Almost overnight, the COVID-19 pandemic has completely disrupted how we deliver primary care to patients. Before the pandemic, telehealth seemed to be a way to deliver urgent care for acute issues to a select group of tech-savvy patients. Now, at least in my practice, the majority of primary care (acute care, chronic disease management, and preventive care) is being delivered through “telehealth,” meaning that we conduct visits virtually via video or telephone. While, of course, this is currently safer, many patients also seem to value the improved convenience and accessibility of these visits compared to traditional office-based care. However, as we continue to move forward providing virtual care to patients during the pandemic and beyond, we need to recognize our current deficiencies in providing this type of care and acknowledge that providing the full scope of quality telehealth will require more than just a video connection with a patient. Below, I outline approaches to telehealth as framed by the chronic care model, an evidence-based approach to providing chronic disease management in the primary care setting.
Clinical information systems
The inability to collect vital signs and conduct a physical exam presents unique challenges to the delivery of telehealth. Providing true telehealth will require information systems that enable providers to remotely obtain this information when necessary. I imagine a world in the not too distant future where every home has a small telehealth kit, with a portable digital stethoscope, otoscope, thermometer, scale, pulse oximeter, and blood pressure monitor. For example, under provider guidance, a patient with ear pain could insert a home otoscope into their ear canal and securely send a picture to their doctor. Likewise, sounds transmitted by an electronic stethoscope could diagnose pneumonia or assess for arrhythmias. While home telehealth kits are currently available for niche markets, we have to ensure that affordable, accurate, and user-friendly technology is accessible to all our patients. Artificial intelligence should help providers correctly interpret the patient-generated data from these telehealth devices. We also need information systems to securely collect, store, and aggregate this information.
If used correctly, telehealth has enormous potential for facilitating self-management support. For example, consider hypertension, which affects nearly half of adults in the United States. Currently, one of the most problematic issues that I encounter when providing virtual care is lack of adequate blood pressure data. The majority of patients I see do not own home blood pressure monitors, and even if they do, there is no way for me to ensure either that they have correctly obtained their blood pressure or electronically receive their readings. Providing patients with validated home blood pressure monitors, educating patients on their correct use (including both positioning and a schedule for when they should check their blood pressure), and being able to review a summary of this data via a secure portal could both better engage patients and greatly improve our ability to manage hypertension remotely.
Delivery system design
We need to re-imagine our model of telehealth as much more than the interaction between a patient and her health care provider during a single video session. For example, nurses and other clinical staff members should be able to virtually review overdue lab tests or procedures with patients. They should also be able to evaluate patient-generated information that is sent to the practice, such as blood pressure readings, and notify health care providers about patients needing action. Our information systems should facilitate this team-based care by summarizing patient-generated data and highlighting actionable information. In addition, virtual group “visits” or asynchronous online support forums, facilitated by health care professionals, could supplement the traditional patient-provider interaction for chronic disease management.
Providing health care virtually should not diminish our ability to use clinical decision support to guide our care. Our telehealth video platforms should seamlessly integrate with our electronic health records to ensure we have full access to the patient’s chart, reminders, templates, and drug checkers at the time of the visit. We should have the capability for patients to receive and complete forms, such as the PHQ-9 depression questionnaire, during a patient visit. We should also be able to electronically share educational handouts and decision aids with patients during or after a visit.
The health system
It is imperative that our health systems continue to recognize telehealth as a means of providing quality, patient-centered care in the post-pandemic era. This will require continued reimbursement for telehealth services by both public and private payers, along with the evolution of billing codes to support telehealth visits, remote patient monitoring, and chronic care management. We need an accelerated shift away from payment based on encounter-based care to value-based care. We also need efficient health information exchange using open-APIs to break down our current medical information silos and allow aggregation of patient-generated data from multiple sources. Our quality metrics should capture patient-generated data if collected properly. Privacy restrictions, many of which have been waived during the pandemic, will need to be re-evaluated to ensure that patient health information remains adequately protected.
Telehealth has the potential to dramatically improve access to care. “Virtual” visits eliminate the need for patients to take time away from work, find transportation, and travel to the doctor’s office. For example, through telehealth, instead of a typical visit every three months, a diabetic patient can be seen virtually every week as needed. Visits for acute care can be conducted nearly instantaneously. However, during this recent detonation of telehealth, we have quickly identified major barriers. Many patients do not have access to a smartphone or do not know how to use them for video visits. Broadband internet is limited in many rural areas. We can overcome many of these issues by expanding broadband access in rural areas, utilizing cell phone networks if possible, ensuring that software undergoes usability testing by older adults, and providing training to both patients and their caregivers.
Over the past few months, the COVID-19 pandemic has catapulted us into a new telehealth era. For many, this transition has been patch-worked together to enable us to continue to implement our previous delivery model during a crisis. As we move forward, it is imperative that we remember to apply proven evidence-based strategies for providing quality health care to telehealth, while also re-imagining how technology can help us deliver care in a world where “Zoom” is now the new norm.
Cara Litvin is an internal medicine physcian.
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