How to practice high-quality telemedicine in the era of COVID-19

My practice received its first question about coronavirus from a patient on January 28, 2020. Though there were over 200 deaths reported in China by that time, no one could have imagined how drastically this would come to disrupt our lives at home.

Thankfully, I had a head start.

As a doctor at an integrated telemedicine and primary care practice in New York City, nearly two out of every three of my medical encounters that month was already virtual.

I spent much of January caring for patients who had contracted seasonal viruses, like influenza or norovirus (i.e., the stomach flu). My patients reached out nearly every day with bouts of fevers, fatigue, diarrhea, and vomiting. Our team did all we could to encourage each of these patients to stay home and avoid spreading their highly contagious virus throughout the community (sound familiar?).

We are now guiding our patients through the COVID-19 outbreak using the same tools we use to guide them through any healthcare need – real-time monitoring, proactive outreach, and team-based care.

After our first COVID-19 question, our team started compiling information about every patient who reached out with symptoms that even slightly resembled COVID-19. This soon turned into a comprehensive patient registry containing the epidemiologic risk factors, clinical risk factors, symptoms, and a follow-up plan for each patient. Based on their total risk level, we follow up with these patients every 24 to 120 hours.

Every day, one provider on the team texts or schedules a video visit with each follow-up patient, reassesses their symptoms, and re-stratifies their risk. Most patients respond with a text message letting us know that their symptoms are the same or slowly improving. But for patients at higher risk, we want more information. We help these patients acquire a thermometer or pulse oximeter to follow up on their respiratory vitals. With this data, our team can provide patients and their families with thresholds on when to seek out a higher level of care.

Our job for these patients is clear: provide treatment at home and only recommend the hospital if there is no other option. By centralizing data and establishing clear triggers for a new plan of care, a single provider can follow up with over 30 COVID-19 patients in a single day.

Of all the patients with COVID-19-like symptoms, so far, not one has required hospitalization.

The other providers at our practice spend their days talking with patients via text, phone, or video. They have mastered one of the most valuable diagnostic tools in medicine: taking a history. But no matter how skillful they are at asking the right questions, a solo provider in the current outbreak can be cognitively and emotionally overwhelmed by the information coming in from patients.

Back when our brick-and-mortar medical offices were open, our team used to hold a daily huddle to discuss complex patients on the schedule that day. With the offices closed, this ritual still stands. Instead of discussing whose hypertension is poorly controlled or who is overdue for a Pap smear, now we focus on issues inevitably impacted by COVID-19. We discussed whether to prescribe steroids to a patient with an asthma flare likely due to COVID-19, or how to keep a patient feeling isolated and suicidal safe at home. This routine serves as an important reminder that we are not only providing COVID-19-care. Patients continue to have medical and mental health problems that are amplified by this pandemic.

During my medical residency, a senior doctor once told me that when it comes to sick patients, never worry alone. Our entire clinical team worries about COVID-19 and how the pandemic impacts our patients’ health. More than anything, the frequent huddles create space to share those concerns in the open. Even if there’s not an immediate solution, we can rest a bit more assured, knowing that no one is worrying alone. We tackle these challenges as a team.

As the number of confirmed cases of COVID-19 in the U.S. has skyrocketed to over a million, medical providers have a clear mandate: treat patients at home and keep them out of the hospital.

But to be effective, this will require more than simply swapping an office visit for FaceTime or Zoom. A coordinated, proactive, and team-based system can help patients get the care they need and keep communities safe. These elements are essential for an effective telemedicine response to COVID-19. And after the crisis has passed, I hope we continue to use telemedicine as the foundation for a new model of care, not simply as a shallow replacement for the doctor’s office.

Anish Mehta is an internal medicine physician and medical director, Eden Health.

Image credit: Shutterstock.com

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