Aug. 28, 2020 -- Telehealth has moved from the fringes of medical care to the center.
The fear of the coronavirus has driven patients to meet with their doctors, their child’s pediatrician, therapists, and counselors via computers, cellphones, and virtual reality.
A Department of Health and Human Services statistical report found that in April, about 43% of primary care visits through Medicare were via telehealth. Before the pandemic, more than 99% of Medicare-funded visits were in-person appointments.
From March through early July, the agency says, more than 10 million Medicare beneficiaries used telehealth services.
The U.S. Department of Veterans Affairs, too, saw a massive spike in the number of patients seeing doctors online. Between February and May, about 120,000 appointments a week were conducted via the VA’s Video Connect system. That compares to 10,000 a week during the same period in 2019.
Though doctors may be turning back toward traditional office visits, at least for now, telehealth remains a way for doctors to maintain a relationship with patients.
“Telehealth has been a critical means for providing care during the COVID-19 pandemic and will continue to be a vital tool, even as in-person visits are accessible for some,” says Susan R. Bailey, MD, president of the American Medical Association.
And it looks like it’s here to stay. Several telehealth companies are looking to go public or are exploring sales, The Wall Street Journal recently reported. The global market is projected to grow from $25.4 billion this year to $55.6 billion by 2025.
Amwell, a telehealth company, was expected to raise up to $4 billion from an initial public offering of stock, The Wall Street Journal reported. The paper says Amwell hosted 2.2 million telehealth visits in from April through June and had as many as 40,000 visits a day in April, a huge increase from about 2,900 a day in April 2019.
A Fan of Both Kinds of Visits
If telehealth is the future of medical care, health professionals should try to maintain both in-person and virtual visits, says Kate Morgan, a stay-at-home mom and a registered dietitian nutritionist who lives in Kansas.
Morgan also knows what it feels like to be the mother of a patient. Her 5-year-old son was diagnosed with a kidney condition as an infant. He is now in remission. Morgan, her husband, and other children live in a midsize city in Kansas, but her son’s doctors, who are specialists, practice in Kansas City, which is far from where she lives. Before COVID-19, her son’s doctor would drive to her city to meet with patients, including her son, at local facility. But with the pandemic, doctors stopped in-patient visits, leaving only virtual visits.
At the time of this interview, Morgan had used telehealth as a medical option only once. It was a routine checkup for her son. Morgan says they met with a nurse and a doctor virtually via Microsoft Teams, a virtual meeting software.
“Honestly, I loved it,” she says. “I didn’t have to travel; I didn’t have to haul my kid into a building; it saved a lot of time. We were done in 30 minutes.”
Morgan thinks telemedicine is good if you want to have a conversation, but not for more complicated care. She says her son didn’t need any labs or tests. He didn’t need to do a physical exam. The meeting was only a relatively short conversation with her son’s doctor.
“I do think we need both,” says Morgan, who once worked as a diabetes educator in Cheyenne, WY, where she led virtual meetings with patients and met patients in person. “I think it helps if there are established relationships with the clients. It’s much easier to connect with them virtually. If you are meeting someone you have never met before over the computer, it is a lot harder to feel like you’re understood and heard as a patient. I would be a bit on guard with a physician I’ve never met before.”
Thinking back to her days working in Wyoming, Morgan says she was teaching parents and children how to use insulin pumps, and that may be difficult to do virtually.
“I think it would be possible but more difficult for concerned parents to feel confident learning it virtually vs. teaching in person,” she says.
Virtual Reality and Telehealth
Some newer technologies are helping when a closer connection is needed.
XR Health provides telehealth through virtual reality (VR) headsets for physical therapy. All interaction is done virtually, or over mobile phones and computers. Clinicians meet patients virtually to assess problems. If patients want to proceed, they are mailed a virtual reality headset, and they download an app to their smartphone or computer. Inside the virtual reality arena, depending on the specific need, patients can meet with support groups, play video games, or get therapy in virtual environments that help them cope with illness or pain. Within the virtual worlds, clients have direct communication with the clinicians. Information is gathered within the virtual world and transmitted back to the clinician, who charts clients’ progress. Clients can also chart their progress via an app.
Eran Orr, CEO of XR Health, says he thinks a 2D interface -- just talking to a doctor or mental health provider on Zoom or any other online meeting platform -- is not enough to treat people.
“If you want to treat someone, and not just prescribe meds, but actually conduct treatment, I think that relying only on 2D interface is about 30% of what you can do,” he says. “I think that is a major difference in what we are trying to bring to the table. We are bringing an entire 360-degree environment that is closer to the real-world experience. Once you put that virtual reality headset on, you are stepping into our treatment program.”
Steven Lin, MD, a clinical associate professor of medicine at Stanford Medicine, says VR health-based treatments are an “extension rather than a disruption of the patient-physician relationship.”
“The primary advantage of VR-powered telehealth is improved patient access to drug-free treatments for problems like chronic pain, mental health, and musculoskeletal injuries (i.e., physical therapy),” he says.
Possible cons, he says, are lack of insurance coverage and the need for patients to know how to work with VR technology. That may exclude lower-income people, who are more likely to lack insurance and reliable internet service, as well as older people who might be less technologically inclined.
Researchers at the University of California, San Francisco, found that the challenges for older people are particularly troublesome. Their study revealed that more than a third of adults over 65 would have a hard time using telemedicine. This is especially true for older, low-income men in remote or rural areas, and even more so for those with disabilities or other conditions, the researchers say.
Researchers used 2018 data from more than 4,500 patients recorded in the National Health and Aging Trends, which studied Medicare patients ages 65 and older.
They found that about 38%, or 13 million older Americans, were not prepared for telehealth visits via video. Even with someone helping, 32% still could not make it work and 20% could not manage a telephone visit due to dementia or a hard time hearing or communicating.
Texts and Telephone Calls
For those patients who can’t get online, the doctors at telehealth company CallOnDoc text and call instead.
CallOnDoc, founded in 2017 in Dallas, started as a traditional care facility, offering in-person care. The company began to notice that after patients scheduled appointments, they often wouldn’t show up. After it did a survey, doctors realized their customers’ social and economic barriers, as well as other problems, hindered them from attending appointments. To accommodate them, they decided to go to a mostly virtual model.
“We really take our patient experience seriously,” says Hattie Oshun, a physician assistant and co-founder and chief operating officer at CallOnDoc. “We want this to be a one-stop experience for our patients.”
She says before the pandemic, CallOnDoc had to explain telehealth to patients. But now, she says, “it’s a part of our everyday language.”
In addition to calls and texts, Oshun says CallOnDoc allows patients who live close to its office in the Dallas-Fort Worth area to see their doctors face-to-face.
Going forward, Oshun says, there are other industries that are left out of telehealth -- like veterinarian and dental practices -- that the company wants to add to its list of services.
She Likes Face-to-Face Visits
Elizabeth Reiner, an entrepreneur who is a certified midwife in the Washington, D.C., area, understands the kind of deep relationships that are built through in-person meetings. Before the pandemic, she had no official office. Prenatal care, postpartum visits, and home births were done at her clients’ homes. COVID-19 changed that, and now, like others, she virtually meets her clients, but she still attends home births in person, and she has to occasionally draw patients’ blood.
“Some things can’t be done on Zoom,” she says.
To make the Zoom calls personal, Reiner says, she invites her clients to do spiritual practice, something she would normally do in person, to calm the mothers-to-be and their partners. Building that connection with patients, even though virtually, is key.
She says one thing she likes about telehealth is that she doesn’t have to wear a mask while talking to her clients. When she visits her clients’ homes, she does.
“I do think a lot is lost when we can’t see each other’s full faces,” she says. “I like doing telehealth visits in that we can see each other’s full faces.”