[Reprinted: Medical Xpress, 6-16-2020]
The new coronavirus pandemic has necessitated the embrace of virtual medicine regardless of how ready patients, doctors, nurses and health care systems were for the shift.
Now that telehealth has been quickly rolled out across the nation and patients and clinicians have found the experience useful, it is unlikely that virtual doctor visits, in all its various forms, will be temporary, said Dr. Devin Mann, senior director for informatics and innovation at New York University.
“Once we get back to whatever the new normal is, I think they will all play a role in the spectrum of ways that we interact between clinicians and patients,” he said. “The genie is definitely out of the bottle.”
Before the pandemic, the use of technology to deliver health care—often referred to as telehealth of telemedicine—was largely a secondary tool clinicians and patients used to exchange emails regarding test results.
But in a matter of days this spring, as hospitals canceled elective procedures and in-clinic visits in an effort to slow the spread of the virus and preserve protective gear, patients were using telemedicine for everything from simple questions with primary care providers to OB-GYN visits.
There is still much that needs to be figured out for telehealth to be a viable option. One of the biggest obstacles are federal and state regulations surrounding payments, and definitions of what constitutes a virtual visit.
Outdated rules and regulations made telehealth difficult before waivers came from states and the federal government in response to the coronavirus pandemic, said Dr. Jeffrey Wolff-Gee, medical director for care delivery transformation at Swedish Medical Center.
“It got held up for the longest time because the regulatory environment around it made it very difficult to do,” he said. “And now we can do it.”
Here’s what that looks like in practice for six different areas of care. It’s how we go to the doctor now.
Telemedicine has been in use at Seattle Children’s hospital since the mid-2000s for autism, psychiatry and sleep medicine, but it ramped up after the coronavirus outbreak, said Dr. Mark Lo, medical director of telehealth for the hospital. “By mid-May, something like 70 to 80% of our volume was all done virtually,” across more than 40 pediatric specialties, he said.
“Some of the challenging aspects have to do with keeping the kid in view of the camera,” Lo said. “Our ideal state,” he said, would be for virtual visits to be follow-ups, “where the provider knows the patient and it’s not starting from scratch.”
For those practicing primary-care pediatrics virtually, he said, a major component of care would be history-taking from patients’ parents. Parents could also play a role in augmenting video visits by sending photos and videos to their children’s providers in instances where additional visual documentation might be helpful.
But some care simply can’t be provided remotely, particularly for complex patients requiring providers from across disciplines and specialties, or for those needing X-rays, biopsies or physical evaluations.
But Lo said virtual care has been particularly successful with autism, mental health and adolescent medicine specialties at Children’s, and he can envision a future where virtual care is used routinely to complement in-person care.
Lo hopes that might increase accessibility for patients in remote areas. “One thing that’s come up a lot has just been equity of care as well,” Lo said. “We want to make it available to everybody whether they live in Seattle next to the hospital or the furthest reaches.”
Before the coronavirus outbreak, the University of Washington began a partially remote prenatal care program known as TeleOB, equipping patients with blood pressure cuffs and fetal Dopplers for self-monitoring at home and using video for some of their many prenatal appointments.
While telemedicine has advanced rapidly in recent months, TeleOB was ahead of the curve. UW is one of only a few institutions nationally that offers telemedicine options for prenatal care (others include the Mayo Clinic and the University of Utah).
Some components of prenatal care—ultrasounds, vaccinations, lab tests, screenings—must remain in-office, especially if patients are managing a pregnancy complication.
Dr. Sue Moreni, OB-GYN division chief of UW Neighborhood Clinics and director of UW’s TeleOB program, says TeleOB was a useful option for low-risk patients balancing their care with work or family obligations.
Their video visits are conducted over a HIPAA-compliant version of Zoom, with interpreters available. And the home equipment is free, with the expectation that patients will return it at the end of their pregnancies.
As telemedicine becomes the new norm, Moreni hopes it will also promote greater equity in access to health care.
“One of the biggest advantages to telehealth that will hopefully only get better is trying to close some of the disparities in health care,” Moreni said, citing telehealth visits as a useful option for rural or low-income patients who might face unique challenges to accessing a traditional appointment. “That’s really one of the biggest societal advantages when you’re looking into the future of telehealth that that can really offer.”
It’s OK to not be OK. The phrase is ubiquitous for good reason—one-third of Americans are experiencing symptoms of depression and anxiety following the coronavirus outbreak. According to Keri L. Waterland, division director of Behavioral Health and Recovery at the Washington State Health Care Authority (HCA), it’s normal to not feel OK right now. “There’s no shame in feeling emotions around this time and feeling depression or anxiety or even feeling some trauma,” she said.
And if you have access to a phone and an internet connection, initiating therapy with a mental health professional may be easier than you think.
Previously, intake interviews for therapy needed to be conducted in-person. But as behavioral health goes virtual, these assessments can now be provided online, Waterland said. It’s one of many changes behavioral health services in the state have undergone since the pandemic began. HCA has also purchased 2,000 Zoom licenses for behavioral health providers, and procured laptops and other technology for providers and patients.
Waterland said every individual seeking care will have different needs, and not all can be addressed online. But, she said, “We are really embracing telehealth and telemedicine and acknowledging that for a swath of the population this really, really works.”
For immediate help, a new support line, Washington Listens, will soon be operational for anyone experiencing elevated stress due to the COVID-19 outbreak.
Waterland hopes that resources like Washington Listens will help to lessen social stigmas tied to mental illness and emphasize to users that there’s nothing wrong with experiencing strong feelings during a time of upheaval and fear. “When we have our lives really uprooted, having a strong emotion about that is part of what we’re supposed to do as human beings,” she said.
Telehealth was being used by a sliver of UW Medicine’s primary care doctors before the new coronavirus pandemic. That changed quickly with the adoption of virtual services exploding from 25 clinics to 300, and from 130 primary care providers to now 2,600 in the sprawling system.
The broad dispersal of telehealth is something that will become part of a primary care doctor’s practice even after the pandemic, said Dr. Crystal Kong-Wong, a primary care physician at UW Neighborhood Clinics.
Kong-Wong and her colleagues’ first contact with new patients is now through a video chat, which is something that usually didn’t happen with first-time patients before COVID-19.
“I was pleasantly surprised by how much you could get out of a first virtual interaction with a patient,” she said.
On a normal day, Kong-Wong, who is also the associate medical director for digital health at UW Medicine, would see 18 to 20 patients a day. Since the switch to telehealth, she is still having those visits, just in a different form.
“I think for a lot of those patients, having the telemedicine option was a reassuring and powerful tool for them to be able to interact with a doctor that they knew and had an established relationship with,” she said.
As Kaiser Permanente Washington was converting existing appointments and scheduling new appointments as telehealth visits, Dr. Cindi Burdick was reaching out to her geriatric patients because she knew they were at higher risk for COVID-19 and could be impacted by the virtual interaction.
Senior care can be complicated, as many patients are on multiple medications and could be suffering from several chronic conditions. Because of this complexity, Burdick, the medical director of Medicare and Medicaid at Kaiser Permanente, used her patient outreach calls to assess her patients’ needs. She tried to find out if they had enough food, housing and transportation. She wanted to know who had chronic conditions that needed to be addressed, who had health care gaps and who might need advanced planning directives.
“Having affordable care, somebody you really trust, and an integrated system will be really important because you can’t have things falling through the cracks in senior care,” Burdick said.
Using technology will play a larger part in how Burdick interacts with her patients from now on. Because of this shift, she said, it is going to be important for providers to be cognizant of which modality works best for each patient.
Social distancing and virtual visits aren’t ideal for physical therapy, yet physical therapists found a way to navigate the obvious hurdles caused by the new coronavirus pandemic.
After Gov. Jay Inslee issued the stay-home order on March 23, Michael Domingo gathered his staff at GO PT in South Lake Union for a meeting where they worked through a mock session to get an idea of what would be possible virtually.
For people whose jobs largely rely on touching another person, Domingo was impressed with how quickly they were able to adapt.
“I’m actually surprised how quickly our team members have been able to jump into it,” he said.
They found that limiting sessions to 60 minutes helped, as did putting more emphasis on education and making sure patients understood how to do things at home like exercises, recovery from those exercises and soft tissue massages.
GO PT opened on May 11 with new procedures to keep staff and patients safe. No more than three patients are seen at the clinic at one time. Masks are required, as are temperature and health screenings for anyone entering the clinic.
Patients are still making telehealth appointments, and Domingo believes this could be a growing part of the business if a temporary state mandate requiring health insurance companies to pay for telehealth visits is extended beyond June 17, the date Inslee’s telehealth order is set to expire.
The Legislature passed a bill last session that goes into effect on Jan. 1, 2021, making insurer payments for telehealth visits the same as for in-person visits.