Penn doctor explains advantages — and pitfalls — of telemedicine | 5 Questions

Just months ago, telemedicine seemed to be an outlier. Most people, by far, still went into a physician’s office for a checkup, an evaluation, a treatment.

Then came the coronavirus.

Now, practices of all types are offering patients the opportunity to have video conferences with physicians instead of in-office visits. Even in some surprising areas. Abortion clinics are offering telemedicine options. People can get addiction treatment by telemedicine.

To learn more about this new world, and how patients can best navigate it, we spoke recently with Krisda Chaiyachati, medical director of Penn Medicine OnDemand, a virtual-care telemedicine practice that offers consultations 24/7.

We started OnDemand about three years ago, mainly for our employees. We had noticed that despite being a relatively healthy population, our employees often were using urgent care and emergency rooms, sometimes for conditions that could have been treated by primary care. But these were health-care workers who sometimes had 12-hour shifts. Physicians’ offices weren’t open when they got off work. Or they kept putting their health needs off until they were so sick and needed urgent care. Or they didn’t have primary care. We set up this practice to test a theory. Would telemedicine be something our employees would use? Would it be of value?

It turned out the employees loved the service. It got approval ratings in the 95th percentile. It was a health-care option for colds, flus, and the like. They weren’t using it, for instance, for crushing chest pain. Another thing we discovered is we were dramatically reducing costs. So the program grew. We expanded it so it could be offered to Independence Blue Cross and others.

» FAQ: Your coronavirus questions, answered.

Then COVID-19 hit. In a lot of ways, the game stayed the same, but the players started to change dramatically. We had an infrastructure in place to provide telemedicine to more users. In the OnDemand program for employees, we saw — on video — more people in March than we did in all of 2019. Outside OnDemand, we’ve gone from 200 telemedicine appointments per week to over 35,000.

We are currently in a world where 50% to 80% of clinical appointments are through telemedicine. It’s basically become the norm during the pandemic.

Telemedicine will continue to be a part of the way we provide medical care. We are really starting to look at how we can push the boundaries. But we also have to find a middle ground. Every physician and every specialty will have to ask some hard-hitting questions. “With the disease I treat, what do I need to do in person?”

A pulmonologist, for example, needs to listen to the lungs. But here’s a different example: Something that has long been talked about is remote monitoring and management of hypertension. Two basic ingredients are a measurement and a reading. But sometimes patients wait months to be seen. Imagine a world where telemedicine allows better access and providers can help more patients. I think we’re going to get used to collecting people’s vital signs at home and acting on those values. And we should start thinking about having medical-grade devices in the home to make sure we’re getting accurate numbers.

Because of coronavirus, patients are getting used to telemedicine. And they’re going to start demanding it. There’s a cost for patients to show up, and not just a financial one. There’s the time, the driving, the parking, the scheduling of your day. If we ask our patients to bear the burden, we should make sure showing up in-person is worth their while.

Along those lines, access to health care has been challenging for low-income populations. Often, they are working multiple jobs or experiencing chaotic times. So, under the right conditions, they could really benefit from more convenient health care.

Telemedicine can be more patient friendly and holistic. Doctors can see people in their homes. You can say to a diabetic, “Walk over and show me what’s in your fridge.”

And when you think about infectious diseases, maybe we shouldn’t bring people in unless they’re short of breath or exhibiting other signs where a physical exam can help. That way, a sick person wouldn’t have to drag himself out of their house or present an infection risk to others.

Yes, it’s critical that we are careful. An adage in medicine is that vital signs are vital for a reason. They help tell us what’s going on. Having those values, for the right conditions, can guide your provider. There is a lot of anxiety right now over the lack of vital sign data when using telemedicine for coronavirus.

Some services will always need to happen in person — procedures, surgeries, being able to look at a mole and do a biopsy. There can be value in examining people who have an acute problem, like belly pain, or a rash. The physician needs to see or touch to make the right decision.

Also, telemedicine may not be the right fit for all personalities. For some, face-to-face can create a deeper connection. And we should respect that. But people in their 20s and 30s may be more open to telemedicine. We should keep options available for patients and providers.

With telemedicine, on a human level, I’ve lost techniques I typically use to comfort my patients. A pat on the shoulder goes a long way. An exam can be a comforting thing. With telemedicine, we have to use other tools — our voice, our tempo. It’s important to look people in the eye, but I tell patients that my eyes may wander because their health record is in the upper left corner of my screen, and I have to look at it.

In so many ways, the “art of medicine” has shifted dramatically during these last two months. But, as health care gets back to more normal business, telemedicine will stay. We just have to be thoughtful about it.

Generally, insurance companies have been open to covering care, telemedicine or not, that’s related to COVID-19. They didn’t want cost to be a deterrent to getting medical care and a move, from my perspective, for the good of the public good.

Now, insurance companies are seemingly trying to decide how and if they should cover and pay for telemedicine services for non-COVID needs, now and into the future.

We’re all waiting to get more guidance. Medicare has been covering telemedicine since the early 2000s. But it came with two critical rules that slowed the growth. One was that a patient had to reside in a rural area. The other, which was a real Achilles’ heel, was that the patient could not have their encounter from their home. They still had to be in a health-care facility to videoconference with a doctor elsewhere.

Start to learn the limitation of what a provider can do over the phone. Have a conversation about it.

Try to be on time. Get used to the technology. At PennMedicine, we send each patient a text message hours before the appointment, telling them how to connect and when.

Be prepared. If the issue is a rash, have that part of the body pre-exposed. Or take a high-quality photo and send it to us beforehand.

If you can weigh yourself, take your blood pressure, that would be incredible. But you should still be open to the idea that your provider may recommend that you come in.

We all need to get used to telemedicine as a different path toward the same elusive goal: getting compassionate, accurate care, at the right time, at the right cost, from the right place.

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