Reimagining Patient Care with Telemedicine During the COVID-19 Pandemic

Meredith Summa, Princeton University

Introduction

Trust is the cornerstone of driving access for patients. As a patient and physician, one of the most important conversations I had was on a phone with my surgeon. He called me one afternoon after my clinic hours to determine whether I need to proceed with surgery. Given his limited office hours and our distance, the phone call was the only option at the time. The call was pivotal in my decision to proceed to surgery and his clear consise yet compassionate discussion made the decision clear for me. But how was he able to create this for me via a phone call? And how can we train future healthcare professionals to do the same?

The implementation of social distancing regulations in the face of the coronavirus pandemic has driven us to find new ways to communicate with one another, whether it be virtual meetings, birthday parties, or even doctor’s visits. With the virus bringing hospitals to capacity, the way patients are cared for has had to change. At UC Davis Medical Center, one patient, 81 year old Suren Vaniyev, was able to connect with his family for the first time after 40 days of intensive care for acute respiratory distress syndrome caused by the coronavirus through UC Davis Health’s Virtual Visit Program.[1] Normally, this technology is used as a network to facilitate communication between Northern Californian hospitals, however it has now become an essential tool for connecting patients to their families and teams of healthcare providers, with the leader of the program, Jennifer Rosenthal, stating, “If ever there was a perfect match for patient care and technology, this is it.”[2] Telehealth has proven to be exceedingly important during the COVID-19 pandemic and has the potential to become a cost effective, efficient, and high-quality service that is a welcome addition to our healthcare system. However, issues including the preservation of the doctor-patient relationship, access, and privacy must be addressed through effective and streamlined tele training to improve the quality of care in virtual visits and make telemedicine mainstream in the eyes of both clinicians and patients. 

Benefits and Challenges to Telemedicine

Telehealth is efficient and effective when it is properly implemented, connecting doctors to doctors, patients to patients, patients to doctors, and, during the pandemic, patients to families, thus supporting continuous and holistic treatment for a patient. Connected medicine technology has already proven to be successful. The VHA implemented the Home Health Program for Veterans, which is conducted entirely through virtual meetings. According to a survey taken by 17,025 participants in the program receiving care for one or more chronic illnesses, patients responded with high levels of satisfaction with the program and 19% fewer admissions to the hospital. Telehealth has also been used to monitor congestive heart failure patients’ weight, heart rate, blood pressure, and pulse oximetry. Through a Partners HealthCare program, upwards of 3,000 CHF patients are monitored in this way, reporting fewer hospitalizations and fatalities. Furthermore, remote care for ICU patients has resulted in reduced costs, a 30% decrease in the length of stay in the hospital, and a 20% decrease in mortality according to studies conducted by the University of Massachusetts Memorial Medical Center and the NEHI.[3]

During the coronavirus pandemic, meeting with doctors virtually can actually aid in preserving humanistic care. According to the dean of Stanford Medicine, patients diagnosed with COVID-19 are met with doctors in full PPE: face shields, gowns, masks, and gloves. Seeing a physician by way of an iPad and being able to read their facial expressions enhances the human connection, as well as being safer for the clinician and conserving safety equipment.[4] The article also notes the huge spike in telehealth implementation: “Recently, Stanford Medicine's health care delivery system conducted approximately 3,000 ambulatory video visits in a single day—a 50-fold increase over our baseline rate.”[5] The benefits to connected medicine technologies are numerous, providing patients with quality care at a reduced cost and have become indispensable due to the current public health crisis. 

Human to Human Connection

One of the major limitations to telehealth services is the inherent detachment of virtual communications. Maintaining the doctor patient relationship through a computer screen requires the active employment of humanistic skills that come naturally in traditional face to face interactions. The importance of the human connection in medicine is not to be understated, with researchers finding that:

“Positive correlations associated with a trusted physician-patient relationship include treatment adherence, longer provider relationship, and perceived effectiveness of care. Negative correlations associated with a distrustful physician-patient relationship are lower rates of care seeking, preventative services and surgical interventions.”[6]

Virtual visits could change the trust-based relationship between a patient and healthcare provider, turning it into a contractual relationship, making healthcare into a series of disjointed encounters rather than a continuous therapeutic relationship.[7] Additionally, although the efficiency of healthcare technology has made communication easier, when conversations between doctors and between doctors and patients are replaced by it, doctors become isolated, promoting burnout and a decrease in morale which is to the detriment of humanistic medicine.[8] The doctor-patient rapport is much more than just a transaction. Human connection significantly impacts a patient’s prognosis and the relationship between healthcare provider and patient is essential to modern medicine. During times of struggle and distress in a patient's life, it is these empathetic encounters that truly make a difference.[9]

To ensure the doctor-patient relationship is preserved, clinicians must apply evidence-based strategies to maintain the human connection in virtual appointments. Researchers at the University of Michigan have outlined four major guidelines to foster humanism in virtual settings: “(1) Before the Visit: Set up for Success, (2) Beginning the Visit: Establish a Connection, (3) Throughout the Visit: Invest in the Relationship and the Patient’s Story, and (4) Completing the Visit: End on a Meaningful Note.”[10] The first guideline recommends that doctors have a routine in preparation for each virtual appointment, such as making sure to review a patient’s chart and medical history and checking technology function. The second guideline relates the importance of establishing a rapport with the patient from the start of the appointment, recommending that doctors make a formal introduction as they would in person to garner trust, ask the patient what they are comfortable discussing due to privacy concerns, and agree upon the goals of the virtual appointment. The third guideline emphasizes the importance of body language in communicating empathy: eye contact, sitting up straight, and validating a patient’s emotions and needs. Because a virtual visit gives insight into a person’s home life, doctors should take care in assessing a patient’s environment, looking for signs of housing insecurity, domestic violence, substance abuse, and food insecurity. The final guideline focuses on the successful completion of the appointment. Doctors are encouraged to restate what was discussed during the appointment and establish a follow up plan for future interactions, explaining the options the patient has within the healthcare system.[11] These simple strategies can easily transform a detached, transactional online interaction into holistic and humanistic care.

Addressing Privacy and the Digital Divide

As expounded upon in “Covid-19 and Health Care's Digital Revolution: NEJM,” one of the major barriers to the widespread adoption of telehealth technology is maintaining privacy virtually in accordance with HIPAA regulations. According to the article,  

“In a 2019 Price Waterhouse Cooper survey, 38% of chief executive officers of U.S. health care systems reported having no digital component in their overall strategic plan; 94% of respondents pointed to data-protection and privacy regulations, the Health Insurance Portability and Accountability Act (HIPAA, 1996), and the expansion of HIPAA rules and penalties under the Health Information Technology for Economic and Clinical Health (HITECH) Act (2009), as factors limiting implementation of digital strategies.”[12]

In response to the pandemic, however, Congress lifted restrictions to access for metropolitan recipients of Medicare. The Office of Civil Rights at HHS has also decided to not penalize the use of “HIPAA-noncompliant private communications technologies to provide telehealth services during this public health emergency.”[13]Due to the changeable nature of the regulatory environment, clinicians need to be informed of the updated standards of privacy for telehealth through efficient means of transmission such as webinars, workshops, and newsletters.[14]

Access to adequate bandwidth and connectivity is essential for the success of telemedicine technologies. Although telehealth has the potential to reach a wide range of populations, patients in vulnerable and underserved groups may be unable to afford the technology required. Furthermore, some populations, especially elderly patients, may be uncomfortable with telemedicine software and will need adequate training in order to benefit from telecare. These disparities have the potential to create a “digital divide” that excludes these populations.[15]  To help avoid and bridge this divide, the American Medical Association has outlined ways that healthcare providers can adequately prepare for virtual appointments and ensure telehealth technology is feasible on a case by case basis. According to the AMA Telehealth Quick Guide, healthcare providers should conduct patient surveys to assess access to adequate bandwidth and the privacy of a patient’s home environment. Healthcare providers should make sure they schedule time for virtual appointments, have a quiet and private space to conduct telemedicine visits, and document these visits as they would any other appointment.[16] Only with proper assessment and training can telehealth technologies be truly accessible.

Telehealth Education and Training

According to a survey of family physicians, 41% reported that the largest barrier to the widespread use of telehealth technology is a lack of training.[17] However, in the current public health crisis, the rapid adoption of telehealth is unavoidable, with Massachusetts community health centers reporting an increase in telehealth services from 506 to more than 83,000 in the first months of 2020.[18]  The medical school curriculum must be altered to accommodate adequate training for telehealth technologies in addition to traditional high touch healthcare services, including training in digital literacy, telehealth privacy regulations, and fundamental health technology skills[19], as well as training in performing virtual examinations such as assessing a patient’s body language and physical appearance.[20] These skills cannot be learned simply by reading about them. Instead, proper telehealth communication should be enforced through “application, feedback, and practice,”[21] for example by students performing mock virtual exams and receiving feedback on their performance or by shadowing trained clinicians during their virtual appointments.[22]

In the United States, telehealth education programs are not standardized, resulting in varying levels of competency across the healthcare system.[23] However, telehealth education has increased significantly in recent years, with 60% of medical schools having telehealth courses in the 2017-2018 academic year versus only 41% in 2013.[24] One educational model for tele training consists of five skill areas that are fundamental to the use of telehealth technology: “(I) digital communication skills; (II) technology literacy and usage skills; (III) mHealth products and services; (VI) regulatory and compliance issues; and (V) the technology business case.”[25] The model stipulates the importance of clear organization of telehealth services and presumes that students have mastered “the relevant clinical or professional bodies of knowledge and associated technical skills”[26] Additionally, these skill areas outline the core competencies associated with telehealth services, and may be altered depending on clinical specialization.[27] As telehealth services become more widely adopted across the country, a streamlined, effective, and efficient education system is imperative to maintain a high quality of care virtually. 

Conclusion

Due to the current crisis, connected medicine technologies have become indispensable and are likely to continue to proliferate long after physical distancing restrictions are lifted. These technologies have the potential to become a staple of the healthcare system, providing cost effective, high quality care to a widespread population. However, without proper education and tele training measures, virtual appointments sacrifice empathy, privacy, and access to healthcare. Although it is unrealistic to expect to replicate the in-person experience through telehealth, with streamlined strategies, these technologies provide a unique avenue for patients to receive high quality care regardless of personal or global circumstance.

References

[1]Finney, Karen. “Telehealth Connects a Family during COVID-19 Care.” UC Davis Health, 5 May 2020, health.ucdavis.edu/health-news/newsroom/telemedicine-connects-a-family-during-covid-19-care/2020/05.

[2]Qtd. in Finney, Karen.

[3] Kvedar, Joseph, et al. “Connected Health: A Review Of Technologies And Strategies To Improve Patient Care With Telemedicine And Telehealth.” Health Affairs, 1 Feb. 2014, www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.0992.

[4] Minor, Lloyd B. “Dean of Stanford Medicine: How Virtual Care Can Make Medicine Even More Human.” Fortune, 9 Apr. 2020, fortune.com/2020/04/09/virtual-health-care-telehealth-coronavirus/.

[5] Minor, Lloyd B.

[6] Bean, Sally. “Tele-Trust: What Is Telemedicine's Impact on the Physician-Patient Relationship?” Journal of Clinical Research & Bioethics, vol. 06, no. 04, 24 July 2015, doi:10.4172/2155-9627.1000e112.

[7] Bean, Sally.

[8] Limouze, John Sanford. “Keeping the Human Connection in Medicine.” Harvard Health Blog, 11 Dec. 2016, www.health.harvard.edu/blog/keeping-the-human-connection-in-medicine-2016121210837.

[9] Jiwa, Moyez. “The Value of Human Connection in Health Care.” The Journal of Health Design, vol. 3, no. 3, 2018, pp. 139–140., doi:10.21853/jhd.2018.68.

[10] Shankar, Megha, et al. “Humanism in Telemedicine: Connecting through Virtual Visits during the COVID-19 Pandemic.” Deep Blue, 12 Apr. 2020, deepblue.lib.umich.edu/handle/2027.42/154738.

[11]Shankar, Megha, et al.

[12] Keesara, Sirina, et al. “Covid-19 and Health Care's Digital Revolution: NEJM.” New England Journal of Medicine, 17 July 2020, www.nejm.org/doi/full/10.1056/NEJMp2005835.

[13] Keesara, Sirina, et al. 

[14] Slovensky, Donna J, et al. “A Model for MHealth Skills Training for Clinicians: Meeting the Future Now.” MHealth, AME Publishing Company, 15 June 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5505927/.

[15] Shankar, Megha, et al. “Humanism in Telemedicine: Connecting through Virtual Visits during the COVID-19 Pandemic.” Deep Blue, 12 Apr. 2020, deepblue.lib.umich.edu/handle/2027.42/154738.

[16] “AMA Telehealth Quick Guide.” American Medical Association, www.ama-assn.org/practice-management/digital/ama-telehealth-quick-guide.

[17] Slovensky, Donna J, et al. “A Model for MHealth Skills Training for Clinicians: Meeting the Future Now.” MHealth, AME Publishing Company, 15 June 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5505927/.

[18] Cooley, Laura. “Fostering Human Connection in the Covid-19 Virtual Health Care Realm.” NEJM Catalyst Innovations in Care Delivery, 20 May 2020, catalyst.nejm.org/doi/full/10.1056/CAT.20.0166.

[19]Slovensky, Donna J, et al.

[20] Veringa, Elizabeth. “Training Clinicians with Telehealth.” HRS, Health Recovery Solutions, 25 Oct. 2019, www.healthrecoverysolutions.com/blog/teaching_telehealth.

[21] Slovensky, Donna J, et al.

[22] Slovensky, Donna J, et al.

[23] Slovensky, Donna J, et al.

[24]Veringa, Elizabeth.

[25] Slovensky, Donna J, et al.

[26] Slovensky, Donna J, et al.

[27] Slovensky, Donna J, et al.