of her spinal fluid (a mild hydrocephalus). She had surgery at Swedish Hospital and is doing very well. However, without the exam I would have totally missed that.
The second problem is that we would have to charge for the time and insurance companies will not pay for cyber visits. We have to charge because presently we give away for free more than half of our services. We can’t afford to give away more. We could discount the visit for cash paying patients. I think it would be worth it to a patient to pay $50 rather than driving 400 miles and taking a day off work just to visit us for a follow up.
The difficulty now is that my out of town patients call with problems and I’m with other patients. It is hard to take the time (and it takes an average of 30 minutes to handle one phone call) between patients to carefully go through their story and make the right decisions. Cyber medicine is done in the same way that face to face visits are done. They are scheduled in advance and the time, 30 minutes of un-interrupted time for follow ups or 60-90 minutes for new patients, is completely devoted to them and their concerns. I think this would be much better.
So, we may be offering this option in the future if we can get past the issues mentioned above. I want to provide convenient care, but not a care that is beneath our high standards.
If you have any ideas about this, email us or start a discussion on our forum ( cascadeneurologicheadache.com/forum )