The Doctor is In... Their Pajama Pants
Now that COVID vaccine numbers are rising and infection rates are dropping, most of us are emerging from our home offices like bears at the end of hibernation, and starting to see patients in person again. It’s a welcome return to something closer to normality, but the truth is, the old normal is probably gone for good. Telemedicine, in one form or another, is going to continue. Now is the perfect time to take a closer look at what it is--and isn’t--good for.
The drawbacks of telemedicine have been obvious from the beginning. It’s harder to gain the patient’s trust, especially if there’s no existing relationship to leverage. It’s impossible to do a decent physical exam. Lab tests, immunizations and warm handoffs to other team members are cumbersome and require additional visits. And for those of us who went into medicine largely for human connection, the lack of direct contact with co-workers and patients felt lonely, sterile and disconnected.
As the pandemic wore on, though, some unexpected benefits emerged. Patients loved the convenience, and were no longer wasting hours in transportation and waiting rooms to see their providers for fifteen minutes. No-show rates dropped dramatically. Check-in and rooming become more streamlined. Providers and staff no longer had to commute, and were more able to balance work with family needs. In some cases, we gained visual insight to patients’ homes, lifestyles and families that we might never have had.
By carefully considering those pluses and minuses, we can design a system that takes advantage of the best parts of telemedicine, while minimizing the worst. The first thing to decide is which visits work best online. Here are a few suggestions:
Routine follow-up for patients who are well-known to their provider. This would include many chronic care visits, as well as routine follow-up of acute problems with minimal risk of complication.
Minor acute problems not requiring in-person exams. Examples might include uncomplicated URI, minor musculoskeletal injuries, minor rashes, seasonal allergies.
Patients who have a difficult time coming in for appointments. This might include people with mobility and/or transportation issues, frequent no-shows, or care avoidance issues. Obviously, some of these patients might do better with an in-person visit, but if the choice is between a remote visit and no visit at all, the lesser of two evils is clear.
Newly-assigned well patients. This one is a little counter-intuitive. In an ideal world, new patients would see their PCP in person on the first visit. However, many are reluctant to come in for an “establish care” visit when they have no symptoms. A quick remote visit might be a low-investment way for them to meet their PCP and begin to build a connection.
Patients with a long list of problems. Expecting providers to address multiple issues in a brief visit creates frustration for everyone involved. On the other hand, requiring patients to come back for multiple visits can place an unreasonable burden on them. Handling some of their problems remotely benefits everyone.
Once we decide which patients can be seen remotely, we need to build the infrastructure to see them efficiently and effectively. At a minimum, we’ll need the following:
Schedulers who are trained to accurately choose the appropriate visit type (remote vs in-person) for most situations.
Time for care teams to review and adjust visit type on their schedules.
Staff support for remote visits that is quickly and easily accessed by providers: follow-up care and scheduling, RN and MA visits, lab, referral, diagnostics, education, counseling, etc.
Streamlined real-time communication between providers and the rest of the care team.
Home monitoring equipment and training for chronic disease patients (blood pressure cuff, glucometer, thermometer, accurate scale, etc.)
Billing policies and strategies that provide adequate, sustainable reimbursement.
Scheduling that allows providers to avoid commuting entirely on some days. On those days, they will need adequate time for chart review, management, follow-up communication and charting.
Virtual “water coolers” or “staff lounges” where remote staff can hang out or check in with each other.
Like anything else, telemedicine can be done well or poorly. But if we put the right system in place, continuing to devote some of our office visits to online care could be a win-win for everybody.
