Telemedicine and COVID-19

In 1999 McGraw-Hill published a book, co-authored by Jeff Bauer, a prominent health futurist, and me, a frontline rural family doctor, entitled Telemedicine and the Reinvention of Healthcare. Telehealth was so promising, we said then, that we expected these technologies to lead the way to not just reforming, but to reinventing healthcare. We asked the obvious question, if telemedicine is such an efficient and effective way to deliver healthcare, why weren’t we seeing a lot more of it? We answered the question we’d posed by citing a number of barriers: onerous professional licensing laws that made it cumbersome to cross state boundaries to practice; getting professionals to take the time and trouble to learn an electronic system; interruptions of practice routines; stingy or non-existent insurance coverage for remote services; and patient resistance.That was 21 years ago. Since that time the technology has improved ahundred-fold, in terms of reliability and ease of use, and the cost has plummeted at about that same steep rate. Until a few weeks ago, we were still asking why telemedicine had not caught on.It took a 120 nanometer (5 millionths of an inch) RNA virus to pivot the whole aircraft carrier of American healthcare 180 degrees, at least with respect to telehealth. All of a sudden, moving electrons rather than people makes great sense. Electrons aren’t contagious. Compared to movingpeople, it costs almost nothing to move messages electronically, over wire, cable or through the air. Concern about patient resistance to receiving services by telehealth has, from the outset, turned out to be purely theoretical. People, especially physically isolated individuals, are glad to get timely care by whatever means.Now that they are being paid for it, physicians are happy--no they’re thrilled--to be doing telemedicine. We’ve practiced telehealth anyway--provided medical care over a distance via communication technology--since the advent of the telephone. Those hours I spent doing phone calls--betweenappointments or after clinic, to patients and their families, listening and giving professional advice, all of it for free--will now be paid for. Well, maybe some of the calls with Medicare and Medicaid recipients will be paid for.Nobody should be surprised that the host of policies hastily put into place by state and federal agencies--meant to make it easier to receive and give, pay and get paid for, telehealth services--have turned into a tangled mess. Some policies pay for real time audio and video only. Some waive co-pays. Some pay for telephone consults. As usual, it will take an administrator or two at every medical practice to figure out how to bill for telehealth services during this window of liberalized payment. The administrators will then have to educate their providers and billing people onhow to proceed. And all of that will add to overhead.The technical stuff, as is almost always the case, is the easy part. One of my sons, a licensed social worker, has a counseling practice in Seattle. He told me it took him ten minutes to get up-to-speed with the secure and private video features of his electronic medical record system. These days Jack does his job from an office in his home. He has not lost one client since he switched over to an all-electronic practice in the face of sequestration. Needless to say, his three year-old daughter is thrilled to have Dad home with her and Mom.

Barriers to practicing telemedicine across state lines have been temporarily lowered for doctors, nurse practitioners, physician assistants and nurse midwives. As has been the case in so many aspects of the response tothis grave pandemic, states have led the way in relaxing licensing requirements for all sorts of health professionals, including nurses, nursing students and retired doctors. However, in this realm too, state and federal regulations are inconsistent and conflicting.As I’ve said in previous pieces (see blogs: “Consumer driven telemedicine,” December 12, 2019 and “What is telehealth?” November 18, 2019), telemedicine encompasses far more than just a patient at one end of a video connection talking to a doctor at the other. It includes many of the ways that physically separated professionals collaborate with each other in patient care, like the radiologist in Sydney, Australia who, in the middle of their day, interprets a chest CT scan for a physician who’s caring for a patient in respiratory failure in the emergency room Wray, Colorado, where it’s the middle of the night.Telemedicine is also about gathering medical information remotely. It’sextremely unlikely, once a person, including even someone who had an asymptomatic of COVID-19 infection, has developed antibodies, that they willever come down with that infection again. Italy, whose epidemic has peaked, is using antibody measures to help determine who can go back to work. In our country smartphone enabled diagnostics that sense antibodies to coronavirus are still a month or two away from deployment.Home genetic testing companies, like 23andMe, are seeking out customers who have come down with severe coronavirus infections, then searching those clients’ entire genomes to see if one or more genes might pop up as risk factors for this serious illness, possibly a big step toward understanding and treating the disease. This too is telemedicine.Tests for antibodies to the coronavirus’ protein coat are plenty sophisticated, measuring inconceivably tiny quantities of these molecules, onthe order of parts per billion. Genome sequencing, though done every day, takes some very expensive and sophisticated equipment. On the other hand, one can measure a few pretty basic things to get an idea of who is likely to have a coronavirus infection. For example, a company called Vital has launched its Coronavirus Checker, an mhealth app that, in the space of answering questions on a few screens and checking boxes for symptoms, plus entering patient age and zip code or country, stratifies the user into a high risk, moderate risk or low risk category for having COVID-19 infection. (“Mhealth” is short for mobile health, which applies to any health app that runs on a smartphone, tablet or other portable device.) High risk people are,of course, counseled to seek immediate medical attention. This is not rocket science. It’s easy stuff. It works. And it too is telemedicine.American society will never be quite the same as it was before the pandemic. I expect healthcare to change most dramatically. Restricting the definition of medical care, and consequently what is paid for, to only what happens when a doctor and a patient are in the same room, is a thing of the past. That tiny virus has freed us to think so much more broadly and creatively about how to provide the care that people really need, in a way that is most convenient for them and most efficient for their providers. Jeff Bauer and I understood that in 1999. Now we all do.

April 15, 2020
 in the
Written by
Marc Ringel, MD

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