We have entered a brave new world in telehealth—and a much bigger world, with the growing acceptance of using smartphones, laptops and other digital devices to access and share medical information.
Even before the COVID-19 pandemic hit, more physicians were integrating these new health technologies into their clinical practice. A recent American Medical Association (AMA) digital health study reports that over the last few years, physicians surveyed had doubled their usage of the tool, citing digital health as a key driver to improve quality outcomes, cost efficiency and patient access.
Telehealth has particularly expanded among primary care physicians and physicians under the age of 50. AMA Board Chair Jesse M. Ehrenfeld, MD, MPH, said, "The rise of the digital-native physician will have a profound impact on healthcare and patient outcomes and will place digital health technologies under pressure to perform according to higher expectations.”
Consumers are helping drive much of this change, as more patients are open to virtual care options. A survey by Deloitte showed that while only 23% of consumers have had video visits, 57% of those who have not used them are willing to try them. But it hasn’t always been easy to find a physician offering virtual visit options. The Deloitte study showed only 14% of physicians offering a video visit capability and only 18% of the rest planning to add the capability in the next year or two. Since the COVID-19 pandemic, those figures are changing dramatically.
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Physicians shared four key issues that matter most as they consider implementing the tool: Does it work? Will I receive payment? Will I be liable? And will it work in my practice?
Physicians are finding the landscape has improved as state and federal laws and regulations have opened the door to new models, greater reimbursements and fewer regulatory barriers.
In response to the COVID-19 pandemic, changes have been fast and furious. Medicare coverage of the tool expanded temporarily during the pandemic to allow clinicians to receive the same amount of reimbursement as in-person visits to Medicare beneficiaries across the U.S. The goal is to limit risk of exposure and spread of the virus among the senior population, and includes telehealth coverage for common office visits, mental health counseling and preventive health screenings.
But physician concerns about the tool go beyond reimbursement, including the ability to create a personal and trusting connection with patients. Brian Levy, MD, is president and chief medical officer of Peak Informatics, a medical director for MDLive, and a HIMSS Physician Committee member. For many years he was a practicing hospitalist, but with an extensive background in health IT, he recently shifted his focus to telehealth.
“When I first started doing telemedicine I thought, how can that really establish a rapport with the patient since I'm not seeing that patient in my office? Can I still establish those sorts of rapport? And what I found out is absolutely,” said Dr. Levy. “With telehealth, you can still establish that patient-physician rapport and gentle bonding just as you would in your regular office setting. For example, just the other day I was seeing a patient over the video and behind the patient he had a wall of guitars. I started to talk with him about those guitars. He was in a great band, was about to go on a tour, and needed some treatments before he went. So, I just learned more about that patient.”
Many physicians and patients are using the technology for the first time and creating their initial impressions. Hill Ferguson, CEO of the telemedicine provider Doctor on Demand, sees a massive increase in consumer interest. He anticipates significant changes in store for brick-and-mortar clinics and physicians in private practice. “They’re trying things for the first time and they’re realizing, ‘Wow, I can actually do a lot more to treat my patients over video than I ever thought.’”
Michael Barnett, MD, is a professor at the Harvard T.H. Chan School of Public Health and agrees. “There are definitely gray areas where telemedicine is not great, but there’s still a big chunk of medicine that could quite easily be taken out of the office and very conveniently delivered in some other medium. For physicians, a good 50% to 80% of what we do—depending on what you practice—really doesn’t need to happen in person.”
While physicians are often concerned about diagnosing or treating a patient without doing a physical exam, many issues are being alleviated as patients can appear on a live video and upload high-resolution photos from their phones. Physicians are finding they can make good clinical decisions and provide appropriate treatment.
“Telehealth is not just about treating the patients—it's about understanding which patients need to go to a higher-level acuity setting and explaining to them why,” said Dr. Levy. Just as in an office visit, telemedicine requires an evidence-based approach. Using the appropriate data, Dr. Levy identifies potential red flags—such as a young child with trouble swallowing or noisy breathing due to obstructed airflow—and sends these patients to the emergency department as needed.
Some great opportunities for virtual care are found in “asynchronous care,” or the ability to deliver care and information not in real time. This is especially useful in managing conditions like high blood pressure or blood sugar management. This approach allows patients to receive treatment based on data collected during their virtual visit and have it evaluated by specialists or primary care physicians over time.
Chronic care is another area of growth, with many companies beginning to establish best practices. A Canadian group is working to reverse type 2 diabetes with more patient interactions via telehealth to review diet, nutrition and exercise on a regular basis. According to Dr. Levy, providing extra time for health coaching and education via the tool can greatly improve care for patients with diabetes and can be particularly helpful in underserved populations.
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Virtual visits also allow for increased access among rural and underserved populations. Despite a digital divide in underserved communities, the majority of low-income individuals do have a smartphone, making virtual visits possible and vital as they reduce obstacles to care such as taking time off work or having reliable transportation.
Daniel Turner-Lloveras, MD, a California physician and founder and president of Salud ConTech, who has participated in HIMSS developer challenges, shared a story of how the technology can have a major impact. During a virtual visit with a low-income, uninsured woman, he heard loud banging noises and asked what the sound was. The patient shared that it was raining and she was in her car. After some follow-up questions, Dr. Turner-Lloveras learned she was in need of housing and his team began working with her to find safe options.
Behavioral health has proven to be another valuable opportunity for telehealth to broaden access. Some benefits as outlined by the American Psychiatric Association include not only increasing access, but also reducing the wait time to see a provider and improving the continuity of care.
Sophistication around the tool is growing as patients of all ages learn how to use their phones and computers to connect with healthcare staff and provide useful images and data for diagnosis, treatment and follow-up. And doctors are learning to gather critical information as they watch live video and listen to audio to assess a patient. The exam becomes even more useful when patients provide data gathered through their own diagnostic equipment, such as a home blood pressure cuff, home glucose meter or a thermometer.
And clinical staff can educate patients ahead of time on how to prepare for a virtual visit, shared John Sharp, MSSA, PMP, FHIMSS, Director, Thought Advisory, Personal Connected Health Alliance and HIMSS. He recommends that patients make a list of symptoms, track related health data and have a list of current medications available. For the call, patients should make sure their technology is set up properly, that they can clearly hear their provider and that the provider can clearly see and hear them.
Since the global pandemic hit, virtual visits in the U.S. are on track to reach 1 billion by the end of the year. In Italy, a country greatly impacted by the pandemic, telehealth guidelines have been in place in all 20 of the country’s regions since 2018. Healthcare providers in Italy have called for their colleagues around the world to utilize home-based care. This approach can be used to screen and triage patients who might have COVID-19 and to keep non-COVID-19 patients home, all helping to reduce the spread of the virus.
“Our challenge has always been that we haven’t had wide-scale adoption because there just hasn’t been wide-scale awareness,” said Ferguson. “Since March, we’ve had everyone from the president of the United States down to local governors to CEOs of healthcare companies all saying use telemedicine as a first line of defense.”
Telehealth is clearly here to stay and ready to expand, well beyond the COVID-19 pandemic. With growing interest among physicians and consumers, now is the time to leverage this healthcare technology and unleash its full potential.
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