Perspectives

Is telemedicine here to stay?


 

It has its limits

BY BYRON P. VAUGHN, MD, MS

The post-pandemic world will include telehealth. Technology disrupts business as usual and often brings positive change. But there are consequences. To employ telehealth into routine care equitably and effectively within a gastroenterology practice, we should consider two general questions: “Was the care I provided the same quality as if the patient was seen in person?” and more broadly, “am I satisfied with my practice’s implementation of telehealth?” This perspective will highlight several areas affecting gastroenterology care: lack of physical exam, disproportionate impact on certain populations, development of a patient-provider relationship, impact on physician well-being, and potential financial ramifications. We will all have to adapt to telemedicine to some extent. Understanding the trade-offs of this technology can help us position effectively in a gastroenterology practice.

Byron P. Vaughn, MD, MS, is an associate professor of medicine and codirector of The Inflammatory Bowel Disease Program in the division of gastroenterology, hepatology, and nutrition in the department of medicine at University of Minnesota, Minneapolis.

Dr. Byron P. Vaughn

Perhaps the most obvious limitation of telemedicine is the lack of vital signs and physical exam. Determining if a patient is “sick or not” is often one of the first lessons trainees learn overnight. Vital signs and physical exam are crucial in the complex triaging that occurs when evaluating for diagnoses with potentially urgent interventions. While most outpatient gastroenterology clinics are not evaluating an acute abdomen, in the correct context, the physical exam provides important nuance and often reassurance. My personal estimate is that 90% of a diagnosis is based on the history. But without physical contact, providers may increase costly downstream diagnostic testing or referrals to the emergency department. Increasing use of at-home or wearable health technology could help but requires system investments in infrastructure to implement.

Telemedicine requires a baseline level of equipment and knowledge to participate. A variety of populations will have either a knowledge gap or technology gap. Lack of rural high-speed Internet can lead to poor video quality, inhibiting effective communication and frustrating both provider and patient. In urban areas, there is a drastic wealth divide, and some groups may have difficulty obtaining sufficient equipment to complete a video visit. Even with adequate infrastructure and equipment, certain groups may be disadvantaged because of a lack of the technological savvy or literacy needed to navigate a virtual visit. The addition of interpreter services adds complexity to communication on top of the virtual interaction. These technology and knowledge gaps can produce confusion and potentially lead to worse care.1 Careful selection of appropriate patients for telemedicine is essential. Is the quality of care over a virtual visit the same for a business executive as that of a non-English speaking refugee?

The term “webside manner” precedes the pandemic but will be important in the lexicon of doctor-patient relationships moving forward. We routinely train physicians about the importance of small actions to improve our bedside manner, such as sitting down, reacting to body language, and making eye contact. First impressions matter in relationship building. For many of my established IBD patients, I can easily hop into a comfortable repertoire in person, virtually, or even on the phone. In addition, I know these people well enough to trust that I am providing the same level of care regardless of visit medium. However, a new patient virtual encounter requires nuance. I have met new patients while they are driving (I requested the patient park!), in public places, and at work. Despite instructions given to patients about the appropriate location for a virtual visit, the patient location is not in our control. For some patients this may increase the comfort of the visit. However, for others, it can lead to distractions or potentially limit the amount of information a patient is willing to share. Forming a patient-provider relationship virtually will require a new set of skills and specific training for many practitioners.

Telehealth can contribute to provider burnout. While a busy in-person clinic can be exhausting, I have found I can be more exhausted after a half-day of virtual clinic. There is an element of human connection that is difficult to replace online.2 On top of that loss, video visits are more psychologically demanding than in-person interactions. I also spend more time in a chair, have fewer coffee breaks, and have fewer professional interactions with the clinic staff and professional colleagues. Several other micro-stressors exist in virtual care that may make “Zoom fatigue” a real occupational hazard.3

Lastly, there are implications on reimbursement with telehealth. In Minnesota, a 2015 telemedicine law required private and state employee health plans to provide the same coverage for telemedicine as in-person visits, although patients had to drive to a clinic or facility to use secure telehealth equipment and have vital signs taken. With the pandemic, this stipulation is waived, and it seems likely to become permanent. However, reimbursement questions will arise, as there is a perception that a 30-minute telephone call should not cost as much as a 30-minute in-person visit, regardless of the content of the conversation.

We will have to learn to move forward with telehealth. The strength of telehealth is likely in patients with chronic, well controlled diseases, who have frequent interactions with health care. Examples of this include (although certainly are not limited to) established patients with well-controlled IBD, non-cirrhotic liver disease, and irritable bowel syndrome. Triaging patients who need in-person evaluation, ensuring patient and provider well-being, and creating a financially sustainable model of care are yet unresolved issues. Providers will likely vary in their personal acceptance of telehealth and will need to advocate within their own systems to obtain a hybrid model of telehealth that maximizes quality of care with job satisfaction.

Dr. Vaughn is associate professor of medicine and codirector of the inflammatory bowel disease program in the division of gastroenterology, hepatology, and nutrition at University of Minnesota, Minneapolis. He has received consulting fees from Prometheus and research support from Roche, Takeda, Celgene, Diasorin, and Crestovo.

References

1. George S et al. Stud Health Technol Inform. 2013;192:946.

2. Blank S. “What’s missing from Zoom reminds us what it means to be human,” 2020 Apr 27, Medium.

3. Williams N. Occup Med (Lond). 2021 Apr. doi: 10.1093/occmed/kqab041.

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