Curbside Consult with Dr. Jayne 6/21/21

I’m a little over a month past my departure from the world of brick-and-mortar patient care. Since then, I’ve been seeing patients in a couple of different telehealth venues, and it’s been a good experience overall.

Putting on my clinical hat, I would say the biggest weaknesses of the systems I use are that they don’t have the same EHR features as you would find in an in-person practice. Sometimes that makes it difficult to understand the patient’s history or their medication list, but given the transactional nature of urgent care telehealth services, it’s not insurmountable. I never thought I would say that I felt “spoiled” by having a certified EHR with all the bells and whistles, but maybe that was the case.

Most of my friends who are in traditional practice settings are still doing some percentage of their visits as telehealth, even as the pandemic eases. This applies to both specialists and subspecialists. Even surgeons are doing plenty of virtual visits, especially in the post-operative, follow up, and second opinion arenas.

Patients like the convenience, but I hear a lot of stories about physicians trying to juggle virtual and in-person appointments in the same day. There are plenty of initiatives across the US to make telehealth a permanent fixture in our healthcare system and the majority of people I’ve spoken with think this is a good idea.

The few naysayers that I’ve heard from are concerned that telehealth is becoming a way for physicians to increase their bottom line, performing telehealth visits where they previously might have a phone call with a patient. This leads to a concern that telehealth will drive up overall healthcare expenditures. Kaiser Health News cites data from PitchBook that the yearly global telehealth market could top $300 billion by 2026, nearly five times the levels seen in 2019.

I don’t doubt that there are bad actors in some organizations that claim to be offering telehealth. Certainly I’ve heard the stories about the two-minute visits and the services that essentially sound like pill mills. On the other hand, I’ve heard the stories of patients spared hundreds of miles of travel in order to get second opinions along with those who are now able to see subspecialists of a caliber not available in their home communities.

I’m trying to arrange a telehealth consultation for a family member who requires genetic testing. Their insurance carrier will only pay for the testing if it is ordered by a genetic counselor, who typically doesn’t perform a physical exam and so there’s not a lot of need for an in-person visit. The patient has had multiple physicians recommend the testing and understands the ramifications of testing, so requiring the additional visit feels like a barrier to care, especially since the patient is an hourly worker in an essential field.

There’s no question that telehealth needs to fit into the overall plan of care for patients, and that it shouldn’t be another source of fragmentation. I’m not sure how well the direct-to-consumer telehealth companies do with sending records back to the patient’s primary physician or other members of the care team. From what I hear, interoperability is pretty low unless the patient belongs to a health system who has partnered with the telehealth company.

In my past life as an urgent care physician, I frequently saw patients who had been referred for in-person care by a telehealth physician who felt that the patient’s condition wasn’t appropriate for telehealth or for specific testing, such as a rapid strep test or a COVID-19 test. Out of curiosity, I always asked which platform the patient had used, and very few of them actually knew the name of the service. Usually they arrived at it from an employer website, so I’m not sure the telehealth platforms are creating much loyalty beyond that with the employer representatives who handle the contracting.

I also saw plenty of patients who had been treated via telehealth in a manner that was inconsistent with the current standard of care. Often these patients came to urgent care because they weren’t getting better or because they had spoken with a friend or family member who said the course of treatment didn’t sound right. Those visits frequently require some degree of finesse because you don’t know exactly what happened in the previous visit or how the patient’s symptoms might have changed between that time and your visit.

Other times, however, you know the care provided didn’t pass the sniff test, especially when patients were given antibiotics that were not indicated for a given diagnosis or when they pull up their visit summary documents on their phones and the care plan can only be described as off the wall. We certainly see those issues play out from in-person care encounters as well, so it’s not necessarily a telehealth problem.

Being in the telehealth trenches allows me to do my work from anywhere, which I tried out for the first time recently. It was a little strange to pack my required white coat in my suitcase along with my sunscreen and flip flops, and I have to admit I was worried about whether I could get the right camera angles to make it look like I wasn’t in a hotel, but everything worked out. I still think that wearing a white coat to show that you are a physician (versus wearing it because it has nice pockets to hold all the things you need) is a little strange, but it’s required on my platform as a sign of professionalism. Personally, I wish the white coat would become extinct for infection control purposes, but it will probably stick around for the remainder of my career.

I see a need for large organizations, especially integrated delivery networks, to spend some time thinking through their telehealth strategies and make sure they make sense for growth and care delivery since many of them reached their current states out of desperation and necessity. There are still plenty of people out there using freestanding telehealth platforms that force physicians to do a lot of data entry and double work, and for their sake, I hope they can transition to integrated systems. The next two to five years will be interesting as far as seeing where telehealth takes us and what value it can deliver.

Ever talked to your doctor while she’s sitting on the beach? Leave a comment or email me.

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