When Telemedicine Began in the US

Some day back in March, a small council of 3 physicians gathered in the offices of their unassuming internal medicine practice fixed just a walk from the University of Virginia campus in Charlottesville.

Fox & Brantley Internal Medicine has operated for a quarter-century alike many other small-scale private practitioners in the rural US: compactly. Their team of three practicing physicians—just one of whom is full-time—and three employees can be found in a small medical complex neighboring specialists, on a strip of local businesses. Private, personal care has an appealing straightforwardness to its procedure; Fox & Brantley were very accessible, and consistent.

But some day back in March, the practice’s partners convened in the empty offices to discuss the means of blowing it all up.

It’s funny that William E. Fox, MD, FACP, could not remember the exact date of this discussion when talking with HCPLive®—“I’m sure I could find it out, if that’s important,” he offered—especially given its significance. The practicing physician was a day away from changing the ways by which he did his job, uninterrupted, for 17 years.

But it’s less surprising when you consider how few of his peers around the country could recall the date when they had a similar conversation with their teams.

About 400 miles north of Fox and colleagues on whatever day it was in early-to-mid March, confirmed coronavirus 2019 (COVID-19) cases were steadily passing the thousands in New York City. Within days, the curve would spike acutely upward, and like a map of interstate highways, the virus’ spread would reach outward from its new epicenter in Manhattan.

And Fox’s team, like thousands others, staring down the impending pandemic, kickstarted medicine’s future, one which has been decades in the making, in a matter of hours. “It was seismic,” he explained. “It was a seismic change. And I think it's one of the most transformative events in the delivery of healthcare in the last 30-40 years.”

The Great Migration

There are a handful of means by which we can date the moment that US healthcare converted to telemedicine.

If we were to largely attribute the change to when the virus first began to spread rapidly, then it’d be in the week of March 16-23: in those 7 days, the US recorded its first day of 1000-plus new cases—and very quickly, its first day of 10,000 new cases.

If we defined it by federal agency and national corporation responses, it’d be a couple weeks prior. President Trump signed the Coronavirus Preparedness and Response Supplemental Appropriations Act on March 6—then, a week later, declared a national emergency which incited the closure of schools, offices, and public events.

Neither way, though, attributes to the fact that almost all clinicians soldiered through direct care at the very front of the pandemic surge. Fox is among those who attested to HCPLive that his practice defined its workers as “essential employees,” in order to assure its doors could not close in case of any emergency calls.

This leads to the idea that it was not the virus nor legislators, but really, clinicians who decided care should convert to telemedicine. To understand when a large, mostly independent group of people would have found interest in an idea, it’s easiest to refer to the source from which they’d learn about it: Google.

According to Google Trends—which gauges the popularity value of search terms on a scale from 0-100, with 100 representing peak popularity—the term “telemedicine” scored beneath 10 every week from mid-June 2019 until late February of this year.

In the first week of March 2020, it reached 12. Through March 8-14, it jumped to 30. The next week: 97. The final week of March? 100.

It’s an imperfect gauge, but anecdotally, that’s what many physicians like Fox and his team did to begin their telemedicine practice. It was through his partner’s research that they came across Doxy.me, one of the more popular, HIPAA-compliant online platforms for physician-patient interaction.

Doxy.me, according to SEMRush, has increased its monthly organic traffic by 416% since March this year. Competing platforms including Chiron (19%) and VSee (63%) have reported notable boosts in traffic as well. Popular physician social media app Doximity, which offers its own peer-to-peer telemedicine features, reached approximately 4 million visits to its homepage last month—a 25% bump since March.

Federal Foundations

But there’s countless logs of data that will go uncounted toward the timestamp of the great telemedicine conversion; like every American suddenly disconnected from the world, doctors hopped on FaceTime, thanks to the very suddenly lenient permissions of third parties.Joe Kvedar, MD, learned of his practice’s about-face in March while on a half-aborted ski trip to Wyoming, about 2000 miles from his colleagues at Massachusetts General and Brigham & Women’s Hospitals.

His departing flight was already among the few not cancelled in the early shutdown of the airways the week of March 8; by the time he was at his destination, most of his itinerary was rendered useless by closures. In the coming days of his trip, he learned his dermatology practice would be manned by one doctor in the house, three days a week, taking emergencies only.

Kvedar himself had been ready for this moment. The incoming president of the American Telemedicine Association (ATA), he’s had plenty of experience in virtual patient visits—as well as telephone screening practices and still-image assessments, as far as dermatology could warrant. He and his team were savvy with what he calls “asynchronous visits,” which simply put, is receiving and responding to patient-sent images over text. Very little about going remote concerned Kvedar. It was parties outside his control which gave him pause.

“In the beginning, it was very much nut and bolts,” Kvedar explained to HCPLive, detailing the questions forming before anyone began telemedicine. “’How do I set this up?’ ‘How do I choose a vendor?’’ The less attainable question was: “how will physicians charge their virtual visits?”

On March 6, the Centers for Medicare & Medicaid Services (CMS) broadened its access to Medicare telehealth services as an eventual extension of the national emergency declaration. Medicare was immediately greenlit for covering office, hospital, and additional clinical visits via telehealth.

Physicians were also OKed to reduce or waive cost-sharing for visits paid by federal healthcare programs, thereby ending a long-held stature in which the only telemedicine paid for by Medicare could be instances of patients receiving services in designated rural areas with limited medical facilities or resources.

Medicare now deemed all its users at a deficit of receiving appropriate, in-person care. Their waiver could start a domino effect among the often implacable private insurers; their choices boil down to finally offering coverage for true telemedicine, or risk losing business in droves.

In a side role as co-chair of the American Medicine Association’s (AMA) Digital Medicine Payment Advisory Group, Kvedar has been responsible for adding new reimbursement codes that would allow for easier telemedicine billing in the last 3 years. The pandemic started in March, and suddenly, the work was done: an infrastructure was set for billing.

“Seema Verma is on the record saying, ‘the genie's out of the bottle,’ and it's not going back,” Kvedar said. “That's pretty powerful. And usually when Medicare pays for something, private payers tend to follow. We'll see where it all lands.”

Blazing a Trail

Regardless, medical organizations proceeded with a confidence that telemedicine would have an immediate, robust role in their fields. They set to work in assuring that all parties involved would share that belief.First and foremost, Kvedar advised, doctors should not do anything dumb.

“Just because we have government discretion to use any video platform, you shouldn't do stupid things,” he said. “You have to pay attention to quality, and you have to pay attention to security and privacy.”

He also stressed that, early on, physicians should be particularly vigilant about fraud and abuse of practice: “One of the reasons that payers are very reluctant is they're afraid that people will bill them multiple times.”

These two points serve to the greater cause of assuring buy-in from third-party payers—and though they're a little obvious, they echo the reality that this is very much so the country’s first spin with virtual healthcare.

As the recently named president of the American College of Physicians (ACP), Jacqueline Winfield Fincher, MD, MACP, started her tenure in late April with expectations unlike any that awaited her predecessors. The ACP began offering telemedicine implementation resources in whole on March 16, and became an even more direct source for the mass of clinician questions which followed.

What could be done for chronically or acutely ill patients? What if a patient might have COVID-19? How do we decide which patients need to go to the emergency room? What if a patient has no telemedicine capability?

These were among the first and most pressing questions to flood the ACP inbox—and, of course, concerns about the practitioner’s livelihood.

“The other great immediate concern was, ‘Would we be able to get the [Paycheck Protection] Program to help us remain open with all our staff remaining employed rather than furloughed, and how are we going to do enough visits to remain open and meet payroll?’” Fincher wrote in an email.

The question of keeping business moving during the pandemic was quickly answered. Kvedar noted his hospital systems conducted about 2600 virtual patient encounters in February. In March, they did nearly 90,000. As of late May, they were averaging about 60,000 weekly. Business is booming.

“Pretty much every delivery system that I've talked to has had similar growth: Providence, Mayo, Cleveland Clinic, Jefferson in Pennsylvania,” Kvedar said. “And a lot of these were already people that were farther ahead than we were, and yet they've had this dramatic growth.”

Still, keeping up visit rates is a taller order for a smaller practice. Fincher and her team was fielding questions on technical barriers inconceivable to the great US healthcare systems: a lack of bandwidth for rural patients trying to follow links to video chats; no available resources to send an older patient who may rely on a child or caregiver to help operate their technology; a need to create protocol from scratch for patients who just had no choice but to come in to the office.

But so as long as physicians were able to clear the hurdle of getting telemedicine started, the benefits were just as obvious. Cardiometabolic-risk patients, who often use everyday devices to track their glucose, heart rate and body weight, were having more efficient and timely check-ins. Crucial follow-up visits for patients with a mental illness were assured to occur. And primary care physicians, long removed from the picture in the care of patients who’ve progressed to nursing homes or even hospices, could feasibly re-involve themselves where seen fit.

The New Practice

Fincher sees a future where some of this never ends. “No question, telehealth is here to stay, especially for following up on medication or treatment changes made at a regular visit.”Fox did not have an email address when he graduated from medical school in 1994. The internet was yet to be fixed for mass consumption, and as such, was beyond the interests of the everyday physician.

Not once—in pre-med, medical school, residency—in any iteration of his training as a doctor, was the term “telemedicine” taught to Fox. And then one day at work, it became nearly all that he and his practice was doing. If he saw 10 patients, 8 or 9 would be over a screen.

If the upside of major healthcare systems is in their sheer size and reach, then their Achilles is the weight of their decisions. The six-person team of Fox & Brantley moves nimbly. There was no board vote nor establishment of a committee to start telemedicine—just a meeting in the office sometime back in March.

“The three of us got together and sketched out how do we how do we want to do this. And we didn't have all the answers at the first moment,” Fox explained.

They reached out to other practices in town, gathered some good ideas and early lessons. They subjected themselves to a learning curve, allowing early failures and frustrations to inform the next day’s ideas. “We're creating it as we go along, and it may need to be modified as we as we learn more about it,” Fox said.

As Fincer attested, there were greater issues around connecting with patients in the countryside, and helping older patients get onto the platforms. But Fox stressed the difficulties of managing COVID-19 testing: everything, from initial screening, to testing stations and personal protective equipment (PPE), was completely undefined.

The practice began screening all incoming patients by phone with the usual triplet of COVID-19 symptoms: any cough, fever, or difficulty breathing? They installed a downstairs doorbell, and required patients have their temperature taken once in the building. If anyone was feverish, they were instructed to return to their car, where they would receive an evaluation for COVID-19 risk.

A newfound burden for a small practice with minimal office space: Fox and colleagues were conducting COVID-19 testing in full PPE, car by car, in their parking lot. But it was a system that wouldn’t disrupt the telemedicine visits, nor the 1-in-10 emergency visit in person.

Though the partners were game for the new practice, it was more important the patients bought in—for their own sake. Fox envisioned a situation where their virtual visits were unsatisfactory. Patients could delay and delay their care, creating a packed schedule in an unpredictable future. And what if a patient’s health worsened before that? Fox couldn’t imagine a worse place to send a trusting patient during the pandemic than an overwhelmed emergency room.

No—it was very necessary for the practice and its patients that everyone was game.

“There were some patients who didn't like the idea initially. But that wasn't the majority. The vast majority actually really loved it,” Fox said. “You know, they love the convenience of it. They love the idea that they didn't need to worry about leaving their home to see the doctor, that they didn't have to worry that they might pick up coronavirus just to see their doctor.”

Couple that last idea with the fact that patients now had a personal hotline to a medical official at a time when COVID-19 fear was more substantial than its clinical understanding. Fox found his patients, for no matter what reason they originally called, would cap the visit with a series of questions on the virus.

A Realized Future

Just as many patients, especially elderly ones, simply enjoyed talking with Fox during the sudden isolation.What’s to be made of a system that’s three months old, born out of necessity, in a setting with as uncertain a day tomorrow as it may have in 2021? Whatever its start date was, telemedicine was an execution of improvisation, but is now a realized goal. Fox recalled a quote: “we accomplished in 20 days what we’ve needed to do for 20 years.”

He imagines that, eventually, guidelines could begin to address what peripherals a patient should own to better integrate virtual exams. It might be soon that every household begins to own certain components of ‘the Internet of Things’ that bolster telemedicine for those who want in.

Fox is curious to see the research that trails the telemedicine launch—as clinical investigators are wont to amplify the successes and hiccups of any new medical venture. He wants to see how it continues to buck the private payer system, imagining this may finally be the catalyst that changes the fee-for-service system which has neglected all the logging and care a doctor has conducted well after the patient has left the office.

Kvedar hopes to learn how this affects whatever becomes of in-person visits. Very slowly, in his virus-burdened region of Boston, practices are beginning to take on capped volumes of patients in its offices. He already hears questions about how to best marry telemedicine with the population that will just never buy in to the virtual experience.

“We went from one-channel delivery in the office, to one-channel delivery in the home,” he explained. “There's a happy medium, and that's what we have to find next.”

Kvedar looks at iPhones, pre-installed with the suddenly HIPAA-approved FaceTime, or the millions who have migrated to Zoom in just months, logging on for their annual exam at 4 PM and their Virtual Happy Hour at 5. He recalls a time when his telemedicine visits were through a TV set-sized box with cables spewing into and out of it, and he realizes they’ve reached the always imagined future.

“The fact that it's all mobile, it's all wireless, it's all on one device, we mustn't discount that,” he said. “There's a lot of things have been happening in the background to lead us to be prepared for an inflection point. And we definitely hit an inflection point, without a doubt.”

To answer the question: telemedicine began sometime between the last two decades and March of this year—inspired by innovation, sparked by an unprecedented pandemic, enabled by scrambling insurers, and championed by providers who may or may not had even known how to do it.

Physicians like Fox, now a veteran through 3 months out of a 25 year-career, saw the beginning of US telemedicine healthcare. They don’t see its end.

“I would say it's feeling more and more normal, and something I really hope is here to stay,” he said.