COVID-19 Proved Doctors are Ready for Telemedicine

David Hill, MD, is no stranger to difficult conversations. As once highlighted by HCPLive®, the Waterbury Hospital intensivist has a reputation for seeking out uncomfortable rhetoric. Whether he’s on his Facebook account or in his scrubs doesn’t matter; he wants to say what has to be said.

This benefits him well in palliative care, an unfortunately necessary and very honest part of his job. He’s not proud to list addressing a worsening patient’s loved ones as one of his finest skills as an emergency doctor, but he knows empathy has its place in medicine.

Unfortunately, one of the first of many resources coronavirus 2019 (COVID-19) threatened in hospitals like Hill’s was room for empathy. Many people began to experience the pandemic-era horror of watching a loved one be sent away to the intensive care unit (ICU) with a worsening infection. They want to be with them at the worst of the disease; the worst of the disease disallows them to be near.

Doctors like Hill bridged the gap. Simple phone calls, FaceTime sessions, video chats let him fulfill the full extent of his job: he keeps the patients’ family safe from infection, he keeps the family informed about their loved one, and shows there’s still a caring human watching over them.

At the height of the pandemic’s ugly peak in the northeast region of the US, frontline caregivers like Hill were on display as the bearers of burden from too few masks, too few beds, too many patients, too little preparation.

But even in the simplest uses of technology—a video chat, from an ICU patient’s bedside to the confines of their home—they showed they are the right users for the technological tools available in this, and in any future, pandemic.

The Case for Proactive Technology

On definitions of legislation, social distancing parameters and public conscience, we are entering a new stage of the COVID-19 pandemic. While many look ahead to the glimpses of normalcy being offered by governors and business owners as practical rewards for 100 days of good behavior, it might be a better use of time to reflect on what preparations failed to force the sweeping quarantine measures.

Look, comparably, to the early curve flattened by South Korea in mid-February. While the small peninsula country may have obvious boundary advantages to the US in cutting off viral spread, it mainly had done so through impressive public health parameters.

The country implemented an aggressive strategy for handling the outbreak, which included mass rapid testing and comprehensive contact tracing. The latter used GPS phone tracking, closed-circuit television cameras, and credit card transaction monitoring to assure absolute accuracy. Citizens were receiving automated text message alerts in the event they may have been exposed to COVID-19.

Doing such, along with rapid and widely available testing, led to the Korean Centers for Disease Control reporting zero new local cases for the first time since February 18.

In theory, contact tracing offers the US an opportunity to limit the damage of a potential second wave, and avoid some of the economic fallout a second shelter-in-place order would produce.

But it would only work under specific government and public health department regulations, making it difficult for success in a country the size of the US. And most importantly, it relies on strong, widely available, and frequently used citizen testing.

Maybe out of necessity, similarly smaller, condensed countries ramped up both measures fairly early on. Pinar Karaca-Mandic, PhD, Academic Director of the Medical Industry Leadership Institute at the University of Minnesota Carlson School of Management, recently told sister publication Contagion about her birth-country Turkey.

Her parents, over 65 years old, traveled back home in December 2019. When the virus reached epidemic, then pandemic status, they were held to a strict at-home curfew. Like all their neighbors, they were then assigned to a general practitioner who would field their concerns and seek updates on their status during the lockdown.

Any instance of COVID-19 testing triggered by these communications yielded a person’s inclusion to countrywide contact tracing, managed by the assigned practitioner. The system fascinated Karaca-Mandic, who’s currently researching population health data during the pandemic.

“It's how you hear about more of the public health departments taking charge,” she said. “But it does make some sense that the family medicine physician, who knows the most about you, creates the contact.”

Like Hill teleconferencing with a patient’s family, this very involved contact tracing is doubly beneficial: the physician can confirm their patients at home, healthy, accounted for, and playing their part in reducing spread.

Old Tools, New Stakes

“Under these isolation procedures, it’s helping both the patient and the family maintain a connection,” Hill told HCPLive. “I think those of us in ‘normal life’ are using video technology to maintain our sanity. It’s even more important for people who are really sick.”The application of technology to pandemic response is novel in the fashion it’s been used during COVID-19; technology in healthcare overall is not a new concept.

Of course, majority of hospitals use electronic health records (EHRs) as part of the Centers for Medicare & Medicaid Services Meaningful Use program. Mobile health applications were developed and adopted by many. And many patients—both in rural and urban settings—can leverage telehealth platforms for virtual visits.

Over the last decade or so, these tools have really come to the forefront of care. Artificial intelligence (AI) chatbots are used for patients to text back and forth with a virtual health coach. Patients can use telepsychiatry to be counseled by a licensed professional in the comfort of their own homes without the stigma or anxiety of going to an in-person consultation.

Busy parents can send a picture of their child’s rash to their primary care physician or dermatologist, and the provider can electronically write a prescription for a topical ointment.

The Great Endorsement

What’s changed in non-coronavirus-related telemedicine has been an urgency and steeped implication of what it means when this technology is beneficial or a hindrance. What was once a unique twist to the healthcare practice—by accounts of physicians, patients, and payers alike, a secondary option—is now the sole practice option. It’s now either telemedicine, a concerning alternative, or nothing.Aside from the more obvious ways in which technology is being leveraged during a time when most people are quarantined in their homes and practicing social distance, health systems have been using technologies to keep patients safe and prevent them from entering a potentially high-risk environment.

Intermountain Healthcare, the nonprofit health system headquartered in Salt Lake City, partnered with American Well to provide triaging technology that keeps patients out of the waiting room.

Like many other greater networks, the health system established a COVID-19 hotline that was staffed with nurses and other providers to direct patients if they needed to get tested. Over the phone, the provider could answer patient questions and could refer the patient to an online symptom checker tool.

There was also a direct-to-consumer video visit which anyone who was suspicious of having COVID-19 could use 24/7. Patients were able to have video visits with a provider to identify what their symptoms were and if they needed to be referred to testing.

Intermountain offered scheduled video visits for all of its specialties and all of its primary care providers. Jim Sheets, MBA, Vice President of outreach services at Intermountain, told HCPLive explained it was quickly and broadly embraced.

“Candidly, it just went through the roof, as far as the demand, because people still wanted to keep their appointments with their providers, but they didn’t want to come into the hospital or clinic and be in a waiting room and potentially be exposed to other people with COVID,” Sheets said.

The government’s role in using such technology has played a big part in its success during the pandemic, Sheets added.

When the pandemic started, the federal government’s waiver on restricted telemedicine visits and uses of care opened the doors for many like Intermountain to learn heavily on scheduled video appointments.

High-risk patients, particularly older ones, can maintain highly valuable visitation and facetime with their physicians, who can offer their standard guidance and prescribing as much as they could in person. As emergency department volume drops across the country due to the pandemic, the process of care which would potentially lead to such a patient being referred to immediate clinical attention is alive and well.

The User, Not The Tool

“It was like night and day, all of a sudden, doctors were saying, ‘Wow, this does make sense. I can connect with my patients at home and it is so convenient,’” Sheets said. “It’s a great service and we will definitely continue it in the future, because it’s just convenient for patients, and it can be an alternate to not running into the brick and mortar clinic,” Sheets said.This is the beginning of technology’s use in the pandemic, but there’s reason to believe the research and application of tools now at the forefront will outlast the virus itself. Karaca-Mandic envisions a future where—whether it be contact tracing, state-by-state logging, or something else entirely—data reporting continues to escalate.

“More proactive data collection, more real-time data collection, and more standardized data collection are needed,” Karaca-Mandic said.

The greatest problem left to be solved is buy-in from a national population which, up to and likely through the publishing of this piece, is waging debate on the value of wearing masks in public—the least significant compromise of the entire pandemic response.

There’s privacy concerns, billing questions, and a general lack of trust in some who would maybe even greatly benefit from participating in telemedicine.

If anything, it’s a great relief to those like Sheets that, mostly, physicians are all in.

It’s one thing for the frontline fighters of the virus to have the capability of wielding technology. It’s another thing when you think of that skill doctors like Hill aren’t too proud of, but use nonetheless: communicating with a patient, when it’s the least convenient.