Large healthcare systems and practices can be very complex and cost intensive. Specifically, their brick and mortar locations, extensive staffing, and IT/server-based infrastructures make it difficult to maintain their function in a cost-efficient manner in private practice. For example, in a traditional medical clinic or healthcare system, there are tiers in which a variety of individuals help obtain health information, eventually permitting the doctor to render diagnostic and therapeutic decisions. These include the front desk receptionist, biller, medical assistant or nurse, nurse practitioner or physician assistant, and the doctor’s secretary. These offices typically have other administrators such as an office manager and assistant.
Some cost savings have been achieved by these traditional healthcare systems via practice acquisition and the reduction of duplicative staffing and management. However, a more efficient model may exist for those who are interested in streamlining patient care and providing more direct doctor-patient contact. A virtual medical office (VMO) can help achieve reduced physical storefronts, streamlined staffing, and an efficient cloud-based IT system.
A simpler cloud-based digital healthcare solution that had previously been developed was recently implemented by the Long Island Heart Rhythm Center (LIHRC), located at the New York Institute of Technology College of Osteopathic Medicine. This solution utilizes a HIPAA-compliant VMO that provides direct doctor-patient contact with a more efficient healthcare delivery. This paper outlines the essentials that doctors who are going into practice may find useful. This system has been extremely useful to LIHRC, and has been well received by patients.
THE LIHRC MODEL
Electronic Health Record
In order to understand the simplicity of this novel digital healthcare solution, we began exploring the options related to electronic health record (EHR) systems. It is important for these systems to be both HIPAA compliant and cost effective. Initially, we started exploring server-based systems, which appeared overly complicated and costly to acquire. We found cloud-based options to be much more cost efficient. These latter systems include cloud-based EHR, electronic fax, and remote implantable device monitoring. The electronic health record system at LIHRC permits electronic referrals, billing, orders, co-pay tracking, viewing labs and imaging, patient communications, faxing of reports, and drug alerts as standard features. The user interface of LIHRC’s EHR is shown in Figure 1.
When starting a medical practice and/or a center such as the LIHRC, HIPAA compliance is an important matter. We began studying how this could be achieved using a paperless system, and learned that it is possible to facilitate the flow of medical information to and from an EHR through a linked HIPAA-compliant electronic fax system (Figures 2 and 3). At the LIHRC, the EHR and electronic fax system are linked through a single login, and documents can flow easily between one another.
Remote Medical Management
Remote medical device management is similarly cloud-based and easily allows for the safe and secure movement of data while maintaining privacy between the medical electronic fax and the EHR. For example, with the CareLink Network (Medtronic), it is easy to view all types of transmissions and operate from anywhere (home, office, or on-the-go); other implantable heart rhythm device companies offer comparable systems for their devices (e.g., Merlin.net Patient Care Network, Abbott; LATITUDE Home Monitoring System, Boston Scientific; and Home Monitoring, BIOTRONIK). The VMO allows for easy creation of reports, billing, and sending of referrals. The ease of the system has allowed the detection of all sorts of tachy- and bradyarrhythmias. Figure 4 shows an example of remote cloud-based implantable device monitoring. “New Transmissions” should be viewed in a timely fashion, and “New Patients”, “Missed Transmissions”, and “New Summary Reports” should be checked on a regular basis. The system records and documents the timeliness of report reviews. Remote monitoring reports can be sent and/or dragged directly onto the computer’s desktop into the electronic fax program, and interpretations can be amended and sent directly into the EHR.
In a traditional health care system, there is often multi-layered medical staffing such as an office manager, secretary, nurse practitioner/physician assistant, house officer/fellow, medical assistant, receptionist, billing team, and others. In a VMO, an assistant, nurse, or volunteer could be employed on a per diem basis to keep costs manageable. A VMO utilizes a cloud-based system in addition to an office assistant (nurse), a combined office manager/biller, and an expanded role for the physician to condense the need for all of the workers in the traditional system. It is important to create a workflow in the office for the VMO to run smoothly and efficiently. The workflow at LIHRC is shared amongst its members in a manner to optimize efficiency. Tasks include intake, copays, basic vital signs, gathering of medical information and data, history and physical examination, device interrogations and reprogrammings, billing, referrals, test ordering and correspondence, and scheduling. An exam room and separate office are also helpful in facilitation of patient flow; the assessment and plan can be discussed by the physician while the next patient is getting ready to see the doctor in the exam room. In addition, remote monitoring can be built into the daily workflow and schedule, and can be performed anywhere.
ADVANTAGES AND DISADVANTAGES OF A VMO
A VMO can significantly streamline staffing as well as cut the cost of computer/IT infrastructure. Office space can be obtained on a per diem basis, so the only thing necessary is a laptop and access to Wi-Fi for the medical professional to access the cloud-based system. For an EP practitioner, the addition of a stethoscope, blood pressure cuff, and ECG machine would be necessary to see patients in a clinic setting (Table 1). Device programmers are also necessary if interrogation and/or reprogramming are required. With a streamlined staff, not only are costs reduced, but patients receive more direct access to their physician (since he or she no longer utilizes the services of a physician assistant or nurse practitioner to see patients and perform an initial patient intake and examination).
Additionally, the need for costly servers is eliminated. A traditional medical practice utilizes a server-based system that requires physical equipment as well as constant IT support for installation, maintenance, and updates. Through payment for the cloud-based service, a VMO is no longer burdened by the costs of maintaining their own servers.1-3 Furthermore, a cloud-based resource allows for easy scalability and payment only for the services required.1-2 For instance, the LIHRC is allowed to purchase a variety of different billing solutions that directly interface with the EHR. Additionally, with a much smaller IT infrastructure, even the cost of electricity is decreased, with the added benefit of decreasing the carbon footprint of the medical practice.3
With the limited number of resources needed, a physician may conduct his or her clinic in a variety of affordable locations that best serve the patients. The implementation of a cloud-based fax and EHR allows for the elimination of paper-based resources; this significantly cuts the costs that a traditional practice must carry, while also decreasing the carbon footprint. Not only are the costs of physical paper and printer supplies eliminated, but so too is the need for employees responsible for managing and scanning paper records.
The ease of use and low cost of a cloud-based VMO has created a new paradigm in healthcare. It is particularly useful for those who have transitioned from a large practice in a healthcare system to private practice. Similarly, it has created an option for those coming out of residency, so that they are not limited to finding jobs only within healthcare systems and large clinics.
While many advantages of a VMO have been discussed, there are a number of disadvantages as well. Without the use of ancillary medical staff and personnel for the management of the practice, a wider range of practice responsibility falls onto the physician. Additionally, with the reliance of cloud-based services, the practice could not properly function in the case of a failed laptop or a nonfunctioning internet connection. Table 2 summarizes the key advantages and disadvantages of a VMO.
A VMO model similar to that described herein has also been applied to areas lacking infrastructure. For example, VMOs have been used in both disaster areas and medically underserved parts of the world, where access to medical professionals and the resources to sustain a traditional medical office are limited. Haskew et al describe the implementation of such a cloud-based system in rural Kenya, specifically for maternal and child medicine.4 In a location that had previously used paper charts, use of this EHR resulted in a significant reduction in missing patient information and allowed for the easy sharing of data to multiple clinically sites, allowing for improved patient care.4 Additionally, de la Torre-Diez et al describe the implementation of a cloud-based system in rural Spanish health centers that allowed for the use of various eHealth applications such as telecardiology to help patients that normally may not have access to such specialty services.5 The cost effectiveness of such a system and the ability to not worry about the physical location of the physician is what made this implementation a success.
This paper outlines the success of a new digital healthcare solution used by the Long Island Heart Rhythm Center. Cloud-based, HIPAA-compliant products are available and adaptable to the EP practice. Our center can now offer a state-of-the-art EHR system that integrates with a paperless fax as well as remote implantable device monitoring systems. The ease of use and cost efficiency, as well as direct doctor-patient contact, helps make this approach a winner for patients. VMOs will integrate cloud-based telehealth and billing solutions directly into the EHR to further reduce cost and efficiency into healthcare. In addition, artificial intelligence will play a role in providing algorithmic solutions without the initial physician involvement. Graduating medical students need to be aware of VMOs, telehealth, and artificial intelligence as they begin their careers. VMOs are also very useful for home physician visits, and have the added benefit of no office overhead and higher reimbursements.
We look forward to more streamlined and cost-efficient digital health innovations and solutions in order to impact patient care and help improve the practice of medicine.
For more information, please contact Dr. Cohen at firstname.lastname@example.org, or learn more at www.liheartrhythmcenter.com.
Disclosure: Please note that the commercial systems mentioned in this article (including Practice Fusion, Updox, and the CareLink Network by Medtronic) are not for endorsement purposes, but are presented as an example for educational purposes since they are used by the Long Island Heart Rhythm Center.
Disclosure: The authors have no conflicts of interest to report regarding the content herein.
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- Cilliers L, Wright G. Electronic Health Records in the Cloud: Improving Primary Health Care Delivery in South Africa. Stud Health Technol Inform. 2017;245:35-39.
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- Haskew J, Rø G, Saito K, et al. Implementation of a cloud-based electronic medical record for maternal and child health in rural Kenya. Int J Med Inform. 2015;84(5):349-354.
- de la Torre-Díez I, Lopez-Coronado M, Garcia-Zapirain Soto B, Mendez-Zorrilla A. Secure Cloud-Based Solutions for Different eHealth Services in Spanish Rural Health Centers. J Med Internet Res. 2015;17(7):e157.