Establishing virtual care as an accepted part of the healthcare system as a result of the COVID-19 pandemic is fundamentally changing not only where care is delivered but also how.
The implications of this for physicians and patients were discussed during a panel discussion at the ViVE 2022 conference this week in Miami Beach. While all speakers were from the US and the discussion was framed in the context of the US healthcare system much of what was said had direct relevance to Canadians.
“Pre-pandemic was mainly just telehealth,” said Carrie Nixon, managing partner in Nixon Gwilt Law and moderator of the panel discussion. “Right now, we’re in a space where virtual cares is encompassing remote patient monitoring … chronic care management services … asynchronous communication and artificial intelligence algorithms and applications.”
Commenting on the impact of changes in delivery forced on the system as a result of COVID-19, panelist Dr. Kyna Fong (PhD), CEO and co-founder of Elation Health said “not unexpectedly, there’s been a huge upswing in adoption of virtual care in independent (physician) practices. I’d say over two thirds of our clinics have incorporated virtual care into their regular everyday delivery of care for patients.”
Similar to what has happened in Canada, Dr. Fong observed that during the pandemic payment for virtual services has been on parity with delivery of in-person services for fee-for-service physicians. But she also noted that physicians using other payment models were already using virtual care and interacting asynchronously with patients.
As in Canada, where primary care physician advocates stress the value of a longtitudinal, comprehensive relationship, Dr. Fong said virtual interactions required due to the pandemic were seen in many instances to strengthen this relationship. “Some physicians would tell the story of having their first telehealth visit and finally seeing what their (the patient’s) home looks like or show them the way they kept their meds.”
Another panelist, Dr. Tania Elliot, chief medical officer for virtual care, clinical & network services, Ascension Healthcare, confirmed this beneficial aspect of virtual care. As an allergist, she said the ability to use virtual care with thousands of patients and see into the patient’s homes was “transformational”.
“For respiratory disease in particular, one of the most important things we could do for patients is understand their home environment and understand what might be triggering their respiratory symptoms. “ By doing a live walkthrough of patients homes in virtual visits or viewing the information asynchronously, Dr. Elliot said, she was able to assess ventilation, heating and other issues that can impact respiratory care and as a result better manage their condition and reduce the medications they required.
Additionally, she said, patients who were victims of domestic violence and unwilling to have an office visit were able to share their story in a way that otherwise would have been totally missed.
“I felt like telehealth really enabled me to see people living their daily lives,” said Dr. Elliot. “Telehealth is not just about access and convenience, it’s about longitudinal care delivery.”
However, Dr. Elliot acknowledged that not all physicians have had the same “eye-opening” experience with telehealth and its unrealistic to expect them to be at the same maturity level in providing virtual visits. Also – as in Canada – she said there are ongoing concerns about whether virtual visits will continue to be reimbursed adequately going forward.
Overall, Dr. Elliot said “when we’re asking physicians and practices to do more telehealth, we have to recognise that that is going to require change management and workflow related changes and perhaps interacting with different types of technologies. We have to think through the lens of the patient experience, the physician experience and the office staff experience if we’re going to expect that our physicians are now engaging in this hybrid care model (of virtual and in-person care).”
Panelist Dr. Roy Schoenberg, president and co-CEO of American Well, said one needs to appreciate the “visceral” impact telehealth can have on people by allowing them to experience care in their own environment. Another big change, he said, is that virtual care now is not just providing a channel such as the phone or video for the physician and patient to communicate but is also enabling other technologies to enhance the delivery of care.
A very important implication of this, said Dr. Schoenberg is that health care is now expanding beyond the 0.01% of the time when the patient directly interacts with the clinician in the office. With remote monitoring devices and automated technologies, he said, a much larger part of the patient’s life becomes part of the healthcare that surrounds person on an ongoing basis.
“The transition from looking at telehealth as a where healthcare happens to how health care is being rendered is the change,” he said.
On the issue of digital literacy and whether some patient populations are being disadvantaged by the growth of virtual care, Dr. Elliot cautioned against imposing one’s own perceptions and assumptions on these groups. She said data from her organization showed socially vulnerable patients from disadvantaged areas as identified by zip code used virtual care to the same degree as other populations. “We can assure these patients have access to virtual care,” she said, be it through family members, libraries or whatever.
“It’s incumbent upon us to problem solve for patients,” Dr. Elliot said. “We’ve seen 50% fewer no show rates for virtual visits than in person visits. People will figure out a way to access their doctors. We need to give them the tools to do that.”
However, panelist Dr. Geeta Nayyar, a rheumatologist and executive medical director at Salesforce stressed there was still a need to find the right balance about when to deliver care virtually and when to do it in-person. “Bladder surgery cannot be done on Zoom,” she said.