• Fresh Perspectives

    Telemedicine II: What We’ve Learned So Far

    Editor’s Note: This spring we asked our new physician bloggers how they had adjusted to telemedicine. Now several months into the pandemic, we asked for an update regarding the lessons they’ve learned. Here is what they shared.

    patient having video call with doctor on laptop

    Making Sense of the Whirlwind

    The journey on telemedicine utilization during the pandemic has been bumpy, sometimes funny and many times frustrating, and it has left me with more questions than answers. Organizations, physicians and policy groups are all rushing to make sense of what must be one of the most rapid shifts ever in health care delivery.

    In the university-based primary care clinics I work in, telemedicine was rare (0.5% of all visits) prior to the pandemic. But within weeks of COVID-19’s arrival in Colorado, a massive shift led to telehealth accounting for 73% of total visits in April.

    Although I only have two or three telemedicine visits per half day in clinic, the rapid shift to telemedicine in April and back to in-person visits by June has left me feeling uncertain about the future of telemedicine. I have dealt with this uncertainty by leading a group of 28 primary care clinicians across a variety of practice settings in Colorado in focused discussions about lessons learned from our experiences. After doing some qualitative data analysis, conversations coding and thematic analysis, some interesting themes and recommendations took form.

    The following are some of the key findings from those conversations, which can be viewed in more detail on a North American Primary Care Research Group poster presentation. Within our group, clinicians recognized that telemedicine has the potential to increase patient access to health care, but they also are concerned it could exacerbate existing inequities in health access. Clinicians specifically mentioned inequitable patient access to broadband internet, appropriate technology, home monitoring equipment, language barriers and culturally appropriate outreach.

    From a practice standpoint, telemedicine can be an effective replacement for certain types of in-office visits, and many clinicians shared that the technology reduced no-show rates. However, there wasn’t agreement on which visit types are bests suited for telemedicine. For example, some clinicians seemed to think behavioral/mental health visits were well suited for the technology, while others thought it might exacerbate existing avoidant behaviors and coping strategies. Clinicians also expressed concern that inappropriate use could result in poor patient outcomes and increased liability. Many clinicians gave examples of missed diagnoses in virtual visits compared to in-person care. Finally, practices faced challenges with billing and reimbursement, and how best to implement new workflows.

    Clinicians also had recommendations for how to improve telemedicine, including clarifying the future of payment and billing, developing workflows that allowed clinicians to work from home to conserve personal protective equipment and reduce overhead, clarifying the use of home monitoring equipment, promoting equitable patient access to telemedicine, assessing which types of visits are most appropriate for telemedicine, and training on how to utilize it.

    I hope that as telemedicine becomes a routine part of the health care landscape, policymakers will listen to the voices of front-line clinicians regarding what we and our patients need to make it work.

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

    Language and Financial Barriers

    Telehealth is not a panacea. Don’t get me wrong; I love it, and it’s been extremely helpful for visiting with my patients for quick follow-ups after adjusting meds, or even as a check-in for my patients diagnosed with COVID-19. But it has been a challenge for my primarily urban, Spanish-speaking patient population to get on board.

    What I’ve realized is that the technology divide in our country has been amplified by the surge in the use of telemedicine, and low-income, non-English speaking persons are among those being left behind.

    Poor connection?

    It’s because my patients can’t afford Wi-Fi, and telemedicine platforms aren’t optimized for cell phones.

    Patient needs an interpreter?

    Sorry, this will have to be a telephone visit instead of video, if it happens at all. Our EHR vendor has its own telemedicine product, which I have tested, yet many of my patients can’t log in. They either don’t understand the instructions, or they get an error saying the browsers on their phones aren’t supported. To me, this signifies that phones with older browsers (and their owners) are being left out. So, although the intention to increase patient access to care is a noble one, it’s not yet a reality for many poor and marginalized patients.

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

    Rural Access

    In mid-March, when the gravity and scope of the pandemic was realized and we began shutting down many things in our lives, my practice took the extraordinary step of discouraging our patients from coming into the office in order to reduce the risks for them and our staff. We were able to quickly pivot as a practice, and we implemented telehealth visits within 48 hours when many regulations were suspended due to the public health emergency.

    While telemedicine expansion has been a welcome change in health care, there are still many barriers to widespread adoption that physicians and patients face in rural areas. We routinely face issues with technology, including internet connectivity and patients’ abilities to access and use appropriate equipment. Many of our patients do not have access to high-speed internet in their homes, and they either do not have smartphones or cannot appropriately use them to conduct a visit.

    Telemedicine is likely here to stay, so we must be aware of the barriers that rural communities and practices face and work to address them as we strive to implement widespread adoption in our health care system.

    Tate Hinkle, M.D., Alexander City, Ala.

    Small Practice Issues

    When COVID-19 descended on Kansas City in the middle of March, we easily migrated all of our patient encounters to phone, email and videoconference. As a direct primary care practice, we had previously communicated with our patients using these tools, so it wasn’t a major change. We didn’t have to fight for reimbursement or remember to file the right codes. We just did it because it needed to be done, and our patients were thankful.

    As the months have dragged on, however, things have gotten harder. We’re a small office, and although we want to do more in-person visits, we just don’t know how to do it safely. It’s been hard to procure enough PPE to protect ourselves. (How much is enough? And how do we answer that question when we don’t know when this will end?) It’s been impossible to risk-stratify patients. (What symptoms count? Do screening questions work?) And our clinic – a mere 200 feet from the state line – sits in a community with more than a dozen erratic, uncoordinated jurisdictional regulations that leave everyone confused. Our building is old, and the ventilation is hard to predict; we’ve resorted to seeing patients in the parking lot and saving in-clinic visits for issues that absolutely must be seen in person and would not be appropriate for a visit in the car.

    But with the weather changing – it has rained, sleeted and snowed so far today – we’re struggling to figure out how to keep our small practice safe and open, to keep sick patients at just the right distance to care for them while keeping ourselves safe, and to also keep providing excellent, high-value care. It’s an exhausting exercise we go through on an almost daily basis. We’ve had patients lament the fact that they can’t come see us. Another asked when we would allow car visits to end. One simply asked: “How does this all work these days?”

    The truth is, we don’t know. We’re figuring it out on a daily basis. In the meantime, would you like a telemedicine visit?

    Allison Edwards, M.D., Kansas City, Kan.

    Tips to Consider

    The perfectly efficient clinic day is like a no-hitter in baseball: It’s extremely hard to achieve, but with the right mix of staff, patients and systems, it’s possible. A day in which you can go from patient room to patient room, finishing notes between, with phone calls perfectly spread out as to never overwhelm feels wonderful.

    Introducing a tool like telemedicine could cause a nosedive in clinic efficiency. Patients unable to connect, doctors unable to hear patients, and chief complaints that are ill-suited for virtual visits could all create a frustrating black hole in the middle of your day.

    There are, however, a few easy ways to make sure that telemedicine visits improve your clinic efficiency, and, more importantly, your patients’ access to care and their health care experience.

    First, have a dedicated IT team or person. If you need troubleshooting help, you need to know who to call and how to get hold of them easily.

    Second, choose a tool that is easy to use. Ease of use is most important for the patient side, because their frustration will inevitably be more common than yours, and you have the opportunity to learn your tool over time while they do not. There are dozens of options on the table; I would suggest choosing one that does not require an additional app download for patients. It’s also good to plan whether you will do same-day visits, scheduled visits initiated by patients or just follow-ups you schedule yourself. And understand whether the technology you are choosing supports scheduled virtual visits and/or what your workflow will be for scheduling.

    Third, have a good plan for how to know which chief complaints are appropriate. This could be a list you put together yourself or an algorithm. I put together a list of conditions I would be comfortable with and made sure my scheduling team had that list. I also published the list on our website advertising telemedicine services.

    Finally, be OK with backups. I’ve converted a number of video calls to phone calls because of technical difficulties, with varying degrees of success. A rash is much more appropriate for a video call than a phone call, but for diabetes, either method can work.

    I love seeing patients in person, but I also have had many people make visits during 15-minute breaks from work and thank me for offering video visits. It makes life a lot easier for some people.

    I truly hope that we can continue using video visits in the future. It’s likely worth your time to let your legislative representatives know how you feel about it, positive or negative, because I imagine it will be a topic of consideration in the coming year.

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


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.