Web-side manner25 November 2020
US Medicare claims for telemedicine jumped from ten thousand a week in March to well over a million a week in April. Most doctors weren’t trained for this. Tim Gunn asks Kevin Curtis and Matt Mackwood, telemedicine specialists at the Dartmouth-Hitchcock Health System, and Graham Kendall, head of the UK’s Digital Healthcare Council, how healthcare can best adapt to the remote world while maintaining its connection with patients.
Ten months and a lifetime back, Graham Kendall asked some trainee GPs what they thought about telemedicine. Presumably after having their phones confiscated, they looked up and told him they didn’t really believe in it.
“Basically, they’d been taught that face-to-face is always the optimum solution,” says Kendall, who, as the head of the UK’s Digital Health Council, wasn’t just trying to make conversation. “They were very sceptical that you could deliver care remotely, or have a safe relationship with patients that wasn’t face to face, even though all of them would complain about having to take time out of their day-to-day lives to deal with their healthcare needs. It was this really strange mismatch.”
That might seem amusingly – prehistorically – naive today, but GPs in some countries are among the only professionals who still think making a phone call could be an innovative approach to fulfilling their job roles. And as absurd as that sounds, there are still plenty of reasons to think twice about changing the healthcare paradigm. You can’t just ‘move fast and break’ patient safety, and with digital media catalysing issues like vaccine rejection and mistrust of authority, physicians – the archetypal experts in most people’s lives – had a good case for sticking to the top-down model that puts them at the centre of healthcare.
Still, when there’s a viral pandemic raging, the vulnerable person you can only talk to on the phone is probably at less risk than the one 3ft across from you. People have had to adapt. As Kevin Curtis, the medical director for connected care and the Center of Telehealth at Dartmouth-Hitchcock health system in New Hampshire, puts it, there simply wasn’t time for doctors’ minds to linger, as they are wont to do, on all the things they couldn’t replicate virtually. Instead, they had to work with what they could. “All of a sudden they said, ‘Yes, I still wasn’t able to do these things, but holy cow can I accomplish a whole lot.’”
And holy cow, did they. Over a matter of weeks in February and March, Dartmouth-Hitchcock had a 20,000% increase in outpatient virtual visits on its hands. Even for a system with a mature telehealth service in place, that big a jump couldn’t happen completely smoothly – but it might have as much to teach us about the weaknesses of the ‘optimum solution’ as anything else.
Still, it didn’t come easy. Kendall’s next doctor encounter made his trainee GPs sound prophetic. As he tells it, the pain of injuring his finger over lockdown was compounded by the cringing discomfort of watching society’s heroes being brought low by their webcams and laptop microphones. “In most walks of life, they would have been doing this for the past 20 years,” he sighs. “It’s easy to assume that because we are familiar with using technology in our non-professional lives, it will just translate over to our healthcare provision, but we need to help people on that journey.”
At Dartmouth-Hitchcock that falls to family physician and Assistant Professor Matt Mackwood. For him, every journey begins with the first step. The technical prowess will come; first it’s about convincing people they have it in them to care for patients virtually. The pandemic helped with that. “I’ve had providers who I would have thought were Luddites say, ‘I had to do an evaluation for a concussion and I didn’t think it was going to work at all – but it did and it worked fine’,” he explains. “You have to just push them out of the nest a little bit and then they learn to fly.”
Of course, he gives them a bit of guidance to go along with the shove. Point one: telemedicine relies far more on history-taking than it does physical exams. The ideal remote encounter is one where the doctor can work out their patient’s issue simply by talking through their symptoms and medical history. Two, if that’s not possible, providers need to consider how to draw the line between what’s necessary for a diagnosis or treatment plan and what’s simply nice to have in support of one. There’s more scope for disagreement there, and even a bit of tension when doctors get into the esoterica of whether or not a prized stethoscope can add anything to their understanding of a patient with a particular history. But then – number three – even for injuries like Kendall’s finger, where a physical exam might seem crucial for a diagnosis, a doctor could schedule an X-ray directly from a telemedicine appointment instead of using it to confirm a poked and prodded conclusion. Lab tests, too, can be moved upstream to compensate for the fact patients and doctors might not be sharing the same physical space.
“It’s easy to assume that because we are familiar with using technology in our nonprofessional lives, it will just translate over to our healthcare provision, but we need to help people on that journey.”
Then you start to realise some of the explicit advantages that come from going remote. Multidisciplinary teams capable of finding the best approach for particular patients are far easier to assemble virtually, for instance. Equally, seeing into people’s homes could clue physicians to social and environmental factors impacting their health, as well as making it easier for family members to contribute important information. In fact, somewhat counterintuitively, Curtis finds that the first plunge into the virtual world can jolt physicians into focusing their attention on patients.
“Almost the first time you start doing telehealth,” he explains, “you know that you need to be all in.” Webcams provide doctors with a real-time patient’seye view of how they’re coming across, effectively counterbalancing the urge to check schedules and health records while people explain how they feel. Halfway through making the point, Curtis turns away to type into his second screen. It’s a demonstration – he’s just hitting random keys – and I’m not being asked to justify myself for taking up his time, but without the covering sense of intimacy that comes from being in the same room, some part of me still feels rejected.
Not that any doctor intends to send out that message – many would like to spend more time face-to-face with individual patients than they’re able to – but it underscores the extent to which healthcare systems can communicate that the people they exist to serve are actually a secondary concern. The tradition of face-to-face appointments in centralised clinics and hospitals exists because – in largely urbanised western countries, at least – doctors could see more patients if they didn’t have to travel between appointments. “But,” Kendall points out, “the assumption has then been built into the system that doctors’ time is the only thing that counts, and patients’ time is essentially free, and it doesn’t matter how disruptive the care is for them.”
As a result, unless they happen to have a local doctor who can sign, deaf patients can only get primary care on the rare occasions they can both book an appointment and find a translator to attend it alongside them. That’s just one example – carers and people who have difficulty travelling to clinics often spend worried months of their lives at the mercy of what a programmer would call bad user experience design.
Incredibly, some of Mackwood’s patients found it easier to access healthcare as a result of the pandemic. After a whole year of failing to bring one chronic migraine-sufferer into neurology, he was able to use the shift to remote care to get her a phone visit that met her needs within two weeks. “It’s just opening doors for so many people for whom the requirements that to us as providers feel so simple – like ‘come in’ – are actually a huge burden,” he says. Often, the valid comparison isn’t a visit to the clinic; it’s no healthcare at all.
Coding and coding
Kendall doesn’t necessarily agree with Matt Hancock, the UK’s health secretary, that in future the default consultation should take place via video, but he appreciates the effort to decentre care from specialist facilities. If there has to be a default, he says, it should be that patients and physicians make a decision on the best format at each stage of the care process. It’s a minor change, but it could help engage patients in their care and limit non-compliance.
“I’ve had many debates with people about whether we should be using video, phone calls, face to face or text messages,” he explains. “And to me, that’s kind of like debating whether a hammer or a saw is a more useful tool. They’re different things. You need to use them in a coordinated way.”
That’s not to say you couldn’t pick one or the other, but you certainly wouldn’t get anything done quickly. If it isn’t already, it will soon be the duty of the trainee GPs Kendall buttonholed to refer patients into specialist secondary care. They’re going to need the entire toolbox. The rapid adoption of generic virtual platforms helped to blunt some of the pandemic’s impact, but according to Kendall’s models, there will be between nine and ten million people in the UK waiting for those secondary appointments by the beginning of 2021, up from 4.5 million in February 2020. With the continuation of social distancing measures, it’s telemedicine or bust. Kendall’s job now is to make sure it works.
Thankfully, with all the data-gathering capabilities that come with telemedicine, he should be able get a handle on that quickly. The safety and efficacy metrics evaluated by DHC members who provide remote consultations highlight the paucity of information we have about what happens in face-toface appointments. As Kendall puts it, “Triaging at the end of the pathway or in the middle of a pathway is as important as triaging people at the beginning, and digital gives the opportunity to do this in a much more evidence-based way, in a much more auditable way – in a way that you can actually track.”
So far, the DHC has found that the providers who have flourished through the pandemic have engaged with commissioners, insurers and front-line clinicians to meet their specific needs, rather than simply distributing plug-in platforms through central authorities. Indeed, more one-size-fits-all thinking is liable to replicate some of the same problems.
But at least we know generic appointments are happening. How, for instance, do we record interactions with apps that address people’s needs without requiring them to speak with a doctor? “That’s a really, really good health outcome,” says Kendall. “And yet, it’s not really a consultation, so we’re not counting it, and, therefore, it doesn’t exist.” And that which doesn’t exist rarely gets funding.
There are exceptions. Mackwood relates how his previous role at a subscription-based health maintenance organisation allowed him to focus on providing remote care in ways that didn’t need to fit into the typical US fee-for-service framework. But even at a rural telemedicine leader like Dartmouth- Hancock, prior to the pandemic, phone visits, not being reimbursable, weren’t available either.
Mackwood hopes we’re not going back to that world. From highs of around 3,000 virtual visits a day, Dartmouth-Hancock is back down to around 600 – which, as Curtis notes, is still a lot more than eight – the pre-Covid average. From a business perspective, the system is comfortable with supporting as much as a quarter of all consultations virtually, but both doctors expect a wave of research, data and publicity to start to impact those calculations soon. Things go viral quickly.
Dartmouth-Hitchcock’s increase in outpatient virtual visits through February–March 2020.
Dartmouth-Hitchcock Health System
People in the UK waiting for secondary appointments by the beginning of 2021, up from 4.5 million in February 2020. Digital Healthcare Council