Resident Perspective: Ready or not, time for telehealth

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Wednesday, April 1st

Medicine residents work in the hospital as well as the outpatient office. Cleared to go back to work, I’m scheduled to see some of my patients in the office. In an effort to limit the exposure to coronavirus for both the patients and the office staff, as many appointments as possible have been converted into telemedicine visits. These are essentially video-chat appointments using a HIPAA-compliant app where I can talk to a patient, ask about their symptoms and have them show me any relevant physical exam information, like using the camera on their phone to show me the back of their throat. I complete the online training modules that all providers have to pass and I think I’m as ready as I’ll ever be.

Something is off as I arrive at my clinic prior to my shift. First, it’s nearly empty, no front desk employees are there to wave to, and there are new standing hand sanitizer dispensers everywhere. Magazines from February populate the waiting room tables which may not be alarming for most businesses, but for my clinic, not having new editions of Philadelphia Magazine on display is shocking and noteworthy. No patients in the waiting room and doors to individual offices are closed, preventing natural light from gaining entry to the normally well-trafficked hallways. This place definitely feels more bunker-like than I remember. The few staff and attendings that are present are all wearing scrubs and face masks. Recognizable but unfamiliar, the pandemic has now officially warped and invaded every facet of my life and there is no sanctuary for normalcy.

Previously, only a small portion of physicians were utilizing telehealth visits. Fewer than 1% of Medicare beneficiaries used it prior to the pandemic.  Presumably because there is a learning curve on both the provider and the patient’s end, you have the opportunity to be more thorough during an in-person visit, and the big one: it wasn’t fully reimbursed by Medicare. Recently, under the Stafford Act and National Emergencies Act, Centers for Medicare & Medicaid Services (CMS) announced its beneficiaries will now be able to use telehealth to access their PCP for non-routine visits. Important to note, this is only temporary, as once the crisis is over (whatever that means), CMS will go back to its prior payment structure. Notably, other providers like social workers, psychologists, dieticians, etc. that are also integral to a person’s overall well-being will be covered.

Many of my appointments for the day involved patients interested in COVID testing. There’s an algorithm providers are to follow to determine who should be tested given the scarcity of tests. Mainly if the patient has symptoms, has other elevated risk factors such as coming into contact with a known COVID positive person, or recent travel to a coronavirus “hot spot”, they should be tested. This doesn’t cover a lot of other vulnerable people or others who should be tested, but the algorithm is designed to only catch the most likely positive cases at this point. The rapidity with things like which screening tests are performed and whom to test are just part of the equation in this constantly developing situation. Someone who is not eligible for testing one week, very well may be eligible the next.

I’d never performed a telehealth visit but the obvious problems that come to mind, like poor internet connection and not being able to get a gestalt on a patient that you can by an in-person exam, were apparent. In my first session I immediately encountered an  issue with a patient which our staff couldn’t get in touch with to see if they could convert their in-person appointment to telehealth. The patient’s partner had lost their job and couldn’t pay their cell phone bill so they were splitting the phone and the voicemail-box was full. The current economic crisis will of course exacerbate issues like this. Additionally, most commercial insurance as well as CMS will pay for audio/video calls but not necessarily only an audio (traditional telephone) call. My next patient actually was having difficulty accessing the proprietary HIPAA-compliant app on his phone, necessitating a phone call appointment which ultimately won’t be billable. Other appointments went smoothly and were unremarkable but already it’s clear there will be growing pains in moving patients to telehealth.

I’m a big believer in the future of telemedicine for many reasons but primarily because it provides a lower threshold for patients to access their providers, and this will be beneficial to delivering healthcare. These next few months will be telling if we can make it work nationally from a logistical standpoint. I’m not as convinced from a reimbursement standpoint as I’m sure there will be many kinks to work out. If my first foray into telehealth has shown me anything it’s that for my patients telehealth is a generally welcome idea in theory– many of whom did not grow up with cell phone technology– but in practice it’s a different story. Since the beginning of the quarantine, there’s been a surge in popularity of video and teleconferencing software connecting co-workers and friends alike. This current crisis will hasten the public’s comfort with interacting over the internet.  We’ll see how long it will take to successfully adopt and integrate into daily medical practice but the test has arrived regardless of whether insurance, the public, or providers are prepared.

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Filed under coronavirus, Health Care and Medicine, Pandemic, Residency

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