Coronavirus offers the chance to explore telehealth’s wider potential

Remote visits are essential to reduce the spread of the virus. After COVID-19, which populations might still benefit? Where might digital medicine fall short?

Dr. Aditi Joshi, director of JeffConnect, Thomas Jefferson University Hospital’s telehealth platform, opens EPIC, the
hospital's electronic medical records program.  That way she can look
up at patient's history and see scans and other test
results before meeting with them virtually. (Courtesy of Aditi Joshi)

Dr. Aditi Joshi, director of JeffConnect, Thomas Jefferson University Hospital’s telehealth platform, opens EPIC, the hospital's electronic medical records program. That way she can look up at patient's history and see scans and other test results before meeting with them virtually. (Courtesy of Aditi Joshi)

Lauren P. Martin gave birth to a baby boy five weeks ago. When she had her first postnatal appointment, she had some questions about her stitches, about discomfort, about whether she could exercise.

But in today’s coronavirus-conscious world, she spoke by phone, rather than in person, to an OB/GYN from her practice at the University of Pennsylvania.

“I love the practice, everyone is fantastic, but it’s hard to do over the phone,” said Martin, 36, a wealth management adviser in Philadelphia. “They said I could send pictures, but I thought, mmm, no thanks.”

Martin’s pediatrician is still unsure how they will handle her son’s first vaccinations, scheduled for April 23. Right now, they plan on taking all the information over the phone the day before, then rushing the baby through to get his shots and basic measurements. Little Austin will be in and out in less than five minutes, his mother said.

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Because of COVID-19, many medical appointments are taking place over the phone or video now, as doctors want to limit the amount of exposure the public has to other people who might be ill. A survey released Thursday by the American College of Physicians found that, even before the virus struck, 14% of their doctors had video meetings with patients weekly. Now that insurance is covering telemedicine, and remote visits are essential to reduce transmission, the numbers are expected to expand dramatically.

Whether digital medicine will continue to boom after the crisis is a question: Which populations might benefit? Where might telehealth fall short?

Before COVID-19 hit, JeffConnect, Thomas Jefferson University Hospital’s telehealth platform, typically received 20 calls a day, according to its director, physician Aditi Joshi, an assistant professor of emergency medicine. Now, it’s 200 calls a day.

A month ago, many of these people would have just shown up in the emergency room. Today, they are able to call instead and find out if going to the ER is really necessary, Joshi said – and that convenience might be something they want to continue.

“For a lot of people, this is their first time using telemedicine, and the reality is that it’s just like any other medical encounter and you can make patients as comfortable as you would in person,” said Joshi, who herself is currently recovering from COVID-19. “My fellow was telling me that there was an elderly gentleman who called in because he just wanted to try it, you know, ‘In case I get sick later, I want to know how this works.’”

“And so he figured it out, he downloaded it [the JeffConnect app], he made his account, he called us and successfully connected.”

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There are several reasons telemedicine might be more enticing to the public in the future, said Charles Barbera, an emergency medicine physician who is vice president for pre-hospital and unscheduled care at Tower Health, which includes Chestnut Hill and Brandywine Hospitals. It’s easier for people who may not be able to drive, he said, often better for people who are already feeling sick, and is now covered by most insurance.

Tower’s medical staff has been using telehealth with about 250 patients with chronic conditions, such as emphysema and congestive heart failure. Patients are using monitoring devices to keep track of their blood pressure, blood sugar or oxygen levels. If something is abnormal, a doctor reaches out the next day. If the situation doesn’t improve, someone gets sent to the house.

One of the biggest barriers to expanding telemedicine was insurance companies’ refusal to cover telehealth visits, and regulations stating that. But COVID-19 has changed all that,  Barbera and Joshi said, and most major insurance companies are covering telemedicine services.

“It’s going to be hard to roll that back once we’re through this,” said Barbera. “I don’t think it’ll be possible.”

A forced natural experiment

Josephine Briggs is the interim executive director of PCORI, the nonprofit Patient-Centered Outcomes Research Institute based in Washington, D.C. The organization has done a number of studies on the use of telemedicine outcomes.

While telehealth has been common particularly in rural areas without specialists, she said, COVID-19 will be “transformative” in terms of telemedicine’s use across the board.

“I’m a kidney doctor and I’m old-fashioned enough that I know face-to-face is really important, particularly when it comes to building a relationship with a patient,” Briggs said. “But we are going to learn important things about when a remote approach brings a good, or even a better outcome.”

She pointed to studies showing that electronic meetings are particularly helpful for those with psoriasis, as well as those struggling with depression who meet with their therapists virtually.  However, a study looking at a walking exercise for patients with peripheral artery disease found no overall improvement for those who connected virtually.

There are also concerns about the amount of preparation needed in terms of equipment and software, both for the provider and the patient. And there are privacy issues that might impair patients from being totally honest with their doctors from their homes, as opposed to through confidential, face-to-face meetings.

“I don’t think of telehealth as a solution for a cheaper health care system in any way,” Briggs said. “This is a forced natural experiment that will give us practical experience.”

Beth Duddy, a 60-year-old copyeditor, had two virtual visits recently, both by phone. The quick “med check” with her psychiatric nurse practitioner went fine because it was quick and routine, but a therapy appointment didn’t work as well.

“It’s not ideal for therapy,” she said. “It’s too easy to be distracted by the room, I’m walking around cleaning off my desk and folding my laundry, and that’s not conducive to getting into what’s been going on.”

Duddy would have preferred a video meeting with her therapist, but that wasn’t possible.

“That would be much better, but the place that I go to is very low-budget, and my therapist doesn’t have her own laptop that I’m aware of,” she said. “My guess is that they don’t have the budget for that, so I don’t know how they’d pull that off.”

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