Telehealth use has surged during the coronavirus pandemic, with the technology spreading far and fast. Doctors and patients alike must be wondering if this is the beginning of a whole new kind of doctor–patient relationship, one that might totally transform our health care system?
Maybe. But I’m not convinced, and Americans may not be either as the initial Telehealth surge appears to be leveling off a bit. I am certain that there will be some level of permanency to the current telemedicine and telehealth rules, and rightly so. They were too strict pre-pandemic. But there are some downfalls and holes or gaps in Telemedicine that no one seems to be talking about.
First, it appears that proponents of Telehealth presume it is the answer for everything and every kind of healthcare specialty.
But consider this, well-trained clinicians use all of their senses — not just hearing and vision when assessing a patient at an in-person encounter. They appraise the whole patient:
Is there a new limp?
a shift in posture?
a new pallor?
A hint of slurred speech or memory?
Often, it’s what patients don’t notice or complain about that is essential. And there is no diagnostic test more cost-effective than the laying on of hands. Many of my surgeon and primary care providers, have told me that they have found treatable cancers multiple times in routine exams that would be impossible to replicate in the virtual world. Could a FaceTime or Skype visit detect a lymph node too firm, or a spleen or liver too large, or an unexpected prostate nodule (with a normal PSA lab)? Absolutely not.
What about physical therapists, who were recently added to the “CMS-approved list” for Telehealth? During an in-person PT encounter with a patient, physical therapists are able to take empirical measurements, make hands-on corrections, and take action with the patient to ensure that the patient is actually making progress. Also, keep in mind that Medicare is very specific regarding the circumstances under which it will pay for such therapies.
Providing PT, via Telehealth delivery, is downgraded to a Q&A of the parent or unskilled caregiver, acting as a go-between on video, that can’t possibly evaluate or assess the patient as effectively as the actual therapist face-to-face.
Now in saying this, I am by no means taking issue, with physical, occupational, or speech therapy modalities. I am merely saying that each instance where Telemedicine and/or Telehealth are expended to peripheral treatment regiments, can really have additional collateral consequences.
Consider the constitutional system exam with the patient, via Telehealth, where vitals are “taken.” I’ve been asking my physician clients how they are handling this part of the virtual visit. It has been concerning to them to say the least. A typical encounter is reported that the patient does not have a blood pressure device, a working thermometer, or a scale. So, when asked, via Telehealth, what their BP is? They guess, or their temperature? Again another guess, and their weight? Either a decline to answer or another guess. You see a pattern here?
There are times and places where virtual care makes perfect sense. During the pandemic, when in-person exposure must be limited, it has been crucial for keeping doctors and patients connected and to make sure there is continuity of care for those most vulnerable and to have access to their physician. In parts of America where no alternatives exist, Telehealth has been a lifesaver — especially in enabling the delivery of scarce specialty services to support family physicians in remote areas.
There is growing evidence that virtual care for some mental health conditions works well, too. And virtual care likely works better for the young and healthy than the elderly and sick. Technologies for remote monitoring of certain key health parameters — heart rhythm, blood sugar, weight, respiratory rate — may help people control their chronic conditions better and assist clinicians with diagnosis and treatment, as long as the patient has these devices.
The past few months have represented a crash course in Telehealth for doctors and their patients, and this exposure will undoubtedly leave us better positioned to use the technology moving forward. But I believe that Telemedicine will work best when it is adapted to patients and their needs rather than the reverse. It should be one more tool that builds upon and promotes the human relationships and caring clinical eyes, ears, and hands that have always sustained us when we are sick. It should be considered an “added delivery of medicine” not a replacement for in-person care.
There is trust that is built-in relationships between patients and clinicians when they meet face-to-face for the giving and receiving of care. And that trust — the kind that lets anxious patients return to sleep at night, the kind that settles the stomach of a new mother with a sick baby, the kind that makes a cancer patient believe her doctor cares about her personally as well as professionally — grows fastest and strongest through in-person relationships.
Trust and face-to-face encounters are even more important for patients with complex and intertwined problems. It has been reported, by AHA that approximately five percent of the American population accounts for 50% of health care spending. These are sick, fragile individuals who often have multiple conditions — diabetes, heart disease, hypertension, arthritis, dementia, depression — that are complex and difficult to manage under the best of circumstances, and even more so on a screen.
The key to helping these patients can be keeping them away from hospitals when a symptom pops up. But for doctors and patients to have enough confidence to wait and watch depends on having a history together, one based on familiarity and trust. That is why the “original” regulations for Telehealth, prior to the pandemic, included the “established patient relationship” as a qualifier. How can a new patient have that same kind of trust if they have never met the physician face to face? Think of online dating. Once the couple meets in person, how often does that relationship last?
I believe that Telehealth has been a lifesaver for many patients, both Medicare and non-Medicare. It should be expanded beyond the original regulations, as the rural patients need access to care when it is not readily available but is available through Telehealth. Originating sites should include the patient’s home, for those patients that are unable, physically, or mentally to get to an onsite visit. Expansion needs to be discussed, reviewed, and determined by outcomes and fails during this pandemic and not by telehealth vendors who want the flexibilities to continue as they are now.
Face-to-Face care needs to remain the “gold standard” for patient care, and Telehealth as an additional delivery of that care, but not a replacement for. Payment parity was a gift from our payers during the pandemic, and if the PHE is extended many payers have said this may continue, again, only during the public health emergency. The in-person visit has to be valued monetarily and tangibly as a higher deserving payment, or there is no incentive to pay physicians for their “work value” under the RVU formula.
As the Medicare population moves and shifts over generations, the use of technology will become easier. The question though, is what is the line that gets drawn on the use of this technology?