Telemedicine Tales: Let's Reschedule When You're Not Shopping

May 20, 2020

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Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center, and I blog at Common Sense Family Doctor.

Before COVID-19, my experience with telehealth was limited to patient portal messages, telephone calls on evenings and weekends, and the occasional patient emailing a photo of a rash. All of my tried-and-true techniques for building rapport with patients involved physical proximity. I entered an examination room, greeted the patient (often shaking hands), sat down on my stool, then slid close to the patient sitting in a chair or on the examining table, deliberately ignoring the computer on the desk and not breaking eye contact for the first few minutes of the visit.

The past 2 months of primarily doing video visits has been a big adjustment. Frankly, billing for virtual care has been the easiest part. Now the computer in the room is impossible to ignore; I not only sit in front of it to chart, as I always have, but I open the app that I use to connect with patients. If there are no technical glitches (and there have been lots), the beginning sequence goes more or less like this: The patient appears on my screen, I introduce myself and verify his or her date of birth, and then I apologize for my awkward camera configuration that makes it appear as if I'm looking away from the patient. I still try to type as little as possible during the visit and close other open screens to keep distractions to a minimum.

At Home at The Home Depot

During virtual visits, most patients are situated in quiet, private places: home offices, bedrooms, tastefully appointed living rooms. But I have also visited patients in moving vehicles (not driving themselves) and in the aisles of discount warehouses and home improvement stores, places that make patient confidentiality a challenge and a video examination that requires disrobing out of the question.

I will admit that video visits offer advantages. Now I can ask the older patient who is unsteady on his feet to show me the layout of his home to identify potential fall hazards on camera. If a patient can't recall the name of a prescription that needs refilling, I can ask her to just go to her medicine cabinet to retrieve the bottle. I can see for myself the animal companions that have been keeping them sane in a locked-down world. For patients without cars who would otherwise need to pay for a taxi or take risky public transportation, these types of visits make complete sense if they don't need a full physical examination or laboratory tests.

No-Shows and Awkward Angles

Telehealth has caused some logistical issues. Rather than being checked in when they arrive at the office, patients are virtually checked in at the time they schedule the appointment. Our medical assistants call patients earlier on the day of their appointment to elicit their reason for the visit and any self-recorded vital signs (temperature, weight, blood pressure). But when the virtual waiting room is someone's home, the patient might be doing dishes or weeding the garden, and the medical assistant doesn't always get through.

When I'm ready to see the patient, I send a video invite link in an email and text, but if the patient doesn't connect promptly, I can't be sure whether they are "no-showing" because they forgot about the appointment, forgot to cancel, or are just having technical issues. Finally, depending on the line of sight of the patient's phone or computer camera and the quality of the connection, I can have a hard time reading body language, or in some cases, facial expressions. During one memorable visit with a less-than tech-savvy patient, all that I could see was the top of her head. It was effectively a telephone encounter plus scalp exam.

A Menu of Medical Visits?

I am looking forward to the time when patients and doctors can determine whether in-person, video, or telephone visits best meet their mutual needs, rather than having this dictated by public health emergencies or inflexible payment rules. My practice has begun billing insurance for patient portal conversations that involve evaluation and management services, which I think is long overdue. Some doctors have suggested that, going forward, telehealth and prospective payment models should facilitate more efficient, effective management of chronic conditions such as hypertension.

We need to make sure that vulnerable patients with low digital literacy and limited online access aren't left behind. The past months have made me realize, though, that contrary to my expectations, it is possible to create and strengthen healing relationships in telehealth encounters, or what some family physicians recently called "physical distancing with social connectedness."

Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician.

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