Big data scientists and health-care experts have tried preparing physicians and patients for the arrival of telemedicine for years. Health tracking applications are on our smartphones. Compact ambulatory devices diagnose hypertension and atrial fibrillation. Advanced imaging modalities make the stethoscope more of a neck accessory than a practical tool. Despite these efficient technologic advancements, the idea of making the sacred in-person office visit remote and through a screen appealed to few. In fact, prior to the COVID-19 pandemic, only 15% of medical practices offered telehealth services and 8% of Americans joined in remote visits annually (Mann DM et al.).
When the COVID-19 pandemic hit New York City and admissions for hypoxemic respiratory failure skyrocketed, ED and in-person clinic visits for other acute and chronic conditions plummeted. Prior to clinics officially closing their doors, doctors in New York City asked their patients to reserve office visits for emergency issues only ,with most patients willingly staying home to avoid exposure to the virus. Suddenly, after years of disinterest in adopting telehealth, hospitals and clinics were catapulted into a full-on need for this technology. Overnight, our division’s secretaries and medical assistants became IT support staff. We all learned together what worked, what didn’t work, and how to adapt our workflow to meet everyone’s needs.
Previously, longstanding issues with accessibility and reimbursement presented barriers to widespread adoption of telemedicine. Once the pandemic hit, though, many regulatory changes were quickly made to accommodate telehealth.
Three such changes are worth highlighting (Centers for Medicare and Medicaid Services. COVID-19 emergency declaration blanket waivers for health care providers. March 30, 2020).
First, patient privacy rules became more lenient. Prior to the pandemic, HIPAA mandated that both doctor and patient use embedded video interfaces with high levels of security. Now, health-care providers can use commonplace video chat applications such as FaceTime, Google Hangouts, Zoom, or Skype to provide telehealth without risk of penalty for HIPAA noncompliance. When connectivity concerns arose with our EMR’s embedded telehealth application, a quick transition to one of these platforms mitigated patient and provider frustration.
Second, prior to the pandemic, some private insurance providers reimbursed for televisits, but there were stipulations on how the visit could be conducted. Now, many of the commercial insurers plus Medicare and Medicaid in New York State reimburse the same amount for televisits as in-person visits (fee-for-service rate). Reimbursement rates of audio-only encounters were increased. If these changes are continued postpandemic, it will have an expansive impact on the future of an outpatient practice.
Third, restrictive government regulations relaxed with regard to telehealth deployment. Gone are the demands on providers and patients to be physically face-to-face. Many colleagues worked from home, safely social distancing.
Even though remote medical visits were a crucial part of flattening the curve during the peak of the pandemic in New York City, the telehealth experience is not without flaws.
An informal survey of providers in our own division garnered diverse and spirited viewpoints about seeing patients remotely. Instead of using a stethoscope to pick up a subtle finding, telehealth visits require the use of our eyes to scan a patient’s home environment for insights explaining their chronic cough (Where is the mold? Where is the water damage? Where is the bird?). We use our ears to hear the intonation of our patient’s voice to know when he or she is concerned, anxious, or are at their baselines. We would implore patients to put on their pulse oximeter and perform activities of daily living and/or exertion. On multiple occasions, patients would perform their own, unsolicited walks about their home to show us what they could and couldn’t do, where they place their concentrators, and where they are likely to trip over oxygen tubing. We learned to depend on them to reach the conclusion that they were at their normal state of health.
For straight-forward encounters with existing patients, most of our colleagues appreciated the simplicity and efficiency of telemedicine. But when it came to new patients, some colleagues struggled with whether they should see them for the first time over video. Universally, providers felt feelings of inadequacy without an in-person examination and review of diagnostic information.
Along those lines, many of our colleagues worried about their ability to perform the most fundamental role of a physician over the phone/internet for all patients: building trust with a patient. Eye contact, the physical exam, and verbal and nonverbal communication that engenders confidence and displays empathy remain a challenge. Multiple colleagues commented on the difficulty of communicating a new horrible diagnosis over a spotty internet connection. Others expressed concern about the inability to review chest imaging in-person with patients as this often enhances patient comprehension and relieves anxiety about diagnostic possibilities.
Providers also noted that telehealth implementation is not the same for all individuals. Just as COVID-19 disproportionately affects the most vulnerable populations (NYC Health. COVID-19: data. Accessed July 1, 2020.), practicing telehealth has uncovered more ways in which racial/ethnic minorities, low income communities, and older patients are at a disadvantage (Garg S, et al. MMWR Morb Mortal Wkly Rep. 2020;69:458). The relatively quick transition to telemedicine revealed that many of our patients don’t have emails or home computers to connect with online platforms. Similarly, some do not have smart phones with internet capabilities. Many do not speak English and cannot partake in video visits since translators are not yet embedded into the EMR’s video system. Elderly patients were frequently very anxious with telemedicine because of unfamiliarity with the technology, and many preferred a phone conversation. Thus, while more fortunate patients get to use a video interface and its association with higher patient understanding and satisfaction, our most vulnerable populations are often denied the same access to such care (Voils CI et al. ).
Telemedicine will continue to have a significant impact on the future of health care long after the COVID-19 pandemic abates. There will be growing pains, refinement of technology, improvements in policy, and an ongoing general evolution of the system. Patients and providers will grow together as its utilization continues. We suspect patient surveys about their attitudes and preferences for telemedicine will be as varied as the providers surveyed here. A recent survey of 1000 patients about their telehealth experiences during the pandemic reported that over 75% were very or completely satisfied with their virtual care experiences and over 50% indicated they would be willing to switch providers to have virtual visits on a regular basis (Patient Perspectives on Virtual Care Report, Accessed July 7, 2020, https://www.kyruus.com/2020-virtual-care-report).
One hopes that with time and on-going feedback, the fundamental purpose of the physician-patient relationship can be maintained and both sides can still appreciate the conveniences and power of telehealth technology.
Dr. Fedyna and Dr. McGroder are affiliated with the Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, NY.