COMMENTARY

Can Telemedicine Survive? 5 Ways to Invest in the Future of Virtual Care

H. Jack West, MD

Disclosures

September 15, 2021

Telemedicine came onto the scene lightning fast in March 2020, when the COVID-19 pandemic led to nationwide lockdowns. Despite the impressive pace of adoption, telemedicine has an uncertain future. Specifically, it's unclear whether licensing and payment changes enacted in an emergency will persist in the months to come, and whether telemedicine really allows for the same level of care as in-person visits.

But it's important to emphasize that continuing telemedicine services does not have to be at the expense of in-person care. Rather, virtual visits can, and should, supplement in-person visits when appropriate. In fact, many oncologists have found telemedicine to be effective in a range of clinical scenarios.

At the same time, it's also valuable to reflect on why telemedicine is often viewed as the poor stepchild to in-person care. In essence, healthcare providers have spent decades honing the efficiencies of in-person encounters; telemedicine, on the other hand, was cobbled together with almost no planning, foresight, or training. From the practitioner or patient side, most of us were thrown into virtual visits with a cursory slide deck or mandated video, or no training at all. Even more unfortunate, 18 months into the pandemic, many healthcare systems have done little or nothing to improve training or refine the experience for patients and providers. With so little investment, of course telemedicine tends to suffer in comparison with the standard of in-person care.

Now, with the COVID delta variant surging to new heights worldwide, physicians and institutions need to consider telemedicine not as a last resort, but as a valuable tool to use alongside in-person care. With that in mind, here are five highly achievable strategies that can be implemented to overcome the headwinds this technology continues to face.

1. Overhaul state licensing requirements.

Our sclerotic, dysfunctional medical licensing system requires physicians to spend vast sums of money and dozens of hours to produce virtually identical paperwork for every state in which they plan to practice. Allowing medical licensing reciprocity across the United States represents an appropriate solution. Currently, the Interstate Medical Licensure Compact (IMLC) enables eligible physicians to streamline the process of practicing across state lines in 30 states, plus Washington, DC, and Guam. Of note, professional medical societies such as ASCO have pledged their strong support for the IMLC and implore all states to join.

2. Give doctors more support.

In the clinic, physicians typically benefit from working alongside nurses and advanced practice clinicians, and schedulers, all of whom help improve the efficiency and productivity of in-person care. In contrast, when it comes to telemedicine, physicians are far too often left to coordinate care — everything from helping patients figure out the virtual waiting room to completing telemedicine documentation. Incorporating similar support systems for telemedicine as for in-person visits can lead to far greater success and satisfaction for physicians and patients alike.

3. Ensure payment at parity with live visits.

At the start of the pandemic, the Centers for Medicare & Medicaid Services introduced sweeping changes to federal regulations for telemedicine that guaranteed coverage of dozens of services that could be delivered by telemedicine and reimbursed at parity with live visits.However, the future of payments for telemedicine visits remain an open question.It should be no surprise that physicians facing lower payment for their time for telemedicine visits will reliably favor maximizing in-person visits, even if a patient would be well served by a virtual visit. To encourage telemedicine use and minimize unneeded in-person visits, physicians need to be reliably reimbursed for their time. That means Medicare and private insurers should pay the same for telemedicine and in-person care.

4. Support patients and address disparities.

One leading criticism of telemedicine is the potential to increase healthcare disparities. Although it provides greater access for patients who need to travel significant distances or struggle to take time away from work, many patients may have communication and sensory challenges or lack the hardware, bandwidth, or technical facility to successfully navigate virtual visits.These concerns are justified, but many of these issues can also be addressed. Institutions, for instance, could provide patients with internet-enabled tablets featuring clickable icons to navigate directly to the telemedicine portal, a service likely to be sponsored by many companies. In addition, patients who need assistance with anything from connectivity to communication could find their way to decentralized, neighborhood-based "telemedicine stations," with personal support available as needed. These solutions are just a few examples of how we can overcome the current limitations of virtual care.

5. Help docs with "webside manner."

Whereas some of our kids may have been raised interacting with a screen for much of their lives, it may be a relatively unnatural process for most physicians. The nuances of creating a solid patient-doctor connection online require practice and learning how to translate in-person skills to a virtual forum. Good lighting and sound, optimal framing, eye contact with the camera, an appropriate setting with good bandwidth and without clutter are all important components to the telemedicine experience. Beyond these pragmatic tips, such strategies as acknowledging the awkwardness of communicating through cameras to introducing pauses that can help elicit thoughtful answers from patients are teachable skills that have proven helpful.Physicians (and patients) need time and practice to adapt to a new platform, and they will become more adept with experience.

I'd like to give an honorable mention to the need to clarify malpractice insurance coverage of telemedicine, which is increasingly being addressed but, I believe, remains a source of trepidation for physicians.

I'll underscore that I don't expect telemedicine to be the solution for every patient and clinical setting, and physicians will demonstrate varying degrees of proficiency and eagerness to incorporate into their practice. But these five strategies can serve as attainable ways to allow telemedicine to contribute meaningfully to a new era of healthcare.

What do others think? Do many feel "that dog just won't hunt" and that telemedicine should only be reserved for emergency use? What are some of the other important bottlenecks I've overlooked?

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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