Taking the Long View

The idea of doctors and patients communicating across a distance, via a video connection, is not a new one, Carl Cameron notes. But COVID-19 “opened the floodgates” to making it a reality for millions.

“The barriers that have always been there for telemedicine are, one, you had to be able to see the patient, and two, the reimbursement around it. But with COVID, all that got waived,” said Cameron, chief operating officer at Holyoke Medical Center (HMC). “And the governor came out and said, ‘look, for televisits and the phone, video, however you can get the visit done, and we expect the payers to pay for it like it’s an in-person visit.’”

So health organizations started doing just that. “We started with basic things like getting some iPads, getting some physician PCs set up, and then it was, ‘OK, what are we going to use for an application?’” Cameron said, noting that they started with a mixture of FaceTime, Google Meet, and a product known as Doximity.

“A lot of doctors are familiar with that; it meets all the security requirements of HIPAA in terms of being a secure channel,” he explained. “You basically send a link to the patient, and they just click it, and it creates the connection with the doc. It even uses a virtual telephone number for the doc, so it doesn’t have to be their actual cell phone. It’s a very easy process.”

Among the physicians pleased with the expansion of telehealth is Dr. Kartik Viswanathan of Holyoke Internal Medicine.

“Before the pandemic happened, we were seeing close to zero televisits. During the pandemic, we started doing televisits to reduce the number of people coming in. Infection was rampant, and at that time, we didn’t want people in the waiting rooms, and when seeing patients, we needed to be completely in PPE and masks.”

“The barriers that have always been there for telemedicine are, one, you had to be able to see the patient, and two, the reimbursement around it. But with COVID, all that got waived.”

So government did the right thing, he added, freeing up telehealth to be billed like a regular office visit. “Remarkably, it was very popular with patients. They loved it,” he said, noting that patients appreciated not having to drive to the office, and if a doctor was running late, it was OK, since they were at home. “They weren’t upset if they were 15 or 20 minutes behind.”

Cameron agreed. “We were using it wherever possible and where the government would allow us to get paid for it. Obviously, with COVID, nobody wanted to leave their house — as a country, we didn’t have a good understanding of how the disease spread; everyone was saying shelter in place, so people didn’t really want to go out.

As a result, practices saw significant dips in volume, he went on. “But as we put the telemedicine in place, I was eventually able to bring us up to just below pre-COVID numbers for office visits. We still had some patients, depending on the acuity, who needed to be seen in the office or the ER, but we were doing 75% to 80% of our visits via telemedicine.”

Viswanathan said having the distance alternative reduced anxiety in patients during a generally anxious time. “They were happy to see us. Even with COVID testing, people had so many questions, and just the fact they could speak with us, communicate with us, really relieved a lot of the anxiety for them.”

And now, with medical practices largely back open, albeit under strict safety protocols? “Televisits are here to stay,” he told BusinessWest. “As a provider, I find it convenient, and the patient finds it convenient. I think it will still be 20% to 30% of daily visits even after the pandemic is over.”

Pros and Cons

Viswanathan conceded that televisits aren’t the same as in-person visits, in a number of key ways.

“The challenges come when we don’t know the patients from before — when it’s a new patient we’ve never seen before. There’s a little discomfort level that I haven’t seen him. But for established patients and managing chronic illnesses, it’s just great,” he said.

“It can’t replace all office visits because we really need to see some patients — there are subtle signs we tend to miss if we’re seeing only through a camera. There are procedures we can’t do on a television. If they have a rash, that is not well-examined on television. Those are some challenges.”

Medical organizations have brought up technology access gaps as well, particularly among certain demographic groups. Health Affairs, an online publication of Project HOPE, recently reported that more than one in three U.S. households headed by a person age 65 or older do not have a desktop or a laptop, and more than half do not have a smartphone. While family members or caregivers can help, one in five Americans older than age 50 suffer from social isolation.

Access to technology is also a barrier in other ages and minority groups. Children in low-income households are much less likely to have a computer at home than their wealthier classmates. More than 30% of Hispanic or black children do not have a computer at home, as compared to 14% of white children.

“We evolved from doing it very quickly and responding to the pandemic — how do we keep our patients safe and get them the best care possible? — to asking, what does this look like going forward?”

Even on the provider side, organizations have work to do to fit telehealth seamlessly into traditional practices, Cameron said.

“We need to continue to beef up the infrastructure so that it allows for effective management of both televisits and in-person visits, so that the physician can be flexible,” he explained. “They can take a laptop, go into a room, do a normal visit with a person, do their documentation, and then, for televisits, go slide it into a docking station where they have two monitors up; they’ve got the documentation and can see the patient at the same time, right in front of them.”

Like other trends that evolved on the fly during the pandemic, like remote work (see story on page 22), telehealth may have served its purpose well during these chaotic months, but to make it a permanent fixture will require planning.

“We evolved from doing it very quickly and responding to the pandemic — how do we keep our patients safe and get them the best care possible? — to asking, what does this look like going forward? With the efficiency and effectiveness I saw with our practices, this is absolutely a tool we can continue to develop.”

One of the evolutions in Cameron’s organization may be a move toward expanding the use of Doximity, perhaps in conjunction with the Meditech web portal, where parients can schedule a telehealth visit on the latter, and the link is sent via Doximity.

“It’s not like the technology isn’t there, and it’s going to continue to evolve and move forward,” he went on. “But what’s made it a reality is now, you can get paid for it, and there’s some funding out there to beef up the infrastructure.”

Peace of Mind

While primary care and certain specialties are making strong use of telemedicine, behavioral health has been a particularly fertile field. The Mental Health Assoc. (MHA) began using its own platform, called TeleWell, through its BestLife Emotional Health and Wellness Center in January, just before COVID-19 arrived in the U.S.

Through TeleWell, clients could connect remotely with a clinician, recovery coach, or prescriber for varying times and frequencies.

“The response from the community has been positive, with many individuals requesting the ability to continue receiving services utilizing TeleWell in the future,” said Sara Kendall, vice president of Clinical Operations.

“The flexibility of MHA’s TeleWell best matches the ability of individuals to receive services, while also in a location of their choice, in which they are comfortable,” she added, noting that client feedback suggests a growing role for this model in the future. “The adaptive world of today has been a benefit to the critical to needs of tomorrow.”

MHA recently announced $13,333 in grant funding provided by Baystate Noble Hospital to advance Well Aware, an information and education initiative that aims to raise awareness of the availability of telehealth services to help people dealing with the challenges of opioid and substance use disorders in the Greater Westfield area.

“The ability to connect via TeleWell can be of critical importance for people who cannot partake of services in person due to the COVID-19 crisis, a lack of transportation, or concern about the stigma often associated with seeking help,” said Kimberley Lee, vice president of Resource Development and Branding for MHA, adding that TeleWell can be an important bridge to enable people to receive the care they need from the safety of their own homes, and that, for people with opioid and substance-use disorders who either wish to enter into recovery or are already in recovery, being able to keep regular appointments with a counselor is critical for them to achieve success in staying sober.

“This is especially important during the unprecedented COVID-19 pandemic, which has upended our society and created a new normal of social distancing,” said Ron Bryant, president of Baystate Noble Hospital. “This practice has resulted in large numbers of people who feel isolated from their families, their circle of friends, and their normal life’s routine. This in turn can result in anxiety, depression, loneliness, and an overwhelming sense of fear and uncertainty, all of which can be addressed through behavioral-health services.”

It’s not just behavioral-health professionals saying telehealth offers an easier and less anxiety-ridden experience, one that makes it more likely patients will keep their appointments. Cameron reports the same trend at Holyoke Medical Center’s practices.

“One thing we found was our no-show rates dropped dramatically,” he said. “It’s pretty easy for the patient. They’re notified at home, and all they have to do is connect. They don’t have to go anywhere.”

As offices reopened to the public, he continued, “we’re probably a mix now of 60% in office, 40% telemedicine. So it’s shifted a little bit, but our goal is to continue to push it as a tool for the providers because, in certain cases, it’s more efficient and effective. It’s actually quicker for the patient and provider.”

Cameron doesn’t expect demand to be an issue, especially as more patients try out a remote visit, he said, noting that a couple of family members recently scheduled televisits and were surprised how easy and effective a visit could be without having to go to the office.

“There’s a push by the state and the feds to keep this in place as a tool to connect with patients. There’s been a push to extend it, make it permanent as a way to get paid, and at the full rate of an office visit. There are definitely enough patients out there who want this.”

Generation Gap

Viswanathan agrees that patients have adapted to the technology. Even older patients, who might not be comfortable with technology, have responded positively when a family member or visiting nurse has shown them how to access it. “When they see the benefits and ease of using it, their acceptance just shoots up.”

Most physicians like having the option as well, Cameron said, noting its potential in on-call situations, when a doctor can send a patient a link and get connected quickly.

“It’s a great tool that gives us much more flexibility. So I don’t see this going away,” he told BusinessWest.

As COVID-19 cases subside, some practices are going back to seeing most patients in person, he noted, but HMC continues to reinforce the use of telehealth. “This is a tool we want to use for the right visits. We want to make sure we give the option to patients. And, as we beef up the technology around it, docs like it.”

One reason, Viswanathan said, is it opens up a practice’s business to patients who may live farther away than they’d like to drive on a regular basis. He also foresees a day when community centers are equipped with telehealth ‘booths’ where patients can transmit their information and be connected to a doctor.

“It will never replace a visit,” he added, “but I think there’s going to be so much innovation around this.”

Part of Cameron’s job will be to continue to educate providers on how telehealth can be an effective tool.

“We still have older docs not accustomed to using all the technology. Back in ’07, EMR was a challenge. Now we’re asking them to do person-to-person visits via telephone or video,” he said. “So I think we’re still early in the process, but I’ve seen tremendous benefit to this that I don’t think is going to go away. And our plan here is to continue to educate, build the technology around it, and make it easier and more efficient for our providers and the whole system.” u

Joseph Bednar can be reached at [email protected]