Part 1 of a two-part series on COVID-19 and telehealth. Part 2, published May 22, covers how barriers to telehealth can be overcome and what the future of this care delivery model may hold.
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The COVID-19 pandemic shifted telemedicine from an outlier to a necessity almost overnight, and doctors say they can't see ever going back to their old model of care.
"It's hard to imagine us going back to doing everything in the office," said Joe Kvedar, MD, president-elect of the American Telemedicine Association in Arlington, Virginia, "It's more convenient, patients are happier, we get the information we need, and we can open up more slots for other patients."
Andrew Gettinger, MD, chief clinical officer of the Office of the National Coordinator for Health Information Technology in Washington, DC, agreed. "There are times when forced change—and I would describe the COVID-19 circumstance as forced change—leads to insights into how things could be done better," he said.
According to the Commonwealth Fund, telemedicine comprised nearly 30% of outpatient visits in April, while the number of clinic visits dropped almost 60% in mid-March and has stayed low. The number of visits to ambulatory practices has rebounded a bit since then but is still one-third lower than before the pandemic.
Pandemic has accelerated telemedicine
The recent rise in telemedicine has been partly fueled by the temporary lifting of several Medicare restrictions on the types of and eligibility for telehealth service reimbursement during the pandemic; the relaxation of HIPAA privacy laws that allow the use of smartphones, video conferencing platforms such as Zoom, and messaging services like WhatsApp; and the ability to provide care across state lines in 48 states.
"This is especially important for people 65 and older, since virtually all are at greater risk of becoming seriously ill if they are infected with the new coronavirus that causes COVID-19," said Juliette Cubanski, PhD, MPP, MPH, deputy director of the Program on Medicare Policy at the Kaiser Family Foundation in San Francisco.
Gettinger, a critical care physician, said that telehealth has been used successfully in his specialty for more than 20 years as a way to meet the Leapfrog Group quality and safety standard of each intensive care unit having access to a critical care physician.
"We've been able to have consultations where critical care docs are able to literally engage in patient care remotely by having access to all the bedside monitoring, all the laboratory tests, all the active drips, and video, and having the bedside staff to do things like listening to the lungs," he said. "Even some of the institutions that have had large influxes of COVID-19 patients with severe respiratory infections are transitioning to remote care for the safety of the caregivers in ICU."
Kvedar said he has been practicing telehealth for 17 years as a dermatologist and has been providing care 100% remotely since the pandemic began. "Taking care of patients with acne is kind of a use case for telemedicine," he said. "Patients love it."
Patients submit high-resolution photos taken with their smartphone and upload them to the patient portal, Kvedar said. Then he calls the patient to discuss the situation; he has done video conferencing, but never by itself. "If we were doing video, we'd get more information, of course," he said. "That's better, and I think patients feel more cared for, but the resolution of the video cam is not up to par."
Better for some specialties than others
He said that every specialty has patients with conditions appropriate for telemedicine, such as those taking self-injected biologic drugs for psoriasis. "These patients need routine follow-up, often with laboratory tests, but if they have no findings, and their skin is clear, they don't need to come in," he said.
According to Gettinger, telemedicine truly shines in psychiatry and psychology. "Patients are much more comfortable remotely than they are in a psychiatrist's office," he said. "And it also gives the psychiatrist the chance to see the patient in their normal environment, which is a real advantage."
In addition to behavioral health, primary care conditions such as earache, cough, sinus pain, sore throat, urinary tract infections, and pink eye (conjunctivitis) lend themselves to virtual visits, as do chronic illness and surgical follow-up and blood pressure and glucose monitoring, Kvedar said. "Where I work, you get a doctor within 6 minutes, and 80% of the time you get your problem solved," he said.
Telehealth also can help prevent the serious consequences of deferred care when patients are concerned about being infected at a clinic or hospital, especially in at-risk populations such as older people, Cubanski said. "There are data to suggest that people aren't going to the doctor when they have chest pain," she said. "People are so scared to go out into the world."
And once patients get a taste of the convenience and speed of telehealth, they will probably be reluctant to give it up, Cubanski said. "Even after we get past the immediate emergency of the pandemic, there might be a lot of reluctance among older adults to go out to the doctor, so the interest in providing services via telehealth will still be there," she said.
Benefits outweigh risks
While some people may say that telehealth is impersonal and disconnected, Gettinger said that patients who see their doctors in their home environment—where a child or pet may make an unexpected appearance—may come to view them as more human. "It's an opportunity to see your physician in a different light and often a better light," he said.
Also, because doctors need to face the camera rather than be facing away while typing notes into their computer, there can be more eye contact and focused attention, he said.
Yet telemedicine is not a one-size-fits-all solution, according to Gettinger. "If you're an orthopedic surgeon trying to evaluate a patient with severe pain from osteoarthritis being considered for joint replacement, you need X-rays, you need the physical exam, and that's obviously going to be more difficult to achieve remotely," he said. "But postoperative care could lend itself very easily to telemedicine" with a photo of the incision and a conversation about pain.
Telehealth also carries concerns about privacy arising from intrusions into meetings held on platforms such as Zoom, but Kvedar said that while he has heard about cases in which someone posted a link to access a meeting on Facebook that someone found and dialed in, he has not heard of hacking incidents per se.
He said that hacking is very rare and that applications such as Skype, FaceTime, and WhatsApp are encrypted and very secure. In addition, healthcare delivery is unlike some services in that it already cares about patient privacy, he said. "It's part of the DNA of a good healthcare provider to care about stuff like that," he said. "I would never want a patient to forego a telehealth encounter because they were worried about privacy."
While telemedicine isn't perfect or suited to all patients and conditions, Cubanski said that it helps bridge the gap. "Everybody would agree that some interaction with your doctor when you need to see them is better than none at all, whether it's via your smartphone or a telephone call," she said.
