COMMENTARY

Telemedicine Beyond the Pandemic

H. Jack West, MD

Disclosures

July 06, 2021

Telemedicine was pressed into service by necessity to reduce the spread of COVID-19. But now that minimizing exposure to the virus and a need for social distancing are no longer prevailing concerns, what role should this technology play in clinical practice?

Prior to the pandemic, healthcare providers cited an abundance of barriers to adopting telemedicine in clinical practice. The Centers for Medicare & Medicaid Services made temporary changes to telemedicine payments in 2020 by offering payment for telemedicine at parity with an in-person clinic visit. In some states, private payers were required to reimburse at the same rate of an in-person visit. Regulators also eliminated penalties for communication with patients that may not be HIPAA compliant.This critical step — combined with the urgent necessity to reduce live visits in many places due to the threat of SARS-CoV-2 transmission — led telemedicine to be instantly adopted, accounting for more than half of all medical visits in some clinics.

But for most, this was the minimum viable version of telemedicine. We hastily launched video platforms with suboptimal user interfaces for both physicians and patients. Patients with lower healthcare literacy, older patients, and those of lower socioeconomic classes were especially likely to be left behind by telemedicine. Physicians accustomed to working efficiently in a clinic found themselves in a telemedicine-based alternative with minimal staff support.

Where Are We a Year Later?

Some physicians and patients reported good satisfaction with the quality of telemedicine encounters. However, many doctors felt that there was a fundamental flaw that could undermine telemedicine's broad adoption: the inability to forge an emotional connection through a computer screen.

Institutions were also wary about committing to telemedicine because it is unclear whether or when the provisional telemedicine-facilitating changes enacted in licensing, privacy restrictions, and reimbursement will be reversed.

This could explain in part why the use of telemedicine has started to recede, although it remains above where it was prior to the pandemic.

Yet, there is largely bipartisan political support for telemedicine, including mounting momentum for Amazon Care, the telehealth program Amazon is creating for its employees nationwide.

This leads me to believe that while we may not solve all the practical challenges of telemedicine, there is a clear will to reduce them.

The user experience is bound to improve beyond the rushed versions thrown into the marketplace last year. The team-based approach of well-functioning clinics can be replicated in a virtual clinic setting. Technological and administrative changes may have to be permanently adopted. For example, routinely providing assistance to help less tech-savvy patients in a virtual waiting room could reduce the risk for aborted virtual visits.

People can adapt.

I remember the first time I saw someone who looked like my grandmother pull out her cell phone to text someone as soon as our plane landed. Texting may have been incredulous in its early years, but today it isn't even noteworthy. Telemedicine may be the next technology to become interwoven into our lives.

An Opportunity to Address Disparities

The potential for telemedicine to widen the disparities in healthcare delivery is a concern, but I believe it offers an opportunity to reduce them if applied well.

Telemedicine could help patients who cannot easily manage the hurdles of visiting the clinic for an appointment (eg, time off work, transportation), only to see a physician for a brief exchange.

The digital divide is also a legitimate concern. But we should acknowledge that we haven't even proposed a solution to this problem. For example, we could use an empty retail space in a shopping mall to create a neighborhood telemedicine center with fast internet and reliable audio/visual hardware.

The difference between widening or reducing the disparities in healthcare is purely a reflection of our will to address them. Ultimately, I anticipate that the benefits of telemedicine will become undeniable and the practical issues will recede or be eliminated.

Utility May Be Decided by Patients

When all is said and done, I suspect that the bottleneck in telemedicine will be reflective of how well, or poorly, telemedicine represents a patient's vision of healthcare.

While there is no question that a physical exam cannot be replicated with telemedicine, most of my colleagues say its benefits are substantial enough to support it going forward, at least for a minority of patients. Most feel that telemedicine is best suited for patients who are seeking second opinions, or for those who are stable and generally doing well on either surveillance or oral medications.

Some feel that telemedicine is a less gratifying experience and that it limits the interpersonal connection between physician and patient. While I appreciate that perspective, I think that our ability to connect is not necessarily undermined by telemedicine. We have interacted in person for millennia, but we have only just begun to do so through a screen. We must give ourselves time to improve.

The utility of telemedicine may ultimately be decided by patients. Even though it may be easier for a physician to see a patient in the clinic, the unilateral burden of these visits rests with the patient and family members. We should expect that many will favor a telemedicine option if presented with the opportunity.

H. Jack West, MD, associate clinical professor and executive director of employer services at City of Hope Comprehensive Cancer Center in Duarte, California, regularly comments on lung cancer for Medscape. Dr West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing education programs and other educational programs, including hosting the audio podcast West Wind.

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