In the wake of this entire COVID-19 tragedy, there was this tiny glimmer of hope, and this was the birth of telemedicine.
For many years, physicians have tried to make telemedicine a part of routine medical care. Telemedicine has been helpful for patients in remote areas who need consultation from specialists who were not available locally. Studies have also demonstrated that telemedicine has been helpful for routine postoperative care, especially for patients who did not want to travel long distances for a simple hernia wound check. Patients were happy to avoid the drive, and care was not compromised.
The major barriers to telemedicine have been the technology and reimbursement. Although we all have smartphone and laptop technology, the more complex machinery is less available, and likely too expensive for everyday use. Although smartwatches can track cardiac arrhythmias, monitor activity, and even record data to a central place, it is not exactly a visit with a physician. There are telerobots and technology that may allow physicians to listen to the heart and lungs with telemedicine stethoscopes. However, remote and rural places will probably not have the capacity for such technology. More mainstream telemedicine with just telephones and computers exists, but companies running these programs have fees, and physicians have been hesitant to invest in these when they may not get reimbursed for their efforts.
In terms of reimbursement, insurance providers have been hesitant to support this and have variably set up payment structures, but at a snail’s pace. They are skeptical that the physicians are going to practice medicine adequately and have not put a consistent price on how much doctors should get paid for this seemingly noncontact patient care.
Then, pandemic. There was a momentary asystolic pause in medical care while we tried to regroup and figure it out—and then telemedicine was born. It was a crash cesarean section kind of birth but a birth nevertheless. Our medical center suddenly gave access to a telehealth system for the entire physician staff at “no” charge. They did not want patients coming to the campus or getting near the tents outside the emergency department where workers were screening the symptomatic COVID-19 don’t-wannabes. Everyone stay home.
Two days after this started, we received a notice from the billing company listing all of the commercial insurance providers and their billing structure for telemedicine. This was based on “conversation length” to include the number of minutes spent on the phone including base visit (10 minutes), short extended visit, long extended visit and maximum visit (15 minutes) as well as the amount they will reimburse for each visit.
We think we are golden. We can lock ourselves in the office, sit down, not wear a mask, and see patients. This should be easy.
Yesterday, I saw five or six patients via telehealth and this was anything but easy. Patients were called beforehand, and the staff explained how to download the app on their devices. This was difficult, as the vast majority of my patients were above 65 years of age, frail, non–English-speaking and/or severely technologically challenged. My staff got an earful: Why can’t I just come in? Can you teach me how to download things on my phone? Where is the button to turn on the volume? Why can’t we just FaceTime like I do with my grandkids? I don’t have a smartphone. Can we still do this? My staff had suddenly become IT support or the Apple Store geeks.
After the app was downloaded and I invited a patient to participate in this telehealth meeting, there came the wait. (And “wait” is a four-letter word to a surgeon.) This was anywhere from five to 20 minutes, which I have come to define as “tech skills index.” Some patients had to call my office on another phone to get more instructions; some pressed every button until we were fully disconnected; and sometimes by sheer serendipity, the right combination of button pressing yielded both a picture and sound. I had to bring one patient into the office for a 45-minute visit in which I also fixed her phone—no charge. I knew we were in trouble when her first question was, “What’s an icon?”
When we begin the telehealth visit, I am happy that the patients can both see me and hear me perfectly. On the other hand, I am mostly looking at their ceilings, the high shelf or light fixture, or perhaps the top of their heads depending on where the phone camera is pointing. Sigh. “Can you please move so I can see you?” “But we don’t know where the camera is!” Patients didn’t feel like they were seeing a physician but more like it was a FaceTime visit with a friend, so they started rambling about their relatives, telling me about their dog—all while seeing half-dressed family members and sometimes a pet in the background. When I asked what medications they were taking, there was a pause, a white screen, and I realized that they had left to find the pill bottles. Then when I asked to see a wound, they tried to point their phone at it, and suddenly I felt like a bar of soap in their shower scanning over their whole bodies. I was thankful this was not a hemorrhoidectomy.
For each visit, I took notes, recorded the time, and tried not to be frustrated. Documentation was puzzling. There was not much of a physical exam, since I could not exactly touch anything. I saw some things: The patient seemed to be breathing because they were talking to me; they didn’t look jaundiced despite the weird lighting in the room; and the wound looked OK. I learned some other things: People have a lot of clutter in their homes; two people trying to get into a camera means I’m just seeing the space between them; and it’s tough to draw pictures to explain surgery with this paradigm.
More confusing: How will I bill for this? I spent 30 minutes with some patients; 20 minutes of it were spent fighting with the technology on their end. I did hear their voices for some of those minutes, but does that count? Is it face-to-face time? I did not always see a face because they could not seem to figure out where the camera was located. So does face-to-top of head count in those minutes?
Telemedicine can be a helpful tool especially in the face of a pandemic. However, its value is best for routine follow-up visits and perhaps those areas of medicine that call for verbal and visual care only. If you have a new problem—bleeding, a new lump, severe pain or something dire—forget telehealth. That computer screen is not going to stop bleeding, drain pus, or determine whether you need an operation. When it comes to surgery, the human touch is important. Even in a pandemic crisis where face-to-face contact is discouraged and social distancing is practiced, some patients just need real surgical care and not a TV doctor.
Dr. Wong is a professor of surgery at the University of Hawaii Cancer Center, in Honolulu.