From the Storm, Rays of Light for Practitioners
The HH&Y Behind the mask study is tracking provider and patient attitudes and experiences through the pandemic. It has shown that the impact of technological changes is ubiquitous, starting especially during lockdown in places like the UK and Germany, and continuing today.
Beyond the immediate disruption, these changes have proven, somewhat ironically, to be upgrades in some unanticipated ways. This article will reveal some key areas where changes in use and application of technology have actually improved medical practice, and will likely continue to do so after COVID-19 has receded.
Televisits and the Unexpected Joy of Zoom
The most apparent shift has been away from face-to-face interaction toward video visits as the norm in medical practice in every context. Prior to the pandemic, many HCPs were suspicious of technology in this context, and resisted telehealth for a variety of reasons.
However, quarantine and social distancing forced HCPs to rely on technology as never before, especially communication technology. They quickly discovered that these were enthusiastically welcomed by their patients. One US Infectious Disease specialist who works for a large, dispersed hospital network said his service went from 50 teleconsults a week to 40,000 in the month of May, “with surprisingly little trouble.”
The shift gave HCPs the ability to keep treating their patients with minimal disruption. Telehealth provided a “lifeline” for practices, both to continue patient care and to keep the lights on. One US payer, who is also a practicing neurologist, put it bluntly:
I think that had we not implemented telehealth, we would’ve been forced to close down our practice for at least 3 months.
But how good was the care
provided through telehealth?
In May 2020, at the height of lockdown, we queried physicians in 3 countries (US, UK, and Germany) about whether televisits were having a negative impact on their ability to provide care.
The overwhelming consensus was “no,” for both video consults (95% “little or no negative impact”) and telephone consults (92% “little or no negative impact”). One UK cardiologist called teleclinics “amazingly efficient,” and while he was expressing himself more forcefully than others, he was not alone in his sentiment that time management was easier with televisits than in person.
Beyond the expediency of video consults, many clinicians actually felt these visits were better than face-to-face visits in some cases. In the same survey, almost 50% of clinicians felt that telehealth, both video and telephone, had improved patient care (Chart 1). In removing distractions like EHR and ancillary staff, video consults have enabled a more direct, focused physician-patient dialogue.
For primary care physicians, the move online has often simplified diagnosis, bringing back, in the words of one US clinician, a “rediscovered joy of doctoring.”
Before the pandemic, multiple distractions, scheduling pressures, and ancillary tasks creating task overload were the hallmark of many clinical encounters; now, clinicians can take the time needed to investigate patient signs and symptoms and reach a more thoughtful conclusion. As one UK physician said in late July:
“Internet and computer-based resources have improved primary care. For instance, in managing skin rashes, patients now receive a link via text to encourage them to submit a picture of the rash along with a typed description of the history. This allows the GP to look at the rash remotely and then ring the patient to give advice and suggest treatment.”UK physician, August 2020
Even specialists, who had long resisted televisits on the grounds that they would interfere with proper physician-patient interactions (and were, again, reimbursed at lower rates), are recognizing the benefits of abandoning the “tyranny of face-to-face consults.”
For chronic patients in particular, telehealth has shown itself to be not merely an expediency, but a net positive. For the treatment of frail patients, removing the need to travel and eliminating the risk of hospital infection has proven to be practice-altering. Even rheumatology, a specialty long defined by physical evaluation of patient symptoms, has moved easily into remote management for stable patients. As one US rheumatologist said:
There are some patients who do not need to come to the office frequently. These are patients who have relatively stable disease and I am simply managing their medications. This can certainly be done remotely. These patients seem satisfied that they do not need to make the trip to our clinic.
US Rheumatologist, June 2020
Questions for the Future
of Remote Medicine
With the major barriers of habit and inertia broken, operational questions remain. How will televisits be reimbursed properly, which is a primary concern for doctors in all the countries we are studying? How will important details be reliably recorded in the EHR? And when the pandemic is over, how will it be determined which visits can be remote and which must be in person? This last question is of particular interest to physicians, as it directly impacts patient care. As one UK neurologist put it:
It has also been fascinating to note which aspects of neurology lends themselves particularly well or otherwise to review by telephone, as some aspects of neurology are heavily dependent on the history and observations, but other parts are more dependent on clinical observations. I noted that headaches are particularly amenable to management via telephone as the diagnosis is entirely history-driven, backed by subjective patient recordings or diaries… [but telehealth] also means that we now have to ask questions about things that we would otherwise have simply made an uncommunicated visual assessment of, were the patient face-to-face in the clinic. These include things like how a patient stands or walks and the appearance of their shaking or tremor.
Neurologist, May 2020
As the pandemic, and our study, continues, doctors are quick to point out more unexpected rays of light created by the pandemic. One has been a rebirth of professional collegiality through doctor-only Zoom meetings. Many physicians have stated that the “endless administrative meetings” are not missed, but the new highly efficient practice of review rounds is a positive. Remote collaboration is now standard, as doctors are now regularly collaborating with colleagues from many miles away.
Even the simple task of renewing scripts electronically has been seen as a huge improvement, with the elimination of pro forma face-to-face visits. Thinking of the pandemic as a series of “tipping points,” one UK neurologist wrote that it was overdue that prescriptions could be routinely filled electronically:
Another tipping point in the healthcare chain has been the use of electronic prescriptions. At the start of the pandemic, most prescriptions for elderly and vulnerable people were still processed manually.
UK Neurologist, June 2020
Areas of need and opportunity
While the above developments are clearly positive, unmet needs remain. The pandemic is still negatively affecting societies around the globe, and rapid adoption of health technologies has not been seamless. Many gaps have been identified in the use of Zoom and other technologies. For example, when the second wave of survey data were collected in July 2020, the numbers of physicians who stated that telehealth was having a negative impact on patient care increased, significantly in some cases.
For example, those who felt that video consults were having a negative effect on patient care nearly tripled, from 5% in May to 14% in July. Interestingly, in this same time period, patients have become increasingly comfortable with televisits, but this gap in levels of comfort likely represents HCPs’ fears of long-term consequences of deferred in-person care and the patients’ increasing familiarity with video platforms, a gap in patient and provider views that may need correcting before long.
Whatever the benefits, clearly, televisits are not permanent replacements for all physician-patient interactions. As the pandemic stretches on, many physicians are increasingly eager to see patients again. This is especially true for elderly patients, who, in the words of one German physician, “are not so good with the internet.”
In addition, many clinicians have been quick to point out that televisits are not the same as telehealth. The former are communication tools, while the latter requires a suite of remote monitoring and testing devices as well as data synthesis and storage. One US pulmonologist notes advances in remote monitoring:
One of the most important changes was the ability to use remote patient monitoring to assess a patient’s oxygen saturation levels using pulse oximetry, obviating the need to hospitalization or discharge to a skilled nursing facility.
US Pulmonologist, May 2020
However, others point out there does not yet exist a reliable wearable device that can measure something as routine as blood pressure. All the clinicians we surveyed agreed that advancing the ability to test and monitor remotely is key to achieving the next phase of telehealth. A UK physician noted that for remote monitoring to work, you need “monitoring centers, not just monitoring devices, and we don’t have either of them.”
Medical education is another area of great unknowns as we enter the age of telehealth. One clinician who works in a teaching hospital in the UK noted that training has had significant ups and downs—virtual rounds are not ideal, but having the time to review in depth cases and solutions with individual trainee physicians has been a “revelation.”
The COVID-19 pandemic has accelerated the evolution of medical practice, particularly in the areas of technology and communication. This has created a need to develop sound processes that enable clinicians to determine the optimal mix of remote and face-to-face visits, as well as the best way to assimilate remote monitoring and testing as these capabilities become available. As with the positive changes we’ve discussed, these will happen in real time and in response to the needs of shifting circumstances.
The storm of COVID-19 will continue, but so will the light of innovation.
The Behind the Mask Team
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