National Cancer Institute/Unsplash
"In the matter of five weeks, we've had a revolution in telemedicine where basically everyone is adopting it," says ophthalmologist Saya Nagori.
National Cancer Institute/Unsplash
The road to recovery was already laden with difficulty for District resident Lisa Kaneff. Hip surgery and six months of physical therapy three years ago weren't enough to erase the chronic pain she's dealt with for most of her adult life. She had hoped a more aggressive procedure in January, to replace her hip labrum, would be her last.
But then the pandemic hit right when she was still recovering. Her physical therapist's office sent a lengthy email explaining that, with a thinning staff and to keep patients safe from infection, most therapists — including Kaneff's — would be offering virtual appointments for a flat rate of $35. The office told Kaneff they could schedule an in-person appointment at a later date, but only one provider was available for it.
"I was like, I don't want to be stressed out and feel like I'm a burden coming in for this appointment, so I would rather just not," she says. Plus, she didn't want to risk getting coronavirus, so she opted for the at-home option.
Doing basic exercises over Zoom on her iPad, Kaneff's appointments have been reduced to "a lot of camera maneuvering and guesswork" with her boyfriend, who's become her de facto therapist, she says.
"If I didn't have a partner, if I didn't know that I had a backstop at home, I don't know what my calculus would have been," Kaneff says.
Over the course of March and April, the federal government made telemedicine much easier by announcing sweeping changes, such as temporarily waiving location restrictions so doctors can see their patients who live in other jurisdictions and expanding reimbursements to include audio-only appointments. States, including D.C., Maryland and Virginia, loosened medical licensure restrictions, and privacy laws were temporarily waived so doctors could use apps like FaceTime and Zoom to more easily reach patients.
Kaneff is among those in the D.C. area who are grappling with a dramatic shift in health care options as the pandemic has made in-person visits for non-COVID-19 patients risky and, in some cases, unavailable. The pandemic has become a trial run of sorts for what health care might look like in the future: On the one hand, it's exposed issues of equity and accessibility around remote care; on another, it's provided hope to doctors and advocates who've been pushing for advances in telemedicine for years, arguing that the benefits, such as cost-saving and efficiency, outweigh the limitations.
'A Revolution In Telemedicine'
Adams Morgan resident Lisa Swanson says she recently had two "televisits" of different kinds after learning that MedStar, her insurance company, covered it. The cell service in her English basement is unreliable, so she video chatted using wifi — but even that can be spotty.
"After troubleshooting for about five minutes going, 'Hey, can you hear me?' I finally stepped outside in my backyard, and my lovely neighbors and my upstairs neighbor got to pretty much hear me tell my dermatologist about my acne," says Swanson. "I was super happy that I didn't schedule a full-body checkup."
Swanson, who describes herself as a "white-passing, young millennial woman in the city" with flexible hours for her job in Alexandria, recognizes her privilege when it comes to health care. But she wonders if telemedicine can break down barriers of access, "not just for people who look like me, but for others in the city or in rural parts of the country who just can't go and see a doctor very often."
The biggest hindrance to progress — for Swanson, at least — is wifi, and she imagines others in the city struggle with tech issues or lack of access to smartphones and tablets.
She's not wrong about that.
J. Desiree Pineda, an endocrinologist and the president of the Medical Society of D.C., says that when the pandemic reached the region, her West End practice switched fully to telemedicine within a few days. Her patients have enjoyed the convenience of the remote appointments, she says, but the preparation can be difficult. Some older patients don't have email addresses, for example, and can't access the instructions for downloading and using Backline, the HIPAA-compliant desktop application she uses.
"There are a lot of technical problems," Pineda says. "A lot of 'I cannot hear you doctor,' or 'You're sideways.' "
Still, Pineda foresees lots of potential for progress in the industry: Video appointments could allow multiple doctors in different locations to observe a patient at once. Or, if patients check vitals at home with their own thermometers, weight scales and blood pressure cuffs, they might feel a sense of collaboration with physicians and become more proactive in their recovery. Not everyone can afford that, of course, but for patients who struggle to find means of transportation to get care, telehealth could be the best option, Pineda says.
Technology such as Bluetooth-connected stethoscopes can send the sound of a heartbeat to a doctor miles away. Recently, one of Pineda's patients used a portable electrocardiogram that delivered test results using a smartphone app. "It was incredible and really good quality," she says. "A lot of things are going to come out of this."
Ophthalmologist Saya Nagori says she's been lobbying for telehealth at the state level and teaching it to other doctors for the better part of a decade. Her College Park practice went fully virtual two months ago, when D.C. had its first confirmed coronavirus patient.
"When I started teaching telemedicine, there was a lot of pushback, and a lot of that was policy-related. A lot was fear-related. A lot of it was misconceptions," Nagori says. "With all this advocacy that I was doing over the course of five years ... in the matter of five weeks, we've had a revolution in telemedicine where basically everyone is adopting it."
There are long-term benefits to telehealth that will save cost, time and energy, says Nagori: Virtual triages can thin out waiting rooms, ensuring that patients who really need immediate care get seen first. Telehealth can help with the impending shortage in doctors by keeping physicians in the field longer and providing useful tech for younger ones. It also allows for freedom and flexibility for patients and doctors.
"I have a newborn at home right now," Nagori says. "But I actually started seeing virtual patients when I was five days postpartum ... I definitely could not have seen patients in person."
Of course, there are limitations — a 25-year-old patient with the newest iPhone will have a completely different experience than a 75-year-old who might not have much use for up-to-date technology, Nagori says.
'A Downside Of Telehealth'
Some types of health care are simply too personal or delicate to do over video chat. Dentist appointments and emergency procedures continue to be in-person. (Although D.C.-area residents, like Kaneff above, say they have struggled to get noncoronavirus medical care like physical therapy.)
By mid-March, Community of Hope's three clinic locations had switched the majority of their noncoronavirus patient visits to mobile, says Carla Henke, the organization's chief medical officer. The learning curve has been intense for both physicians and patients, as many patients don't have reliable internet access, or access to laptops or tablets, she says.
"It was quick. ... It was fairly overnight," Henke says. "We have not really done this prior to COVID, with the exception of some of our behavior health and therapy visits."
And while prenatal care may very well look different after the pandemic, Henke says a full switch to telehealth for expecting mothers is impossible.
"A downside of telehealth — whether over the phone or by video — is that you can't examine the patient, get fetal heart tones with the Doppler, measure a belly or get vital signs," Henke says. "So one part that we've done is work with our managed care organizations to get patients blood pressure cuffs to use at home in advance of the visit. They're also taught over the phone how to use them."
Typically, Community of Hope sees prenatal patients once a month, then every two weeks, then every week further along in the pregnancy. During the pandemic, in-person and telehealth visits have been interspersed every other week, and prenatal patients are seen in an isolated space (among other coronavirus-related precautions COH is taking). Henke says they've taken a patient-by-patient approach to determine if some prenatal patients or new mothers need to come in more frequently. There's been a mixed response.
"Some are not wanting to come into the office because of concern for their safety and wanting to be home during the pandemic," she says. "And then there are others who have concerns and would like an [in-person] exam."
As COH serves some of the hardest-hit areas of the city — especially D.C.'s black population, which has accounted for most of the city's coronavirus-related deaths — Henke says equity continues to be an issue. On top of underlying health issues, food insecurity and housing, wifi and cell service is now at the forefront of health care concerns.
"That's something that community health centers have thought about long before the pandemic — is how are community members getting access to the resources they need," she says. "Some patients' numbers are not in service for the moment. ... So as much as we can, we're updating phone numbers and getting alternative contact numbers. And so that has been a continued access barrier to telehealth for our patient population."
'What Happens When It Ends?'
Longtime telemedicine advocates say that the recent changes are just a taste of what health care could look like if government regulators prioritize telehealth even after coronavirus is no longer keeping people from physically going to doctors' offices.
The Connected Health Initiative, for instance, has worked for years to connect major health groups to tech giants and researchers and is using this moment to push the Federal Communications Commission to expand broadband access to rural communities. Before the pandemic, CHI communications director Ashley Durkin-Rixey says the federal government dragged its feet on telemedicine pilot programs.
"We're still using the fax machine to connect patients to the care they need," says Durkin-Rixey about the slow pace of change in the health care industry.
But in recent weeks, along with the waivers, the Department of Health and Human Services provided $15 million to support telehealth providers, another sign of change.
Neal Sikka, an emergency medicine physician with GW Medical Faculty Associates who's been teaching and researching telemedicine for over 12 years, wonders if this will be the beginning of new progress in the field.
The GW system wasn't exactly prepared to switch to telemedicine at first, Sikka says, but by the end of March, GW had integrated 500 physicians into a new telehealth system. Most patients had canceled their in-person appointments, but "telehealth kind of started to bridge that gap very slowly," Sikka says. "Now, I think we're running maybe 60 to 70% of our base volume, and half of those are telehealth."
Part of the battle is making sure all communities, especially underserved ones, have access to information. Sikka says GW reaches out to houses of worship and partners with other programs to dispel myths about technology and "get the word out" about telehealth benefits.
But will these efforts continue when the federal and state waivers are lifted and restrictions are put back in place?
"Society is going to be very different post-COVID," Sikka says. "We're going to have a lot of challenges for people to get health care — you look at the job losses and people may be uninsured. What does all that look like? I think technology will play a massive role in improving access."
Durkin-Rixey says that CHI is also examining how to make some of the current telehealth realities permanent.
"The COVID-19 pandemic really put the whole idea of telemedicine on a shorter timeline ... but what happens when it ends?" she asks. "There should be a conversation more broadly about what types of visits can be remote. We're hoping there is great data that comes out of this time so we can make that case to Congress and regulators."