Lessons from evolution of telemedicine in response to COVID-19

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The COVID-19 pandemic has threatened our physical and mental health and the very fabric of society. Social isolation has devastating consequences on small businesses, but it has also opened doors to remote business opportunities in the virtual world. Medicine has long been ready to launch telemedicine. However, bureaucratic red tape has prevented this from happening in real-time. Archaic regulations have stifled growth. However, necessity is the mother of invention, and in response to social distancing, most medical practices have taken their visits to the virtual world.

I run a small primary care practice. In response to regulations about social distancing and because of safety concerns of the staff and for our patients, we decided to adopt televisits. We were one of the early adopters.  We did already have the set up through our electronic health record’s patient portal. In the past, we have found that it is cumbersome for patients to use this service. Being an internal medicine practice, we do have a lot of elderly patients, and it is a struggle for a lot of them to understand the intricacies of televisits. 

In response to the crisis, we have used several modalities: FaceTime, Zoom, Skype, and our portal. The most user-friendly has been FaceTime, followed by zoom. The ability to bond with patients at their convenience at the comfort of their home offices is priceless. We can share a part of their life. One of my younger patients who suffers from chronic depression was able to share his room and had his dog present at the visit. I had heard a lot about his dog in previous visits, but now I could get to meet him. Another patient had an outbreak of a rash that was diagnosed as herpes zoster by me on FaceTime; another elderly patient was able to show me her swollen legs and had her medications adjusted. These visits were profoundly gratifying for both parties, especially at this time of disaster.

I have also been amazed that once regulations have been removed, things can be done much more quickly. If the system works well, patients can get quality care at home. This can change how we provide care completely. Primary care offices care always running behind and not able to see patients on time, leading to unnecessary waiting in the waiting room, which is dreaded by most patients. We can provide most of the care remotely. The presence of remote devices like blood pressure and heart rate monitors, wearables that can count steps and give data on quality of sleep can interface with our devices. We need to look at the outdated coding and billing system and relax some of the regulations that have been keeping this from happening.

The electronic health record vendors have failed miserably in interoperability and ease of use and have contributed significantly to physician burnout. If we were to work remotely through efficient systems, it might enable us to see more patients, and valid reimbursement of visits would prevent patients from going to urgent care and ER unnecessarily.

I could often provide the right care to my patient that is well known to me rather than another doctor who does not see the patient regularly and sees them for urgent issues only.  Even if telephone calls were reimbursed at a decent rate, a lot of unnecessary downstream visits could be avoided. I would venture to even say that things like hospitalization for chronic disease can be intervened and prevented upstream if the primary care physician can adjust their medicine remotely by the ability to check on the patient remotely through televisits. Primary care physicians are also less likely to order unnecessary testing due to a therapeutic relationship with a patient and might be able to see and advise on their patients that are admitted to the hospital. This is the time when the patients need their physicians the most, and this opportunity had ended with the start of hospitalist medicine.

A big piece of this is compensation. Also, the federal government has mandated reimbursement of televisits at the time of this pandemic, my initial data from the billing seems to indicate that we are being reimbursed at the same rate by some insurances, but others are decreasing their payment significantly. Certain insurances are already paying two-thirds of the traditional face to face visits. Traditionally it has been believed that face-to-face visits are more effective and should be reimbursed at a higher rate. However, my ability to provide remote care to the patients at the time of this pandemic shows that I can prevent unnecessary ER visits in urgent care visits and reduce costs downstream. These visits do not replace the in-person physician visit but can enhance the patient experience and make our delivery of care more efficient and meaningful.

I have worked in busy emergency rooms and as a hospitalist and urgent care physician. I can share that most urgent care physicians are overwhelmed with patient load and are more likely to order diagnostic testing. We can prevent this by having remote visits or even a telephone call, reimbursed at a decent rate for a primary care physician. The downstream impacts can be significant, allowing our ER doctors to see only true emergencies and focus their time and energy on those that need them.

Telehealth also opens the door for patients to access quality sub-specialists remotely, even across state lines. We might want to think about national licensing in this era of technology. We also need to work on payment systems that are fair and make it worthwhile to do telemedicine.

One thing is clear: This pandemic has opened the door to telemedicine forever. We are living in a global world. We need to work through innovation and do a much better job of using technology to our favor while not letting go of the traditional face to face in-person physician-patient relationship. It is a brave new world out there. Maybe we will go as far as look at this as one positive to come out of the COVID-19 pandemic.

Talal Khan is a family physician and can be reached at Personal Primary Care.

Image credit: Shutterstock.com

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