I spend many hours every week in meetings regarding telehealth. I lead one on proving the value of telehealth. I participate in others focused on mental health, pediatrics, ocular care, the business of telehealth, the associated technology, etc. etc. etc. Over time I’ve realized that, in most cases, the focus is totally on video visits. Having spent many years leading virtual care for Kaiser Permanente in Colorado, in my humble opinion, telehealth encompasses MUCH MORE than video visits. My definition of telehealth is any care process that does not have the clinician and the patient in the same room at the same time. This includes care provided via secure text, e-mail, telephone, video, remote patient monitoring, social media, mobile apps, even sources of information for self-care.
Imagine how much more care could be provided in less time with the use of text and email? Of course, phone is so very easy for everyone, and especially useful with patients cared for by a clinician for quite a while. When no visual input is required and even if it was available would not change the treatment plan, it seems that these easier and less time-consuming options make a whole lot of sense. The cost of our healthcare system could decrease. What a concept!
My favorite example is a personal one. I was diagnosed with osteoporosis at 50yo, I am now 64. My endocrinologist has NEVER touched me, and never will, for this diagnosis. There is nothing to touch, nothing to see. Of course, I need to get my bone mineral densitometry test done when told to and I need to report in on my exercise and calcium/vitamin D intake, as well as any falls/fractured bones. What in these activities requires anything beyond connection by text or email?
What other symptoms/diagnoses can you think of for which visual input makes no difference in the treatment plan? Discussion of lab/imaging results? Erectile dysfunction? Irritable bowel syndrome? ESLD patient awaiting transplant? ALL infectious disease follow-up care??
An allergist I know has indicated that for follow-up care of a patient with asthma, more often than not a stethoscope is used because ‘that’s what we’ve always done. That’s what the patient expects.” If so, what visual input would change the treatment plan?
A very seasoned general surgeon told me many years ago that “I don’t need to touch a patient’s abdomen to do a differential diagnosis for abdominal pain.” If so, what visual input would change the treatment plan?
Of course, the United States healthcare reimbursement system works against most of these options. Clinicians certainly are and likely will always be reimbursed for in person care. Over the years, and particularly during COVID-19 times, reimbursement has become more consistent for care by video and remote patient monitoring. There has been some reimbursement for phone visits. I hypothesize that this won’t last beyond COVID-19. Certainly, reimbursement for care by text or email is not coming any time soon. This would not be an issue for providers who are reimbursed for value versus for how care is provided. Permanente physicians are salaried, with incentives based on clinical outcomes and patient satisfaction. They are therefore motivated to provide care using the least amount of time, as long as equivalent (or better, often in the case of mental health!) clinical outcomes can be expected.
Malpractice, of course, is also an issue for clinicians. Could a clinician be blamed for missing a diagnosis or providing inappropriate care because a patient has not been seen in person? Of course he/she could.
I so passionately recommend that clinicians take some time to think about what input is needed that could change the treatment plan.
I so passionately recommend that we all, as patients, think about the same thing each time we are in a doctor’s office, or connecting by video.
What do you think?
