May 14 2020

It’s Time for Telehealth

Perhaps one of the positive outcomes of the pandemic is an acceleration of acceptance of telehealth and telementalhealth – treating patients online instead of in person. For example, we have been trying to institute telehealth where I work for years, but have met with roadblocks. Then, all of a sudden, we were able to do it. Our clinic manager estimates that we accomplished in three weeks what would have otherwise taken three years. I have been doing mostly telehealth visits for the last two months now. It’s not perfect, but for many patients it is an ideal option.

The advantages are pretty obvious. A regular visit involves driving into a clinic (which may be in a city, and involves fighting traffic and finding parking), then checking in, and sitting in the waiting room until finally called. Then the meeting happens with the physician. Afterwards you go to check out, and then have to drive home. Depending on the length of the drive, you may spend 2 hours or more total time for 10 minutes of face time with the physician for an uncomplicated follow up visit. Compare this to signing onto an app from the comfort and convenience of your home, having the 10 minute visit over video, then you are done. This also means you are not sitting in a waiting room with potentially sick individuals. Many patients also have a difficult time getting to the clinic. They have physical limitations, and may even require special transportation to get there.

You can even do a limited physical exam over video. Anything that is purely visual and doesn’t require physical contact can be examined. But many patients do not require a physical exam as part of their follow up – their original exam was normal and there is nothing to follow. I see many patients with migraines, for example. Once it has been established that their headaches are indeed migraines (the workup, including exam, for other causes is negative) there is no need for any further physical exam unless something changes.

What are the limitations? As mentioned, the inability to do a full exam is the primary limitation. We also cannot obtain vital signs like blood pressure, temperature, pulse, and respiratory rate. Any visits requiring a procedure, like blood tests, vaccine, or other treatment, obviously have to happen in person.

What about just the therapeutic relationship between provider and patient? That was one serious concern, video is simply too impersonal. I think this has turned out to be a non-issue. Video is just fine for human communication. For telementalhealth visits this was really the only concern. Mental health does not require a physical exam. Visits may also be much more frequent, one or more times per week, and so the advantage is magnified. But concerns over the bond with the client were the primary stumbling block. This appears to be a complete non-issue as well. The studies we have so far show that telementalhealth has similar outcomes to in person visit, including this recent study of CBT for health anxiety. This is still a young field, and many different types of therapy will need to be tested in many conditions and situations, but so far no flags have been raised for remote mental health visits.

What’s interesting is that I went from zero telehealth visits to being forced to have almost all telehealth visits. The latter has been working well, but is also not ideal. I am looking forward to the post-pandemic world, where I can select which patients need to come into the clinic and which ones are optimal for telehealth visits. For patients who do not need an exam (that cannot be done over video), do not need procedures, and just need a conversation to monitor their therapy and make adjustments, telehealth is perfect. Another requirement is access to and comfort with the technology necessary to do it.  In my experience over the last two months, about 75% of patients manage just fine, even older ones who struggle a bit with the technology. If we had time to make the system more user friendly, had more infrastructure, and had more time to get patients onto the system, the percentage would be even higher.

I have some patients who have a really hard time coming into the clinic, and this leads to many no-shows. From a practical point of view, a telehealth visit is vastly superior to no visit at all. I can also see more patients over time then having to manage patients physically in the clinic. From an economic point of view, I am not taking up an expensive exam room, and expensive clinic staff and infrastructure. I am sitting at my desk at home. Another advantage is that it is much easier for me to see a patient quickly. If a patient is having questions or problems, I can set up a telehealth follow up the next day, something which is much harder to do in the clinic because of scheduling limitations.

In short, telehealth visits can be used for those patients who would benefit the most. It will also result in more visits than solely in person visits. I can see patients more quickly, more often, and with fewer no-shows. In my experience so far, most patients absolutely love it. Seeing their physician on video is enough of a connection, and the convenience is significant.

There is also a potential benefit to the whole system. If, let’s say, 30% of clinic visits were converted to telehealth, that is a 30% reduction in clinic-related traffic and parking, people checking into the clinic, using up staff resources, and sitting in the waiting room. That is also a 30% reduction in the need for exam rooms, which can be a limiting factor unto itself (as it is with our practice). If we extend this to other industries, really thinking about which tasks and jobs can be more efficiently accomplished online, we might take a huge chunk out of rush hour traffic and other resources, including our carbon footprint. A reduction in traffic also has a ripple effect, because it means for those who still have to commute, the drive is shorter, more efficient, and less polluting.

It’s hard to project how all of this will work out. There may be unintended consequences, for example. Collective behavior always seems to be more mysterious and complicated than we imagine, and the only way to really know for sure is to do the experiment. In this case, we were forced to do a massive experiment in telehealth and working from home. From my perspective, the telehealth experiment has been a clear success, and we need to take these lessons into the future, beyond the pandemic. At my practice, that is the plan. I will now have at least one permanent telehealth clinic session per week, and probably more in the future. This would not have happened without the pandemic.

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