By Joseph Gaccione (courtesy of UNLV School of Nursing)
It isn’t easy finding silver linings during the coronavirus pandemic, but if one were to make a list of potential positives, the prevalence of telehealth would have to be on that list.
Although not a brand-new invention, telemedicine – offering medical services and information through electronic and telecommunication means – is helping more people get the care they need without risking their well-being by going out. The necessity for social distancing due to COVID-19 has forced more healthcare providers and medical facilities to adopt additional telehealth procedures, and the benefits are clear. Patients can speak to a professional from the comfort of their own home; it minimizes in-person contact between people to prevent the spread of the virus; and it’s a critical tool for those who have limited mobility or access to a health professional. While the technology doesn’t solve all problems, it is becoming more dependable.
I spoke to UNLV School of Nursing Assistant Professor Aaron Bellow, Jr. (Ph.D., APRN, FNP-BC, ENP-C) and Lo Fu Tan (MD, MS, FCFP, FAAFP), Senior Medical Director of the Digital Health Division at Southwest Medical (SMA) to provide more context on the impact of telemedicine during the outbreak. Dr. Bellow and Dr. Tan both work at SMA, providing telehealth to patients. During our in-depth interview, we discuss their experiences, why some healthcare providers may be slow to adapt to virtual medicine, and where they see the technology going in years to come.
WHAT HAVE THE TRENDS BEEN LIKE AS THE OUTBREAK HAS PROGRESSED, AS FAR AS TELEHEALTH GOES?
BELLOW: “I transitioned over to telehealth when I started working for UNLV. We had seen on average, prior to COVID-19, somewhere around 80 patient per day increasing to 100 patients per day during peak flu season. Then it got as high as 400 a day during peak COVID, and then it settled down. I feel like it’s trending with the cases: as our cases in Nevada have increased, so have our telehealth visits.”
TAN: “Up until what I call ‘Pre-COVID’, (using the start date in Nevada of March 1st), in the winter, we would average around 100 patients in a 24-hour day doing urgent care video visits. Then, I think we maxed out on a handful of days around 450-460 a day. To put that in perspective, we have 13 brick-and-mortar urgent cares in town under SMA, and collectively they probably see 400-500 patients a day. During the front end of this first phase, when we were trying to keep patients from getting exposed, we were not allowing them into the brick-and-mortar settings, whether it was urgent care or primary care specialty care, so many were being directed to a telemedicine visit. Of course, patients were afraid to come in as well. So, the volumes went down probably 90 to 95% in that setting, which was part of the reason why we had our uptick. Prior to COVID – and I think this is a national issue throughout all of healthcare – the utilization of telemedicine has been very slow. Less than 1% of visits were done by video, and in a fairly short timeframe between March & April, [we] added about 450 – 500 clinicians to our telemedicine platform, because we really needed their help. Plus, they needed to see their patients besides in-person. So, all of a sudden, they were forced through this pandemic to start receiving patients by video. The world has changed pretty dramatically, due to the pandemic when it comes to video care.”
BELLOW: “You can classify our care in three different categories. One is On Demand Care, which is urgent care. We have primary care, and then we have specialists. We ramped up services and we started to provide telehealth in all three categories.”
WITH THE RISE IN TELEHEALTH CASES, IS IT ENCOURAGING THAT PEOPLE ARE TAKING TO HEART SOCIAL DISTANCING?
TAN: “I think it’s good. I worked in the telemedicine clinic for the last two days, and three quarters of those patients touch on COVID-19 in one way or another. And I think in general, these people are being responsible, in terms of social distancing, masking, and trying to protect others around them. What we certainly do not want is people to be shy or afraid to get seen in person if it’s necessary. I spent a fair bit of time [talking to] these patients, especially the ones who get on, they’re symptomatic, waiting for results come back. I’m very clear with them: If they get worse, especially if they get any breathing problems, I need them to get seen in person at one of our brick-and-mortar urgent cares or an emergency department.
I think one of the negatives we’ve seen overall, not just in our practice, but there’s certainly case reports out there where people are not getting care, and I think partly is because of concern of getting exposed if they go into an emergency department. Heart attack diagnoses have gone down significantly. Parents don’t want [their children] out of the house, and some of them have had some very significant medical problems that had not been addressed in a timely manner. It is a challenging time in healthcare. I think we do the best we can. We are able to provide access to care for these people. And if nothing else, give them the opportunity to let us know where they’re at with self care. If we really feel that one of these patients on telemedicine needs to be seen, then we have that ability to connect them to one of our urgent cares or directly to an emergency department.”
WHY DO YOU THINK THERE IS AN INCREASED BACKLASH OVER WEARING MASKS?
TAN: “The only way I can rationalize it is that the people who are opposed to it – if anybody has the time or the wherewithal to do the study – I would guess that they are the same people that are opposed to immunizations and doing things for the good of public health. We are five months too late to mask everybody, but at least we’re trying. I don’t have the perfect answer, but I equate social distancing and using masks to our substitute for two things which we don’t have with this virus: 1), a vaccine and 2), what we call “herd immunity”. This means that you take a disease like measles or one of these childhood diseases, and if enough people have been infected in the past, and then add the number of people who have been vaccinated, then the rest of the population is less likely to get infected. So, we don’t have those two things right now. We don’t have herd immunity. We don’t have a vaccine. The only decent alternative is to mask people, or to make them stay at home.”
BELLOW: “I think there’s a lot of mistrust. The thing about science is the word ‘science’ leaves people with the impression that it’s exact and that it’s consistently correct, but truthfully, most advances in science come from error, come from us thinking it was one way and then we tested it and it was wrong. With this being a new virus, honestly, it’s a moving target. We think one thing based on what we know based on current evidence, and then we get a little further down the line and we have to kind of update that thinking. I think for most people that starts to send mixed messages and that starts to create mistrust and they start to think, ‘They’re telling me to wear a mask today. Next month, they’re probably going to tell me that masks contribute to the spread of COVID’. So, I think it’s mostly mistrust.”
YOU MENTIONED PRIOR TO COVID-19, IT WAS A SLOW TRANSITION TO TELEMEDICINE. WHY IS THAT?
TAN: “I think it’s just a combination of things. Even in our organization, where there was a lot of senior leadership support for it, sometimes we don’t have the resources that are necessary. Clinicians have a job already. They’ve got their schedule set out. They’re seeing 30 – 40 patients a day on the schedule or going to surgery, and now they’re being asked to insert this into their workflow. Even though they may have done Skype and FaceTime, just like we talked about the masking, there’s a bit of mistrust. It’s mostly about quality of care, clinical care. Are the outcomes OK? Are we doing the right thing in terms of doing a video visit like this? is this interview valid, because we’re not in person and able to touch each other like in a clinical visit?
Think about Nevada, we’re always around 45th, 46th, 47th, when it comes to physician/clinician to population ratios. We’re in Las Vegas, but we’re still truly a rural state. Our access to primary care and specialty care in town is not good. You would think, ‘wow, here’s a use of technology that can help that population’. And yet, it doesn’t take off until we hit this pandemic. Now, the question is, ‘Are we going to sustain this big rise in video care?’, and the answer is already clear: We have not been able to sustain it. A few months ago, two thirds of primary care visits were being conducted by video. Now that number has gone down to somewhere between 10 to 15% in the last month. Why? Because they’re bringing patients back into the office. Patients want to be seen still by their own primary care provider in the clinic setting. Then the last two or three weeks, we swung back the other way with way more cases. I expect we’re going to go up and down and up and down for awhile, then at some point down the road, we’re going to hit some new equilibrium. That is probably where we’re going to sit at, until people truly recognize that we can do this and provide great care for our rural patients, our patients in town who don’t have transportation or access to primary care physicians. But it takes time and it takes a tremendous amount of resources and a focus to get these things established and maintained.”
BELLOW: “We say patients want to be ‘seen’, that’s the terminology we use as providers when we say that we completed the patient’s care, but more specifically, patients want to be touched, meaning they want to go in for an in-person visit. They want whoever’s taking care of them to do a physical examination, to look at their body, to listen to their heart, and you lose a component of that over the computer. I think that’s important for a lot of patients. They feel like without that, they probably didn’t get complete care, and it’s important to a lot of providers. A lot of providers feel like, if I’m not examining my patient physically, did I really take good care of them? We’re testing new technologies to fix that with digital stethoscopes, digital, otoscopes to look in the ear. We’re trying to address that and create an interface that lets us replace some of that.
I think another factor is the cost benefit. SMA has paid for this platform since 2013, and we didn’t have a lot of utilization. That’s just the platform that enables us to see patients in a HIPAA compliant way; that costs a lot of money, and you don’t have the volumes to justify that cost initially. That’s not even the cost of the providers to staff it. So, there is a cost benefit side to it that I think made a lot of organizations kind of as a whole question whether or not they wanted to spend the money on it.
Also, I think the type of high utilizers of healthcare are still primarily older population who probably aren’t digital natives. I think, as millennials continue to age and those digital natives start to access more and more healthcare because they’re getting older and need more access to care. I think that’ll be a factor, too. I personally thought COVID would be the tipping point, and I thought it would force enough people to use telehealth that we would see sort of a sustained increase utilization, but it sounds like that hasn’t been the case.”
WHEN YOU MEET PATIENTS IN A TELEHEALTH FORMAT, WHAT IS THEIR MOOD? ARE THEY COMFORTABLE IN THIS SETTING?
BELLOW: “COVID forced a lot of people to use telehealth who probably wouldn’t have used it otherwise, but like with everything, there’s always a self-selection bias. There’s always the person who would use telehealth is going to be comfortable with the technology, who would be more comfortable with that type of visit. The people who wouldn’t be would never download the app and make the call. Now COVID-19 did change that, because, in our organization, if you wanted to be tested for COVID, especially in the beginning, one of the only ways that you could was through the telehealth platform.”
TAN: “When we onboard a new clinician, I tell them to look at the camera. It means looking at the patient, and I think from the telemedicine perspective, that’s how we connect to these patients. It really is about that connection whether it’s by video or in the examining room. You’ve got this tiny little window of time to connect with that patient and make them feel comfortable with, what you’re doing for them and what you’re telling them. But I try to tell people it’s no different than when you’re seeing them in person. You got to be on your game, because it can pose more challenges because you don’t have that physical presence with the patient.”
HOW DO YOU SEE TELEHEALTH IMPROVING IN THE NEXT 5 TO 10 YEARS?
TAN: “Part of what we’ve tried to do as an organization is get streamlined. Pre-COVID, we were using a lot of different technology, meaning different companies and different applications. Since COVID, that number has grown tremendously. We’re very good at solving problems in a reasonable timeframe. But we use old technology; it’s very piecemeal. This is not unique to Southwest Medical; it’s happening everywhere in the healthcare world. [There are] a hundred different apps, and you got get online to access something else and on and on. One of the dreams is we’re going to streamline this. We’re going to go with one size fits, all or at least can be applied to many cases. That’s a hope for the near future, that we could retire a bunch of old technology and go with something that we can use to improve provider/clinician experience, which would affect the patient experience as well. The technology is clunky, and we do the best we can with it. That’s the promise of this decade that we’re going to have technology that will fix a lot of these problems for us.”
BELLOW: “I would guess one of the biggest themes you’ll see is a greater integration of peripherals to address some of that loss of the physical exam portion. You’re going to see a greater integration of peripherals that allow me to listen to your heart and lungs, that allow me to look at your ears and throat. I think further down the line, you’re going to see fully integrated telehealth platforms that integrate with wearable technology, like a telehealth platform that can connect to your Apple watch and let me evaluate your heart rate and all of your health data. Amazon and Apple and Google, while they might not have that technology existing within that company itself, all of those companies have a venture capital side, where they invest in new technology, almost all of them have venture capital o r R&D money in some type of integrated artificial intelligence, where it tested some type of wearable technology that has a computer program that mines that data to try and improve health outcomes.”
WHAT ABOUT AN INCREASE IN TELEHEALTH EDUCATION OR ITS IMPACT ON HEALTH EDUCATION?
BELLOW: “Due to COVID-19, we have out of town nurse practitioner students that we couldn’t travel to go and see them for visits for their midterm. We usually would go and see them for their midterm evaluation; whatever clinic they were seeing their patients in, we would go and evaluate them. We had to create a virtual clinical evaluation for their midterm visit via telehealth. So, our students by default are getting some exposure to telehealth just by virtue of us having to adapt our program, to limit exposure and because we weren’t able to travel. So, this semester we did that for our out of town students. Next semester, we’ll probably do it for all of our students. I suspect that’s true of sort of health care medical education across the country; they’re going to get some exposure by default, just in terms of having to adapt to COVID-19.”
TAN: “There are two things that we really need to focus on. It’s the education part – the quality and the training – and the research part. There’s a dearth of literature on what we do, and I think that’s part of the problem with respect to the slow buy-in from clinicians and the population. We don’t have a whole bunch of good evidence to support what we’re doing. That has to change. We added 400 – 500 providers to telemedicine because of COVID-19. What has been missing is concurrent review of the clinical quality. it’s something that we’re working on trying to catch up. So those two things are incredibly important.”