Attitude of Gratitude

Workflow. Billing. Tip sheets. These are some of the words I have associated with telemedicine.

Multiple Zoom meetings, email chains and video tutorials later, our clinic was able to make the transition, though not without hiccups. Our phone calls skyrocketed with requests for rescheduling, postponing, etc. Early on, I found myself returning phone calls, unsure what the rules were about billing but completely certain that the phone calls were all I had to reach patients, to check on how they were doing, to help ease their panic. Truth is, reaching them helped ease my panic, too.

As the days went by, more pieces fell into place. Schedules became more organized. Some clinicians transitioned to working from home. Our ability to adapt was impressive, but I found myself marveling at patients' reactions more. Most of my telemedicine conversations start with a quick check on my own wellness.

"How are you doing?" they ask me. "You have enough masks, right?"

This is usually followed by an expression of gratitude.

"Tell everyone thank you, Doctor," they say. "Thank you for seeing me."

After talking about their own health concerns, they always close the visit with a plea.

"Take care of yourself," they say. "Stay safe."

Sometimes it's a pact that once physical distancing is over, we can talk about their grandchildren or their garden in person.

I'm grateful to my patients that during these trying times, they stand with us. Even when I don't have many answers, which is frustrating on so many levels, they still listen. During a time when we also need their support, they show up.

If you were to ask me now what words I associate with telemedicine, the ones I mentioned in the beginning still apply. However, new words have joined the group: gratitude and privilege. It's a privilege to take care of people, and I'm feeling that lesson now more than ever.

Astrud Villareal, M.D., D.I.M.P.H., Dallas

Playing a Vital Role

My initial reaction to starting telemedicine in our practice was one of excitement. The idea of limiting my risk of getting infected with COVID-19 while still being able to take care of my patients was extremely appealing. However, it almost seems too easy. My colleagues are risking their health and their lives in emergency rooms and ICUs while I can safely see patients in the comfort of my own home. Something about this just didn't seem fair to me at first.

Our local hospital reached out to my practice, an independent federally qualified health system, to see if some of our doctors would be willing to help in the event that their doctors became ill or there was a surge in cases.

Although I would be willing to do that if necessary, I've realized that my role in this isn't to be intubating patients or managing ventilators, neither of which are my area of expertise. Rather, by doing telemedicine I am still caring for my patients in a way that allows them to stay home. I provide them counseling and encouragement and answer their questions in this unprecedented time. I can leverage my relationship with my patients and use the trust that we've established to help them prevent the spread of the virus.

We all have a role to play in this pandemic, and right now serving my patients through telemedicine is mine.

Luis Garcia, M.D., York, Pa.

Has This Visit Gone to the Dogs?

I've transitioned to almost 100% virtual visits during the past three weeks and it's been an adjustment. Although in most instances, I can still make a connection with the person on the other side of the video screen, overall, I feel less connected to patients. But I've had a least one instance of increased connectivity with patients through virtual visits.

I was doing a medication review with two of my favorite patients, an elderly couple with multiple chronic conditions that put them at high risk for complications from COVID-19. They were holed up in their home in the mountains, not leaving the house and trying to stay safe. After our conversation about congestive heart failure medications, they shared their struggle with the significant isolation of being alone for weeks without much social interaction.

In the middle of our conversation, the mailman dropped off a package on my doorstep, and my dogs started barking up a storm, one of the downsides of working from the "home office." I began to apologize to my patients, worried about the disruption in the middle of a serious conversation. Almost immediately, they asked what kind of dogs I had and if they could see them. Turns out they had always had dogs until last year, when Roy, their Australian shepherd, passed away.

I spent the next five minutes chasing my dogs throughout the house and positioning my phone to better show my furry family to my patients. They really missed Roy, and seeing my dogs brought back happy memories and helped push back the gloom of isolation.

The intimacy of giving my patients a glimpse into my home and virtually introducing them to my dogs led to a happy moment for an isolated couple. In this instance, I felt the virtual visit helped me get to know my patients better than an in-person visit.

Kyle Leggott, M.D., Aurora, Colo.

Pleasantly Surprised

I've never imagined such an explosion in the use of technology. Within the past week, my hospital system went from zero telemedicine visits to performing at least 50% of daily outpatient visits via telemedicine, and now telemedicine is being considered for other uses, such as rounding in the hospital.

This incredible increase in utilization has come with surprises. First, the platforms are getting easier to use. I've had successful visits with 90-year-old patients because all they have to do is click a link that has been texted to them. Of course, there also have been the predictable, periodic difficulties with bandwidth and connection, but I have been pleased with how easy telemedicine is to use, both from my side of the screen and theirs. People are calling from work, their homes and their (parked) cars. Functionally, telemedicine has proven its utility and benefit.

However, I still have no idea what is going on in terms of payment. CMS has provided nearly daily updates and changes in regulation, drastically increasing access for Medicare beneficiaries. Unfortunately, I do not know if private insurers will follow suit, if they will offer pay parity, or if they will pay at all. We also don't know if private payers will care where patients are located (including those across the state line 15 miles from my clinic), if they cover only certain types of visits and not others, if I need to code a modifier, etc.

We are converting as many visits as we can to telemedicine to prevent exposure to COVID-19, regardless of coverage, but I can honestly say I don't know if we are going to be compensated or not. I know that primary care is seeing a decrease in volume of 50%-80% in some areas, which spells financial disaster for many small clinics and systems. If those clinics close, where will their patients seek care when they need it the most?

Now is the time to overhaul our insurance system, as well. Telemedicine has become simpler to use due to a sudden increase in demand. I think it's time to for our insurance system to follow suit.

Stewart Decker, M.D., Klamath Falls, Ore.

Expanded Access for Addiction Care

COVID-19 is changing how people do everything, and accessing health care is at top of the list. The increased availability of telehealth is one of those major changes. Here in southwest Missouri, we are doing everything we can to prepare for an eventual insurgence of COVID-19 cases. We have rescheduled nonessential appointments, and now many of us are carrying out telemedicine visits for the first time.

I started telemedicine visits two weeks ago, and now they comprise one-third to one-half of my schedule. On a typical day at my clinic before the pandemic, I would see about two dozen patients for things like wellness exams, lab reviews, medication refills and a few acute visits. Now that we are only seeing essential visits, I am down to about 10-15 patients a day, a handful of which are via telemedicine. So far, things have gone quite well.

To my surprise, I actually enjoy telemedicine and have found that the format makes it easier to have a series of focused encounters in a short period of time. The patients like these encounters, too. In fact, I think that the social-distancing environment created by the virus has made patients grateful to have exams completed from the safety of their homes. Together, we have discovered it feels natural to be conversing via this medium, even as I toggle between tabs to review labs, allergies and medications.

Federal agencies recently removed restrictions on addiction telephone consults, so we also are offering telemedicine visits through our addiction clinic.

If there is a silver lining in this crisis, it is that barriers to care have been removed. Previous barriers to telehealth have been insurance payment limitations, Drug Enforcement Administration restrictions on addiction care, and the lack of experience that many clinicians and patients had with this modality. I hope that the expansions in access are here to stay.

Kurt Bravata, M.D., Buffalo, Mo.

I Miss My Patients

Nearly overnight on March 16, my massive multispecialty organization shifted from using telemedicine for 15%-20% of patient encounters to more than 80%. We are trying to see as many patients via video or telephone as possible, and adoption has been amazing. The initial goal was to convert about 50% of face-to-face visits to telemedicine. In my practice, I have been able to convert more than 90% of visits to telemedicine due to patients' desire to obtain care without risking exposure.

I was initially inundated by the extremely high volume of patient questions, concerns and routine health care needs. We converted normal, 20-minute face-to-face visits to 10-minute telemedicine visits. Honestly, it felt like I was running on a treadmill. By the end of the day (40 patients later) I was exhausted.

More recently, we have adjusted schedules so there is a mix of short urgent visits and 20-minute telemedicine visits, which makes my days more tolerable. However, full-time telemedicine is not the utopia I envisioned. All the onerous and tedious tasks of medical care -- documenting, coding, billing, technological challenges -- remain, but without any of the good parts -- the smile, the physical touch, the relationship and nonverbal communication -- which I miss to a shocking degree. I've always been one to embrace technology and thought I would love telehealth -- however, I miss seeing my patients.

A colleague of mine said "never let a crisis go to waste," and I agree with him that barriers to telemedicine have been obliterated literally overnight. Now we must fine-tune the system to get the right balance. What we have learned is that telemedicine is a valuable tool, however, it is only one of the myriad tools that family doctors possess. It is best used within the context of an existing doctor-patient relationship and it should be given an equal, or nearly equal, amount of time as a face-to-face encounter.

There is no question that the rapid adoption of telemedicine is here to stay. Now we just need to make sure it works for everybody.

Alex Mroszczyk-McDonald, M.D., Fontana, Calif.

Glad to Help

Telehealth is interesting.

I'm not used to it, so it's a bit disorienting, but it provides access for my patients.

I can talk to patients who are far away.

I can meet with patients in their own homes.

I can provide support and reassurance.

I can explain medications and educate patients with clear plans.

Many organizations have risked everything -- including getting paid and keeping our doors open in the long run -- to provide this service in a time of desperate need.

It feels good.

I'm worried about my community health center and smaller practices, but I'm glad we're doing it.

Lalita Abhyankar, M.D., M.H.S., New York City