Telemedicine in the Age of COVID-19

The COVID-19 pandemic has altered almost everything previously thought sacrosanct. These were not elective changes, but forced upon us by a reality that does not care about race, religion, gender, political or philosophical persuasion. While the negatives of the SARS-CoV-2 virus and the COVID-19 disease it causes have been huge and horrendous, especially in the healthcare space, there have been some positives. I have been writing elsewhere on some of these topics, including the epic and heroic work done by healthcare workers and those that support them, and the incredibly rapid repurposing of the healthcare industry to aid in this battle facing humanity. If you are part of the healthcare family involved with patient care and supporting the healthcare infrastructure, this has been a soul restoring experience. This is why we got into this profession. In a sobering perspective, however, one must remember that there is no guarantee that humanity will win this or future confrontations with the microbial world.

Patients should not defer their care out of fear of this virus. Chronic perhaps smoldering conditions may become acute problems if ignored. If you have needed to see your doctor in the last few weeks, there is a reasonable chance that you have encountered a new mechanism to see you that keeps you and the healthcare team safe in the face of an infection risk that could be fatal. That strategy is the sudden rise of telemedicine, or remote care.

I have been engaged in telemedicine for over four years, mostly with a platform that is international, but recently advising some companies that are focused on patients here in the US. There have been many arguments against the use of telemedicine: it’s too technical for patients (and for keyboard averse doctors); it’s too expensive and payers (insurance companies) don’t want to pay for it; it’s too hard to set up; it’s too sterile and patients want to see their doctors in person; it’s not as effective as in-person visits; and doctors can’t do physical evaluations remotely.

Moreover, one of the greatest barriers to telemedicine is the very human proclivity to resist change. All the reasons above were fully active in January and February of this year. But now, in a few short weeks, almost all healthcare providers who can do it, are doing it. So, what changed? That rhetorical question is answered by the fact that when face to face encounters now include the risk of being infected by a potentially lethal virus that can survive on almost any contact surface, much less aerosolized by breathing, one tends to embrace changes that were previously thought to be daunting.

I’m not going to review all the telehealth options available to healthcare providers and our patients, but instead just do a generic retort to the aforementioned barriers to adoption.

One key principle is that telemedicine should not be considered as another layer to complicate the patient-physician relationship. Telemedicine is just another tool to facilitate the visit.

Besides the palpable threat of death, one of the major reductions in resistance has been the insurance companies agreeing to pay for telemedicine visits as if they were in the office. This has allowed us to use fully secure (HIPAA) video and audio platforms, or smart devices, or even plain old telephones, to conduct the remote visit. The concern I have is that some physicians have been using phone calls and billing them as office visits, which perhaps meets the letter, but certainly not the spirit, of the law. The caveat has been that this allowance may only exist until the COVID-19 emergency is active. When over, and if audited, this possible abuse of the law may cause the insurance companies to terminate the option. More on this momentarily. 

Most telemedicine companies have made the connection technology between patients and providers as seamless as possible, usually by providing a text message to the patient with either simple instructions or a direct link to the provider’s computer or device. Integration of telemedicine into electronic health records is optimal, perhaps facilitated by artificial intelligence using a technology like natural language processing to make documentation easy. That’s a topic for another article. Formal consent to provide care via telemedicine should be obtained prior to the actual encounter.

The idea that the telemedicine visit is too sterile and patients won’t like it is discarded once patients actually do it. In my experience, patients really like it if they are an established patient with the doctor. They get to see their doctor, and vice versa, have the same conversation and recommendations, yet did not have to drive or get transportation, or arrange someone to take them, and leave the comfort and security of their residence. These benefits are even more enhanced if the patient resides in an assisted living facility or nursing home.

Telemedicine studies have shown that the effectiveness of the visit, depending the metrics used, as well as patient satisfaction, are comparable to in-person visits. Patient education materials can be similarly provided with telehealth tools either before or after the visit. In my estimation, completely new patient evaluations are much better done in person, mostly because the personal link is otherwise absent, and the limitations noted next.

One criticism that does have validity is the inability to do a general physical examination. Some targeted and limited examinations can be done by careful observation and a compliant patient. Some specialities such as dermatology and neurology are amenable to telemedicine. Vital signs such as blood pressure, pulse rate, regularity of heart rhythm, and weight are remotely obtainable by home devices and the growing use of wearables. Remote stethoscopes as well as other clever blue-tooth connected devices have been developed by some of my technology colleagues.

What may disrupt this telemedicine evolution will be the financing structure after the pandemic scare. In this COVID crisis, many new codes have been developed to facilitate remote care, both for the benefit of continuity of care as well as safety for all. It is my hope that rather than just snap the legislative finger when and if the COVID pandemic is politically deemed over and cancel out the reimbursement structures that have been erected, thoughtful reflection will prevail. It would be better if the insurers carefully review the benefits to the patients and weigh those against the cost. I predict they will find true value. One thing that will assuredly return will be the emphasis on privacy. That fact alone should make providers seek and adopt HIPAA compliant platforms as soon as possible.