Three months ago, these medical encounters almost certainly would have entailed commutes, time off work, parking, the bustle of check-in procedures, waiting rooms and even flights. But overnight, the novel coronavirus changed the way we interact with one another at home and at work, and one of the biggest shifts has been in health care. Millions of households have now tried telemedicine, and many doctors and clinics are using it for the first time to deliver care to patients and their families. When the pandemic passes, we should welcome this growth and continue to increase access.
It’s not as if telemedicine is new: Providers began experimenting with it via phone and radio in the early 20th century; in the 1960s and ’70s, NASA funding and the rise of television allowed the possibilities to take shape; and since the 1990s, the increased use of personal devices and the Internet have led to more and more telehealth applications. But resistance to its widespread adoption remained. Lack of reimbursement has long been cited as the primary factor holding back the growth of telemedicine services, but it’s not the only factor.
Some doctors and patients have been reluctant to embrace the remote practice of medicine, which traditionally deems human touch essential. Certainly an in-person encounter allows doctors to make a more complete physical assessment. When we are in the examining room, we can, for example, spot issues in a patient’s gait, detect an odor, appreciate moods and witness interpersonal interactions with family members — all things that can be missed in the rudimentary images of many telemedicine encounters.
On March 30, however, the Centers for Medicare and Medicaid Services (CMS), the largest health-care payer in the country, temporarily waived rules to allow more flexibility during this public health emergency. Now, for more than 80 new services, ranging from physical therapy consultations to physician nursing home visits, CMS allows remote health care to be billed and paid the same as an in-person visit. As for that “essential” human touch, it’s a luxury in the midst of the highly infectious coronavirus pandemic.
Covid-19, the illness caused by the coronavirus, has, in a matter of days, demanded that whole segments of health care go virtual. Not only does telemedicine make it possible for patients to remain inside their homes to slow the spread of the virus, but hospitals can now better prepare for a surge of patients into our emergency rooms and intensive care units.
It has been a mammoth undertaking. Even within our hospital during this pandemic, we have expanded teleservices. Our emergency room surge center has several new robots to extend the reach of the ER doctors; now they can attend patients inside the main ER and in our newly annexed surge area (our former lobby for outpatients, now set up like a field hospital) without having to run back and forth or change gowns and masks between patients.
Our robots are quite simple. They are merely iPads strapped to wheeled stands — someone wheels the stand to a patient’s bedside, where the doctor talks from the screen. The iPad has a program giving the remote doctor the ability to zoom in on parts of the patient for a closer exam. A nurse can bring in a more sophisticated robot, its screen attached to a more complex base. A stethoscope attachment on this robot can transmit the sounds of the heart and lungs to a remote earpiece.
It took only a few weeks to set up these robotic systems and deliver health care remotely throughout the hospital. Both adaptations can help keep health-care workers safe outside the rooms of our covid-19 patients and sometimes outside the hospital walls altogether. Our patients receive our expertise remotely, and at the same time we save some precious masks and gowns, protecting us all in the long term. And when the anticipated surge of covid-19 cases happens, we will be able to see more patients quickly.
Only a few months ago, pre-pandemic, I met with physician subspecialists from across town in the hopes of setting up teleconsulting services for the occasional inpatient at our community hospital. I was shut down faster that you can say covid. The doctors had an expertise we needed infrequently, so a regular commute seemed unnecessary, even wasteful. But I still wanted our patients to benefit from these doctors’ expertise, so I arranged a demo of a televisit using our hospital’s robot. Before I could start it, however, the doctors stopped me. “We are hands-on physicians,” one of them said. “We don’t work over the computer. We just aren’t going to do it.” So instead, we talked about arranging round-trip transport for the patients to see them. Transporting an inpatient by ambulance within San Francisco, a city of only 49 square miles, costs up to $1,500 each way. That doesn’t account for the fatigue and disruption to the patient and family, whose whole day must now be dedicated to preparing for and making the trip between facilities — and the patient isn’t feeling well to begin with.
Now, nearly every doctor is embracing virtual capabilities. Is it a good thing? Good for patient care? Good for the health-care industry? Good for outcomes? Here in San Francisco, our “flattened curve” suggests that telemedicine, by supporting social distancing, may have at least contributed to slowing the transmission of the coronavirus, but it also seems to be adequately addressing both the chronic and less urgent but acute health needs of the city during these past several “shelter in place” weeks. The number of emergency room visits has significantly decreased at San Francisco-based hospitals, a trend echoed at sites across the state. We haven’t seen the rates of morbidities and mortalities from non-covid conditions rise, despite the city’s order to close many of our outpatient services and limit some services to telehealth. Urgent care clinics defer to telehealth options whenever possible, seemingly without repercussions for our emergency rooms.
But what about the long term? What role should telemedicine play when our lives allow us to again be within six feet of one another? Are the iPads tossed aside and the days of clinic waiting rooms and exam tables returned? I suspect not. For one thing, we have reset expectations about convenience.
Controlled studies of telemedicine are rare, so it’s hard to prove it will be good for health care. Cost analyses often fail to capture the value of physician time, patients’ and caregivers’ lost work and transportation outlays; instead, they focus solely on billed health-care charges. Patient perspectives and inconveniences are rarely factored in, and it’s also difficult to appreciate quantitatively how much inconvenience is a deterrent to accessing health care at all. Studies on clinical outcomes, too, focus narrowly: They tend to look at varied but isolated factors like reduction in hospital readmission, rather than a patient’s health and well-being.
Some of the best data on the costs and health outcomes of telemedicine come from the prison systems, where telemedicine has become an ordinary part of care delivery over the past three decades. Multiple prison studies have shown that telemedicine improves treatment for hepatitis C, for example, and leads to better virologic control of HIV. Prison health-care systems can also show significant savings in transportation and security costs. Specialists can see more patients, eliminating weeks of wait times.
Several health-care systems are betting on the success of telemedicine outside prison walls, too. A fact sheet put out by the Kaiser Permanente Institute for Health Policy says that telemedicine drives quality in part because it leads to an acceleration of care and eliminates barriers to it.
I am grateful that the CMS has removed financial and regulatory barriers to telemedicine at this time, but I am also hopeful that the covid era will result in the sustained development of long-needed teleservices. Our doctors have acquired competence and confidence in providing remote consultation, while our patients have quickly understood the benefits of getting advice about their health and well-being without leaving the comfort of their homes. The demand for telemedicine might be hard to quell.