Curbside Consult with Dr. Jayne 7/19/21

Due to changes in licensure waivers as states decide that the pandemic is over, despite the fact that we’re not even close, my telemedicine work is becoming rather spotty. Unlike some of my colleagues, I don’t have a dozen state licenses, so I’m limited on the patients I can see.

For part-time people like myself who the telehealth vendors hire as independent contractors, it’s difficult to justify the effort to obtain multiple state licenses, not to mention the ongoing costs. Licensure in the US is a patchwork across the states. Although some belong to an interstate compact, others don’t, which makes it even more confusing.

Looking at my nearby colleagues, however, nearly everyone is practicing some flavor of telemedicine, whether it’s some evening moonlighting or as part of expanded offerings on behalf of their practice. I’m always interested to hear about telemedicine experiences from my proceduralist colleagues, so I enjoyed reading this article in JAMA Surgery last week. It specifically addresses the use of telemedicine in surgical subspecialties, proposing that telemedicine will go beyond being a “pandemic adaptation” and will continue to evolve. The article outlines the timeline of increasing telehealth surgical services – initially when elective surgical procedures were suspended and surgeons began to use the technology for preoperative, follow-up, and emergent surgical care visits, but then later in 2020 as COVID-19 cases began to spike.

The authors note that current telehealth technology can make it difficult for surgeons to physically assess their patients and may impede interpersonal communication. However, many patients are able to report specific data points, such as vital signs and pain scale that are often gathered during a visit, and patients are certainly able to tell a physician whether it hurts when they move or touch certain parts of their body as well as what their current level of activity might be.

They cite several potential advantages for telehealth surgical services, including improved access, continuity of care, and reduced disparities. Additionally, patients may have less travel time and expense. Although the authors don’t specifically mention it, I know from personal experience that surgical telehealth consultations have opened up availability for second opinions across the US. One of my close friends was able to have consultations with multiple renowned surgical oncologists in a matter of days, which might have been weeks to months had she needed to travel. Of course, that doesn’t take into account the time she would have missed from work or the travel expenses.

The article goes on to focus on three factors that will most impact the degree to which telemedicine will replace and/or supplement in-person visits.

First, they note that “with interpersonal relationships being a core attribute of high-quality surgical care, perhaps more targeted implementation of telemedicine is required.” They propose established patients as “an attractive subset” for postoperative visits or routine follow up. My only major surgery was somewhat emergent, and I certainly didn’t have the opportunity to form an interpersonal relationship with the surgeon, who came to the hospital early on a Sunday morning to remove a gallbladder that had gone rogue. The next morning, I was seen by a nurse practitioner from the office, handed a script for 10 Percocet, and hustled out the door. A post-op incision check took less than 90 seconds, and I honestly can’t remember if there was even an exam or if it was just a visual inspection of the surgical sites. The idea that our physician-patient relationship was a core attribute of anything kind of makes me laugh.

Second, they note that “substantial technological innovation is still needed to enhance surgical diagnostic capacity of telemedicine.” They propose the use of remote monitoring and wearables to provide supplemental biometric data such as heart rate, sleep time, activity levels, and electrocardiogram data. They note a need to process the data “in clinically meaningful and easily presentable ways” to “accelerate their use in clinical practice.” I don’t disagree with that. None of us want to see hundreds of disparate data points that might be out of context. However, this bullet might relate better to some surgical subspecialties than others.

Third, and I think most of us agree with this, “given the direct relationship between insurance coverage and adoption of health care innovation, continued coverage for telemedicine services and further refinement to the existing policies are needed to sustain this mode of health care delivery.” They go on to mention that payers are already rolling back coverage for telehealth services not related to COVID-19, and if it hasn’t happened by the time this piece comes out, it’s likely that Medicare will soon end coverage for audio-only telehealth visits. This is going to be the end of telehealth services for many patients, especially those who struggle with technology or who might not have the capability of executing a video visit.

A few messages down my inbox was another article about telehealth. Specifically, “how to bring warmth to your virtual care visits.” This piece from the American Medical Association seeks to answer the question: As the US health care system remakes itself into one that includes more virtual visits, how can physicians maintain the empathy and “human touch” that are so crucial to a strong patient-physician relationship?” It summarizes comments from the AMA’s Telehealth Immersion Program, which is designed to help physicians implement, improve, and build their telehealth efforts.

The speakers quoted in the piece have some good points, such as seeing things in the context of a video visit that they wouldn’t have seen in-person – such as fall hazards in the home, companion animals, etc. However, they note the need to focus additional effort on communication skills and relationship management. Most of the tips offered though are the same we’d recommend for physicians struggling with in-person communication – communicating clearly, showing respect, taking time, and displaying empathy. I didn’t find anything new or earthshaking in the article, but then again, I rarely do when the AMA is the source.

One thing that I think health systems and other entities need to think about when they’re talking about expanding telehealth is balancing the convenience factor with the need to support physicians. For example, if an in-person visit typically has a support staff member who documents the chief complaint, assesses and documents vital signs, reconciles medications, and updates histories, then there’s no good reason to simply shift that work back onto physicians. Unfortunately, that’s what we see in a lot of telehealth practices. Some of it is because organizations are still using telehealth solutions that are not fit for purpose or integrated with the EHR, and other times it’s because organizations are just taking advantage of their clinicians.

Those organizations that offer more transactional or direct-to-consumer telehealth services need to be careful about expanding those offerings without thinking about their providers. Many telehealth-only physicians moved into that sector because they prefer the transactional nature of that model of care. Simply put, they don’t want to go back to doing the things they hated in practice, such as tracking gaps in care, refilling medications, reviewing pages of blood pressure logs, and more. If they’re asked to take on additional responsibilities, they’re likely to ask for greater compensation, which will be interesting in an industry with a fairly thin margin.

All in all, it’s clear that telehealth is here to stay. I’m sure it’s going to continue to evolve, although I don’t have a crystal ball to know which way things might go next.

What do you think about the evolution of telehealth in the US? Leave a comment or email me.

Email Dr. Jayne.