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October 1, 2020
6 min. read

A Response to 'The Promise and the Peril of Virtual Healthcare'

ND Medina

In a June 2020 article in The New Yorker, writer John Seabrook discussed telehealth as the future of healthcare and whether or not this was a direction for healthcare that we as an industry wanted to travel in.

“Proponents of telehealth have long argued that fifty to seventy per cent of visits to the doctor’s office could be replaced by remote monitoring and checkups,” writes Seabrook. “But, until the pandemic, most Americans weren’t interested.”

Our own Stella Badalova, PharmD and Director of Healthcare Relations at Medly Pharmacy, had this to say about the idea of telemedicine from the pharmacist perspective, a perspective that often involves a great deal of counseling.

“I think the benefits of telemedicine are amplified and the drawbacks minimal with regard to pharmacy practice. Much of the counseling we do is via the phone already. Adding a video aspect to those interactions will only help improve the connections we make with our patients. For example, I can think of so many interactions over the phone I’ve had with patients who are on multiple medications who are confused as to which pill does what and when to take them and how often etc. Being able to see what they see during these kinds of conversations is a huge boon to the counseling process,” said Badalova.

While telehealth saves patients both time and money, many patients haven’t been ready to commit to adding telehealth to the slate of services they participate in. “A lot of people clearly want to be in the physical presence of their physician, undergoing the familiar rituals of a checkup—the doctor’s scrubbed hands emerging from the crisp cuffs of a white lab jacket—that no screen can yet provide,” wrote Seabrook.

Medly’s own Dr. Virmitra Desai argued that the patient as well as provider inclination towards an in-person visit is understandable. “One can debate over factors like, assessing the patient on a video call versus in person visit, listening to patient complains versus performing physical examination and confirming those complains, the connection which a patient can feel with an in-patient visit versus on a video call; these are some of the points which might favor in-person visit as compared to Telemedicine.”

However, Dr. Desai pointed out that the risks of the pandemic make telemedicine something that must move forward regardless of any doubts or hesitations. “The efficacy of Telemedicine can be considered a topic of debate for any other year but in the year 2020 with the ever-rising morbidity and mortality associated with Covid-19, Telemedicine must be made full use of,” he said.

2020 is different from years past in the malevolent presence of COVID-19, which must be considered in a digital health conversation. “A lot of other factors also need to be taken into consideration such as overburdening the health care facilities with patients who can do completely fine with a remote video call or audio call with a doctor. It also protects patients against the risk of being exposed to infectious and highly contagious diseases like Covid-19. It also keeps the doctors and other patients away from unwanted exposure from contagious patients,” said Dr. Desai.

That said, doctors have been slow to widely adopt telehealth. “In a 2019 survey conducted by the American Medical Association, only one in three specialists expressed full confidence that virtual care would benefit their practice, and only two in five primary-care doctors did,” wrote Seabrook.

Dr. Desai responded, “Telemedicine is great and its success depends on how efficiently it is used. It is important for a physician to draw a line as to when a virtual visit is enough to make a diagnosis...If this balance of virtual visit and inpatient visit is maintained well then Telemedicine has all the potential to revolutionize health care in the U.S.”

But telehealth is not simply about replacing in-person visits. Telehealth also advances the possibilities for hospitals, as in the Dartmouth-Hitchcock tele-ICU that Seabrook discussed in his article. “The tele-I.C.U. uses a software platform designed for Dartmouth-Hitchcock by Philips, the Dutch technology company. It runs predictive algorithms powered by artificial intelligence to monitor patients’ prognoses. The system constantly updates each patient’s “acuity score,” a grade that reflects remotely gathered patient data—such as blood pressure, oxygen level, heart rhythm, and pulse—to evaluate the risk of a sudden deterioration,” wrote Seabrook.

Medly’s Dr. Desai points out the benefits of such a system, not only in terms of a tele-ICU, but also for teaching purposes. “Telehealth and Telemedicine is an excellent teaching tool whereby tertiary hospitals (example-university hospitals) with more advance facilities can guide and help first responders, primary or secondary hospitals with limited facilities in times of emergency (example- emergency intubation, sudden cardiac arrest, complex procedures ),” said Dr. Desai.

“In the coming time, Tele-ICU has the potential to reduce ICU-related mortality by more accurately predicting patient prognosis. (This can be done by running predictive algorithms assisted by artificial intelligence to monitor a patient's prognosis),” Dr. Desai added.

This is an observation that aligns with practitioners’ own in the case of Patient X, who was assisted with telemedicine via tele-ICU services, as Seabook described: “‘Jesse and I had no time to chart on this patient, so Sadie was writing down every medication that was given, every vital sign, reminding us to cycle blood pressures as needed,’ Kacie Boyle said. ‘She was just there as an extra set of eyes, and when sometimes we didn’t feel we had enough hands.’”

One important consideration Dr. Desai pointed out is echoed by Seabrook, and it’s the question of who telemedicine can really help. “It is worth mentioning that the population most adversely affected by the ongoing pandemic, ‘the Geriatric age group’, might not be well equipped to use Telehealth & Telemedicine as compared to the younger age group (eg. millennials),” said Dr. Desai.

In further consideration of the troubles of the elderly during the explosion of telehealth care, Seabrook wrote, “Often the patients who need care the most—the old and the poor—don’t have smartphones or broadband connectivity, or can’t afford extra minutes on their wireless plans, placing one of telehealth’s greatest promises, of allowing old people to ‘age in place,’ out of reach.”

Seabrook also brings up another factor in the digital health discussion: the relative unknownness, prior to COVID-19, of what telehealth really means. “Telemedicine needs to be advertised well as a significant chunk of patient population are not well versed with this concept,” said Dr. Desai.

Seabrook cited multiple sources that pointed to how unknown telehealth really was prior to the pandemic. “Telehealth totalled just 0.1 per cent of all medical claims filed in 2018, according to fair Health, a nonprofit that analyzes data on insurance claims. The National Business Group on Health, which publishes an annual survey of employee health benefits offered by large firms, found that in 2016 seventy per cent of companies included telehealth as part of their plans, but only three per cent of their workers used it. Some employees weren’t aware that the service existed; others didn’t trust an anonymous doctor,” he wrote.

But the anonymous doctor is well able to diagnose common issues, especially those based on test results. “Personally I feel that some patients have a preconceived notion that an in person visit is always better than virtual care, this is not entirely true as most of the diagnosis are based on the test results (example- blood sugar level for Diabetes, X-rays or CT scan for fractures, lung auscultation for pulmonary disease, Urine analysis for suspected U.T.I, EKG/Echocardiogram for Heart conditions and so on), so in such a scenario where diagnosis is more based on test results as compared to patient symptomology it does not really matter whether it is virtual care or in-patient visit,” said Dr. Desai.

“I would further add that it would be better to take virtual care in such cases as it minimizes a patient's risk of exposure to contagious disease like Covid-19.”

Ultimately the nation has chosen to move ahead with telehealth in response to the highly contagious and fatal COVID-19 pandemic, and that may be a genie we can’t put back in the bottle. If telehealth is here to stay, we must use it on a case-by-case basis where it is appropriate and continue to explore novel applications of such digital health technology. But perhaps nothing can truly replace the experience of seeing your doctor’s hands emerging from the crisp white sleeves of their coat.

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