How telemedicine has been working
Telemedicine, also called telehealth, is the practice of doctors seeing patients virtually through video calls. In the past, doctors had to use a platform such as VSee or Doxy.me in order to be HIPAA compliant, aka adhere to the rules of health confidentiality. But in mid-March, the Trump administration eased restrictions on telehealth services, allowing doctors to use any kind of video platform—whether that’s FaceTime, Skype, Zoom, or Google Hangouts—for virtual visits, enabling more people access to health care during this time. And on April 30, the administration further changed the rules to allow for some health services to be done via phone, and expanded what types of practitioners can use phone or video to provide health services. Overall, these changes give health providers the power to maintain patient care, and are in effect until the pandemic ends.
In mid-March, the Trump administration eased restrictions on telehealth services, allowing doctors to use any kind of video platform—whether that’s FaceTime, Skype, Zoom, or Google Hangouts—for virtual visits.
According to the U.S. Department of Health & Human Services, health care providers are to use their professional judgment on whether to assess or treat medical conditions virtually. The Office for Civil Rights has said it will not impose penalties for noncompliance with HIPAA rules in connection with the good faith provision of telehealth using non-facing audio or video communication tools. However, they’re being encouraged to notify patients that using public-facing video communication apps, such as Facebook Live, Twitch, or TikTok, should not be used in the provision of telehealth. Providers are also expected to enable all privacy modes when using any application, and patients need to do their due diligence in working with their provider to make sure their platform is the right one for their needs.
So, what does a typical visit look like? It depends on the type of care, but in general, it’s as simple as connecting via video chat to talk one-on-one with your doctor about what is currently ailing you, and then a physical exam is conducted as best as possible through the screen. The care provider will usually start by asking the patient questions about their overall health and well-being, then about any concerns they have. While much of the virtual visit is conversation, it can involve the patient showing the doctor an area of concern on their body through video, too, as needed.
Many insurance companies cover telemedicine, and are even making special arrangements and giving special incentives for those who make telemedicine appointments. (You should always call your provider to find out their policy before making an appointment.) For example, Anthem is temporarily waiving member cost shares for telehealth visits, while Cigna is offering out-of-pocket costs that are equal to or less than an in-person visit or urgent-care clinic. Aetna is working with Teladoc, a telemedicine provider, to offer members access to doctors virtually through certain plans, too.
Another key benefit is that telemedicine appointments usually eliminate annoying wait times in doctors’ offices (and in most cases, appointments generally start right on time). Doctors are also authorized to write prescriptions through virtual visits.
How offices are making the leap to digital
Channing Barnett, MD, a board-certified dermatologist practicing in Boca Raton, Florida, officially launched virtual visits the third week of March at Barnett Dermatology after closing down her office to reduce risk for her patients and staff. “We felt like if we were going to do virtual, we had to throw ourselves into it,” she says, noting that they’d been thinking of offering online visits even before the COVID-19 crisis began—so they were prepared. She and her staff began calling individual patients 24 to 48 hours in advance of their scheduled appointments to notify them of the change and give them the option to cancel, and 99 percent of them have been “really appreciative,” Dr. Barnett says, and opted to move forward with their visit virtually. She’s doing appointments like skin cancer screenings and Botox follow-ups via platforms like VSee and now, Google Duo.
The biggest challenge, says Dr. Barnett, has been getting patients—especially elderly individuals—to see how simple it is. But once the office transitioned to an easier-to-use platform, things smoothed out. “Patients are getting comfortable with it,” she adds. “[Virtual visits] work really well for dermatology because [this area is] very visual.”
Another area for which telemedicine can be very effective is physical therapy. Darwin Fogt, a licensed physical therapist, launched telerehab services with his company Phzio (pronounced “fizz-io”) more than five years ago—and says the growth over the past few weeks has been “exponential.” (So much so that the company is still trying to gather accurate data to share.) “Physical therapy has been historically thought of as a hands-on profession, but research has shown that the only thing that consistently provides long-term positive outcomes is therapeutic exercises performed by the patient,” Fogt explains. For this area of medicine, virtual services work extremely well because physical therapists (PTs) are easily able to assess a patient’s condition based on diagnostic movements and motion, and then deliver them a series of exercises they can do at home while being monitored through the screen, with exercises they can do without monitoring at home.
A huge benefit of platforms like Phzio is how quickly you can connect with a professional. For example, say you wake up with lower back pain; you can log into Phzio and see a PT within a day and sometimes within a matter of minutes, depending on volume. Compare that to the time it would take to make an appointment and show up to an in-person clinic, even in a “normal” time, and the trade-off for virtual is nearly incomparable. If you can feel better sooner, it makes a lot of sense to take advantage of PT services offered this way. “The faster a patient can get access to care,” Fogt adds, “the better the prognosis is going to be.”
The American Medical Association (AMA) has strongly encouraged the adoption of telemedicine to support social distancing measures and help ensure the availability of care to those who need it, according to R.J. Mills, AMA media relations manager. However, making the leap to telehealth hasn’t been as easy for some disciplines as it has for dermatology and physical therapy, and many medical practices and hospitals are still determining what care must go on and what can be delayed, rescheduled, canceled, or performed remotely. For non-urgent services, physicians have been reaching out to their established patients to change in-person visits to telehealth as much as feasible, Mills adds. (Emergency services, especially for those with COVID-19 symptoms, are still being recommended for in-person care.)
Telemedicine still has limits—and COVID-19 is highlighting that
One of the biggest barriers to entry for using telemedicine services is the technology curve for both medical providers and patients, but that’s improving, thanks to the government allowing various forms of virtual connection platforms, so that users can find something they’re comfortable with. Nailing smaller details, like ensuring proper lighting and camera angles to optimize what the doctor is seeing from the patient, and vice versa, can also take time. Yet some doctors are seeing even more major problems with telemedicine.
“It’s a significant compromise,” says Raphael Kellman, MD, founder of Kellman Wellness Center in New York. While he is seeing patients virtually, like so many other physicians right now, he says these appointments have severe limitations: not being able to take a patient’s blood or basic vital signs or do a hands-on physical exam among them.
And while it’s clearer that severe and urgent symptoms, like chest pain and shortness of breath, would need to be addressed in person, even some common conditions can’t be effectively diagnosed via telemedicine. For example, it can be difficult to diagnose an ear infection without looking in someone’s ear, and hard to assess heart palpitations without an electrocardiogram, says Edo Paz, MD, lead physician and vice president of medical at the digital medical service K Health.
Dr. Kellman continues that while areas of medicine like psychiatry and psychology will and should be able to transition to telehealth easily, it’s nearly impossible for a Zoom call to replace an in-person visit for more physical conditions.
There are more examples where telehealth doesn’t quite fit patient needs. For instance, a virtual annual visit to your OB/GYN—while being done by physicians across the country, such as the community of doctors at The Association for Women’s Health Care in Chicago— isn’t going to reveal problems that need to be detected through an in-person procedure, such as a pap smear or breast exam. Dental visits, too, are nearly impossible to conduct virtually (though some dentists are making themselves available to patients in emergency situations), as are any kind of check-ups that require blood testing or a physical exam.
Additionally, the psychological effects of the COVID-19 pandemic are going to be profound, and this will have an impact on physical health, too, says Dr. Kellman—exacerbating the limitations of virtual medicine. “We’re going to first see those effects within a few weeks, and in the long-term, [they’ll become] a bedrock of hell,” he says. Stress-related disorders are going to skyrocket, he predicts, manifesting in the physical body through diseases like hypertension and cardiovascular disease.
Overall, when faced with virtual visits as nearly the only option, it’s inevitable that the quality of care around the country is going to decline—which will have a significant impact on the health of America, Dr. Kellman says. Already, he’s seeing a significant decline in the number of patients he’s seeing, and also noticing major challenges in conducting telemedicine visits with elderly patients.
How telemedicine will continue to adapt
It’s clear that in most cases, telemedicine won’t ever completely replace in-person doctor visits. Even Fogt acknowledges that with physical therapy, the importance of human touch means that in-person, traditional PT will never go away. He does believe, however, that telemedicine will be much more widely accepted after the pandemic ends.
Dr. Paz says he believes that both patients and doctors are going to use telehealth for a significant portion of cases that would have previously required an in-person visit. “This is going to have a lot to do with patients enjoying the convenience of telehealth, an understanding that public health risks are minimized with telehealth, and possible changes in reimbursement for telehealth visits (which have typically been reimbursed at a lower level than in-person evaluations),” he says.
Because patients are alone in their home, their comfort level is higher, says Dr. Barnett.
For dermatologists like Dr. Barnett, telemedicine is enabling her to continue to treat her patients nearly as well as she could in person, with the exception of procedural visits. As for body checks—yes, they’re still happening. Because patients are alone in their home, their comfort level is higher, says Dr. Barnett. In a way, she’s more accessible than ever, extending her hours some days if she gets a last-minute request for an appointment; and for self-pay patients, she’s been able to lower her fees, charging about 20 to 25 percent less for virtual visits versus in-person. Looking ahead, her practice plans to continue telemedicine when the world opens back up, with the hope that it will enable them to see patients who aren’t local.
It’s hard to ignore the widespread implications that a mass movement from in-person to virtual doctor visits will have on our health, however. While some types of medicine will be able to maintain nearly the same standard of care through telehealth, discovering and treating more serious conditions will present huge challenges (like the inability to detect diseases that require a blood test or physical exam) that both patients and doctors will have to navigate in the months and years ahead. And aside from the physical component, there’s the personal side to consider, too. “We’re going to be living in a two-dimensional world—that’s not only going to affect the doctor-patient relationship, but normal social interaction will change,” says Dr. Kellman. “The lack of human, 3-D connection is going to have a profound effect on us psychologically and existentially.”
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