“I said, of course, this is much better,” says Azhar, who immediately turned around and went home. “Who wants to go to a doctor’s office right now, at this time of coronavirus?”
The reality is health-care workers are among the most at-risk for getting covid-19, the disease caused by the novel coronavirus — and doctors’ waiting rooms are magnets for people who might be contagious. So across America, doctors and hospitals are asking patients to shift outpatient activity into video chats, voice calls, texts and emails.
Telehealth apps are getting less attention than other forms of social distancing, but they’re turning out to be doctors’ first line of defense to slow the spread of the coronavirus and focus care and limited supplies to the most urgent cases. Telemedicine, as it’s also known, is important, too, for all the medical necessities that don’t stop because of the coronavirus — diabetes, heart conditions, skin rashes and more — but put patients at risk when they leave home for care.
Doctors really, really don’t want to see you in person right now. Officials have urged hospitals to cancel all elective surgeries, and President Trump touted the benefits of telemedicine during a briefing Tuesday. As more Americans get sick with the coronavirus, starting online will probably be your best option to get tested quickly and without putting yourself at additional risk.
“When somebody has symptoms, they may be the last people who should go to a doctor’s office or emergency room. They may be exposing other people — or exposing themselves,” says Andrew Diamond, the chief medical officer of primary care provider One Medical, which has been advising its more than 422,000 members to prepare for the pandemic in part by updating their apps.
Sure, a webcam checkup sounds weird. Doesn’t a doctor need to look you in the eye? (And vice versa?) Apps definitely can’t replace all kinds of care — but you might be surprised how much is possible. When Azhar, the cancer patient, got home, she opened the Weill Cornell Medicine app on her phone and up popped her oncologist, Tessa Cigler. It was their first meeting. Over their 15-minute chat, Cigler gave Azhar an upbeat assessment, saying they would decide on an approach after the doctor received results from one more test.
"It was a wonderful way to do it,” Azhar says.
Developed decades ago to serve far-flung rural populations, telemedicine is finding new purpose in this pandemic. Moreover, most of what patients need to use it now is built into the selfie cameras and cellular data connections on smartphones.
Teladoc Health, America’s largest provider, says its video appointments surged 50 percent in the last week and it’s staffing up in anticipation of more covid-19 demand. Kaiser Permanente, the health maintenance organization, says it has used telemedicine to reduce in-person visits to its specialty doctors by 40 percent in the last week.
“The coronavirus is going to be a paradigm shift, where a lot of people see this is safe and okay to do,” says Dr. Stephen Parodi, Kaiser’s national infectious disease lead.
Tens of millions of Americans already have access to primary care apps such as Teladoc through their insurance and employers. Apps like the CVS MinuteClinic serve people regardless of insurance for as little as $60 per visit. And the New England Journal of Medicine recently found that more than 50 major U.S. health systems have telemedicine programs, including Jefferson Health, Mount Sinai and Cleveland Clinic.
There are access and security concerns to telemedicine that are going to take more work. And not all doctors are on board because of bureaucratic and insurance hassles, not to mention old-school habits. But on Tuesday, the Trump administration temporarily loosened some federal rules to make it simpler for doctors to use telemedicine for Medicare patients and get paid for it. To get a virtual visit, often you just have to ask or do a little digging to see what’s available.
The biggest challenge, doctors say, is going to be changing behavior. Different generations may have different comfort level with apps — but everyone has preconceived notions about what it means to “see the doctor.”
Say ‘ahhhh’ into the camera
Actually, a virtual doctor’s visit usually doesn’t involve opening your mouth to a webcam. (There’s not enough light.) But in many other ways, a telemedicine appointment is like any other. Just less time in a waiting room.
We tested an online visit with One Medical, the primary care service. Virtual visits come at no additional cost as part of the $200 annual membership to the company’s clinics, which is paid by individuals or some employers.
After logging into the One Medical app on an iPhone, we tapped on a button labeled video visits. After about two minutes, on the screen popped up Rebecca Alarcon, a family nurse practitioner. We were at home in San Francisco; she was looking in front of a webcam from a home office a few miles away in Oakland, Calif. (The ability of health care workers to work from home, too, is a big advantage to telemedicine, advocates say.)
Alarcon looked right into the camera, and it worked. The awkwardness subsided after a minute or two.
After an identity check, Alarcon asked questions about symptoms, recent travel and exposure to people known to have the coronavirus. A lot of the visit was just self-reporting symptoms and a temperature check with a home thermometer. A phone camera is useful to show off rashes and other parts of the body, though Alarcon had no way to do other common doctor moves, like palpating the abdomen and using a stethoscope to listen to lungs.
There will always be times a patient needs to go to a clinic to get bloodwork done or other treatments. But there’s an awful lot you can learn from body language or over video, say experienced telemedicine doctors. Such as: Do a jumping jack. Sari Lahham, an emergency doctor at Jefferson Health, says they’re particularly helpful if he suspects appendicitis in a child.
“If they are smiling while jiggling an area that should be very irritated, we don’t worry so much about it, but if they stop and cry and hold their abdomen, I’m a lot more concerned,” he says.
Some 95 percent of the cases Teladoc sees get resolved entirely online — with no need for an in-person visit, says Chief Medical Officer, Lew Levy. (The firm did 4.1 million online visits last year.) The tech works best for visits where patients have common colds, allergies and respiratory problems, or for specialists to review the results of recent tests or bloodwork. Doctors report it can also be effective for longer-term coaching and mental health care.
Ann Patridge, an oncologist at the Dana-Farber Cancer Institute in Boston, says telemedicine is a particular boon for cancer patients, who are especially vulnerable to the coronavirus because of compromised immune systems. The crisis “is pushing us in a direction that many of us have been wanting to do for a while,” she said.
But how can a webcam tell if you have the coronavirus? Getting a final diagnosis does require a nasal swab test — and so far there’s no self-test available. But doctors say a lot of screening comes before that point.
“If you have a thermometer at home, we are already a good step of the way there,” says Diamond, of One Medical. “If you have a fever and you feel like you are short of breath, then what your lungs sound like with a stethoscope is not going to make a difference with the level of care you need next.”
Flu-like symptoms in most people don’t actually mean they have the coronavirus. But if there are enough red flags, doctors refer the patients for testing — perhaps through the new drive-through specimen-collection sites — or by local health authorities. The patients are usually told to quarantine and then informed when results come in.
Rahul Sharma, the emergency physician-in-chief for Weill Cornell Medicine and NewYork-Presbyterian, says telemedicine can ease the mind of patients who don’t have covid-19.
“Right now, it can be frightening even if you have sniffles and a runny nose. It definitely eases their mind to see a provider” via video, he says.
Doctors are bracing now for how it might also be used when things get really bad. They can continue to check in on people who have the coronavirus but aren’t sick enough to be in overfilled hospital wards. It could even help doctors keep working from home when they’re quarantined themselves.
That’s the good news. But plenty of work remains to make telemedicine accessible to everyone.
Lots of medical groups are working fast to get doctors online. But before covid-19, not all of them invested in the technology to enable video calls that are simple and secure. Most smartphones already come with video chat apps — like Apple’s FaceTime or Google’s Duo — but they don’t meet the privacy standards of a federal law called Health Insurance Portability and Accountability Act, or HIPAA. On Tuesday, the Trump administration announced it would temporarily loosen some of those requirements for Medicare patients. Health and Human Services Secretary Alex Azar said in a statement that the change means providers “will be allowed to use everyday technologies to talk to telehealth patients.”
But of course, not everything online can be trusted with mission-critical activity. Some popular video chat services, including Microsoft’s Teams, have failed under increased demand from people working at home.
And just because an app or website promises medical help or information doesn’t mean that it can be trusted with health advice — or your personal information. Beware of apps that aren’t from doctors you already know or don’t say they feature board-certified physicians. You may not get the same care through an app as you would from a doctor you’ve been seeing for a decade and knows you. Google’s sister company Verily has developed a website to help screen patients for covid-19 tests, but it immediately caught the scrutiny of privacy advocates because it required a Google account to access.
Even for established telemedicine networks, wait times could increase substantially as more people get sick, so they’ll have to figure out how to get more practitioners online. Of course, working over the Internet means all those doctors and nurses don’t have to be physically located in disease hotspots.
But red tape remains there: Each state requires doctors to be licensed to practice there, and the rules don’t always allow them to help patients even just one state away. For example, around Washington, D.C., a doctor who lives in Maryland and practices in the District isn’t currently allowed to virtually treat a patient who’s at home in Virginia.
Getting doctors paid is another problem. Before the changes announced by the Trump administration on Tuesday, Medicare paid doctors for telehealth services only in certain circumstances. For example, the beneficiary receiving the services had to live in a rural area and travel to a local medical facility to get the service from a remote location, according to the Centers for Medicare and Medicaid Services.
The agency said that under the new policy, beneficiaries will be permitted to get telehealth services including office visits, mental health counseling and preventive health screenings at home.
Now private insurance firms need to follow. Many states don’t require insurers to pay physicians the same for telemedicine visits as for in-person visits. Only about 10 states had “payment parity” laws as of December 2019, according to a report by the law firm Foley and Lardner.
In Washington state, a parity law is scheduled to take effect next January, but Nancy Belcher, chief executive officer of the King County Medical Society in Seattle, says it should be accelerated so more doctors are encouraged to offer teleservices now. She said one doctor recently told her she was paid $25 for a 15-minute telemedicine visit, far less than she would have received for a regular visit.