Telemedicine: Convenient and Immediate Access (When Appropriate)

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Telemedicine exploded during the pandemic and has held steady as a convenient way for people to get the care they need without leaving the house. Brian Zack, MD, explains how telemedicine helps more patients get essential care and why it isn’t just here to stay, but may become the preferred way to see your doctor.

Pete Kenworthy
It feels like Telehealth, telemedicine, virtual care, whatever you want to call it, has exploded in the last five years or so, right? Especially during COVID. At first it was an insurance issue, right? There was a struggle to get insurance companies to cover the cost like it was an in-person visit, but we’re past that now and it seems like there’s great value in it for people.

Macie Jepson
Well, we didn’t grow up with it. That is for sure, but it is here to stay, Pete. The questions that people struggle with are similar to when to see a primary care doctor, when to go to an urgent care? I asked myself that just recently. When you should head on to the emergency room and really can you get prescriptions filled actually through a virtual visit? Hi everybody. I’m Macie Jepson.

Pete Kenworthy
And I’m Pete Kenworthy, and this is The Science of Health. And joining us today is Dr. Brian Zack, Medical Director for Telehealth at University Hospitals in Cleveland. Thanks for being with us.

Brian Zack, MD
It’s my pleasure. Thank you for having me.

Pete Kenworthy
Can you start with a high-level explanation of virtual care for those who may be unfamiliar with it? It’s actually been done, and I was surprised myself. It’s actually been done successfully since the 1960s.

Brian Zack, MD
That’s correct. The actual first documented telehealth visit was in 1959 in the University of Nebraska as part of medical education, and within five years they were doing crosstown consults to the hospital from various sites.

Pete Kenworthy
Things have changed quite a bit in the last 80 years or last 60 years, right?

Brian Zack, MD
Sixty years, absolutely. But certainly it has exploded. As you said, the first, I would say 50 years was a slow growth that was based on technology, based on interest from both patients and providers and acceptance. But certainly the pandemic made this part of our commonplace, everyday healthcare. To answer your question about all the different names that we apply to it, virtual care, as most people refer to it, is a connection between a patient and a provider at two different sites via an audio/video connection. So usually that refers to both a video screen with an image, and, of course, the discussion that goes in the audio. There are people who do phone visits as well, telephone only, and we have other forms in the digital portfolio of visits that we can do over email, text and et cetera.

Macie Jepson
We like to break down myths here, and one might be that really these services are only for people who can’t get into see a physician or they live in a rural area and that’s who you’re servicing. Is that true?

Brian Zack, MD
No. And I think that’s a really common myth. In fact, I think it was based in some fact to your earlier point about insurance coverage prior to the pandemic, the only insurances that paid prior to the pandemic on a regular basis was Medicare for rural patients, and they had to be very strict criteria to make it eligible, so much so that most providers didn’t even understand those rules and therefore didn’t participate. But as the pandemic hit and in the first months of the pandemic, over 70% of our visits in this system were performed virtually for a few months. That includes primary care, specialty care and urgent care. So most patients were being seen virtually while we figured out what was safe and what was unsafe as the healthcare system, the Federal Government, led by making these reimbursable. And while we don’t want to always associate money with our health, it was that paradigm shift that allowed healthcare systems and physicians to embrace this technology as a safe part of their practice.

And now it is a part of our permanent model. The most important thing to address is that it’s not just for people who can’t get in. It’s an access initiative to allow people to not have to leave work, not have to leave school, whose physician might be across town if it’s a specialist and they want to see them from their home. The most important thing here is, and this is something I try to say over and over again the more I talk about telehealth and virtual care, is we should not both as patients, but also as providers and healthcare professionals, we should not be thinking of telehealth or virtual care as a binary choice between in-person visits and virtual visits. You’re not making a choice, one or the other. It’s a new tool. Don’t think of it as the visit. Think of it as a stethoscope or as an otoscope we use to look at your ears.

It’s a tool that your providers can use to manage your personal healthcare needs. And so what I mean by that is it’s great for triage. Do I need to go, to your question earlier, about when do I go to the ER versus urgent care versus my primary care doctor’s office versus a virtual visit? The answer is it could be used to triage and help you make that decision before you commit to all night in the emergency room. It can be used to follow up on a visit that you may have not otherwise done. And we’ve actually shown some evidence and we being healthcare system that people who do a follow-up visit virtually after leaving the hospital or emergency room because they couldn’t get in with their specialist or primary care doctor are less likely to be readmitted because we’ve addressed any in-between needs that occurred since their discharge. So it is a new part of the healthcare system. It’s not an either/or.

Pete Kenworthy
Yeah. That was the next myth on our list here is that virtual care is only for urgent care.

Brian Zack, MD
Absolutely not. And I think, though, the biggest impact that virtual care has had now and will continue to have in the future is that it is now being used to manage chronic care, to manage how patients flow through the system. One great example will be a patient who was admitted to the hospital for congestive heart failure, one of our most common reasons for admission. When they’re discharged, they’re told to follow up with their primary care doctor and their cardiologist. When we get them in with a member of that care team within three to seven days for a virtual check-in, there are certain questions for congestive heart failure that they ask, like, has your weight gone up? Are you having difficulty with movement or going up and downstairs that would indicate you’re getting worse again? These virtual quick touch-bases that don’t involve an all day trip to the doctor are preventing people from having to be readmitted, are helping care teams pivot and readjust a treatment plan prior to their need to be seen in the office. So it’s a part of that journey.

Pete Kenworthy
So you’re actually differentiating between two different things here. There’s scheduled virtual care where you make a scheduled appointment with your doctor, and then there’s on demand virtual care where, oh my gosh, my throat hurts, or I see this rash on me. Those are two different things, but it’s the same vehicle that gets those answers.

Brian Zack, MD
I’m so glad you asked. That’s a really phenomenal question. So yes. Actually, the majority of virtual visits, and not by a little bit, the vast majority of virtual visits that are our system, and I would venture to say most systems are currently seeing, are in the scheduled category. Any physician who has a clinic, an outpatient clinic, can see patients either in person as we’re all used to the traditional visit or can do a virtual visit. And here at UH, an example, every single department does virtual visits, some more than others, but every single one does. So people, for example’s primary care, which was over 70% virtual during the pandemic has settled into somewhere between eight and 13% depending on the provider are still virtual. Our behavioral health departments, so we’re talking about psychiatry, psychology, counseling, are still over 80% virtual. And that is after the pandemic because it was great for access. And in the mental health space…we talked about congestive heart failure as an example as a follow-up… in the behavioral health space, more people are seeking care because the stigma of going to a provider in person for mental health is decreased. You can do it from the comfort and safety of your home, and actual compliance with treatment regimens is better because they have more resources to check in. If they’re having a side effect, they have the ability to get a quick check-in as opposed to just saying, I don’t like this, I’m just going to stop.

Macie Jepson
This is what confuses me. How can you give me an exam for a sore throat or an ear infection or maybe an eye infection without seeing me? I feel like this is one of the misconceptions…oh, I’ve got to go in, I’ve got a sore throat. True or false?

Brian Zack, MD
It’s both. So the answer is, of course, there are visits and complaints and medical issues that are absolutely not appropriate for virtual care, and so it’s important that as health systems build infrastructure in terms of their digital portals of entry…that’s the fancy way of saying their webpage, where patients go to find way in or their patient care apps on their smartphones…it’s really important to speak to the patient to help them navigate that. A lot of systems are actually creating apps that are about what are your symptoms and what’s the best site of care for you? But where I’m going for is there’s so much part of the physical exam that can still be done on video, and it’s really important that all patients know that here at UH, and I’m sure with every system who provides this type of care, we expect our providers to keep to the same standards of clinical care and quality metrics as they do for an in-person visit.

So if the clinical guideline, I’ll use strep throat, a very common complaint. Strep throat should not be diagnosed virtually because there are so many different causes of a sore throat, and really the only way to know is with a swab, but that doesn’t mean we can’t meet halfway. And there are clinics that are associated with virtual visits where after the virtual visit, we send the patient a list of multiple sites they can go to on their own time to get swabbed, and the treatment team will follow up with an antibiotic if appropriate. Traumas like a fall or a car accident, of course, not appropriate for virtual. Breathing issues, chest pain, not appropriate for virtual. Those patients should go to the ER or to whoever they can be seen as quick as possible. But you mentioned eye infections. If the patient is seen virtually, and I do this from my office, if the patient’s seen virtually, we know as physicians and other providers that there are certain red flags that say this needs to be examined, but if the answers are no, we can actually do that virtually with the expectation of if this doesn’t improve or if you get A, B and C, other symptoms, come into the office.

And this is, pivoting back to the really important point of it’s not about the one visit yes or no. It’s about that continuum and that journey. This was a way to start treatment and if it gets worse, you need to come see me. And patients are very compliant with that. They understand that we’re giving them a convenience in not having to leave work or come in. They can do it from home and we can really start their healthcare journey for this issue virtually. And if it needs to be a follow-up in person, they can do it at a more convenient time for them.

Pete Kenworthy
Okay, so here’s one for you. Virtual care devalues the doctor-patient relationship. It doesn’t feel personal.

Brian Zack, MD
I love that question because I couldn’t disagree more. And I love being able to share my thoughts here. In our previous discussion, I mentioned that it’s not the…I keep coming back to it…it’s not the binary visit, it’s the how does this type of tool fit into the need I have right now? And what I have found and most of our providers have agreed with is that it actually enhances the relationship for a couple of very important reasons. First, access. We are breaking down barriers to care. So if I am seeing one of my patients, they just appreciate that I’m getting them in as fast as possible. I already have that relationship with them. This is building on that relationship. It’s a different way for them to get what they need from me and to me to have that pleasure and the privilege of treating them.

But the second thing that I like to point out is this is a whole new aspect of how providers like myself can see patients in their own spaces. I’m seeing them in their home environment. I’m seeing them, for a patient with mental healthcare needs, is the room they’re in completely messy and disheveled? Evidence that maybe things aren’t going as well. Are they in a safe place? They feel more comfortable. They feel more private. I mentioned previously the stigma sometimes of going in for care.

Another example outside of mental health that I love, that I’m very interested in is obesity management. And so we have a lot of patients… I’m a pediatrician…teens don’t want to talk about their weight. They don’t want to be weighed in the office, but sitting in their bedroom at home, it’s a little safer, and they’re more open to some discussions of healthcare, not their weight, but healthcare. And we can really make a different kind of connection, which I think is much more powerful.

Macie Jepson
Let’s talk a little bit more about safety. I think about my parents. My dad pays cash for gas because, oh, he’s not going to put that credit card everywhere. There’s got to be a concern with some patients about healthcare, public record safety, their personal information being out there on the Internet or what have you. What do you say to that?

Brian Zack, MD
So there’s two answers. And to the patient, I would say the first step is on you, meaning you should not be doing a virtual visit while walking through the grocery store. You should be making sure you’re in a private place that your personal issues and your private matters are not being overheard by others. So we can’t control that part of it, but you can. The second issue, which I think is what you were getting at, is how do we know what’s over the airwaves, if you will, happening with this visit and this information? So there’s a couple things, and I absolutely want to empower our listeners and our patients to ask these questions no matter where they live and no matter who their provider is. All health systems should be using and are required to use secure networks and secure platforms under the HIPAA guidelines. So it’s a HIPAA compliant platform. That means security features are in place to prevent other parties from seeing this information. It means that it meets standards of security and privacy set by the government to make sure your information is safe. No one should ever be recording or taping your visit without your consent in full information.

Pete Kenworthy
A tough one for people may be when they use virtual care, is that the cost is the same for going in for an in-person visit, right? And some people may think, well, this should cost less. I’m not using their office, I’m not using all their overhead costs, right? Why doesn’t it cost less? It costs the same, right?

Brian Zack, MD
So at current state, it costs the same. That may change in the future. Every year we’re finding out more and more about where the governing bodies over billing codes and how these things work, usually led by Medicare, will lead us in this space. But I think the answer you’re looking for is that remember that even though that visit doesn’t need the office, that physician was seeing a patient in person right before they saw you and probably right after they saw you. And their ability to make these options available is dependent upon the staff members at the front desk, the nurses taking care of patients in the back, the rent, everything that goes into maintaining an office. So unless a provider is fully virtual, which almost no one is, this is part of the course of medicine. And more importantly, remember, you’re not just paying for the office space. You’re paying for the trust, expertise and guidance of the physician or healthcare provider in front of you.

Macie Jepson
We touched on this, but I want to dig a little bit deeper, and that is when is virtual care a good idea? When do you need to go see someone, whether urgent care, wait for your physician, emergency room?

Brian Zack, MD
So I think if it is a non-urgent issue, I think calling your doctor’s office and asking for yourself, is this something we can see virtually or do I need to come in for this visit? And that’s in the scheduled space, just like any other doctor’s appointment. Okay. I think in the on-demand space, which is what a lot of people don’t understand, it’s, you brought up a sore throat or an earache, it’s okay to go to your healthcare system’s website that allows entry into the on-demand virtual spaces, if you’re not sure, and usually they’ll guide you. On our site, it very clearly says ear infections cannot be diagnosed virtually. Sore throats for a strep cannot be diagnosed virtually, but we could see you and start that process. Other things, as I mentioned earlier, certainly are immediate referrals to urgent cares or EDs, which are more risky or high acuity complaints: chest pain, shortness of breath, uncontrolled bleeding, trauma are good examples.

As patients get more comfortable with virtual care and as providers get more comfortable, and I think it’s really important for our patients to know that not every provider has the same approach to virtual care. So it is part of that partnership and relationship you have. But if you’re part of an ongoing, regular continuity relationship with a provider, whether they be in the primary care space or a specialty space, and you see them regularly, I think having that conversation, when can we do this virtually versus when can we do this in person, is a really reasonable and now normal conversation. And providers in their own specialties will have no problem saying, when we need to get a weight, when we need to do lab work associated with your visit or other testing, we’ll have you come in. But in the in-betweens, we can do it virtually.

Pete Kenworthy
And there are things that people may not be thinking about, right? You can have that continuum of care for chronic problems. You can have it for prescriptions that may be needed to be refilled, things like that.

Brian Zack, MD
Correct. Anything I can prescribe in the office at current state, I can prescribe virtually. There are some limitations and they probably are going to get a little tighter on controlled substances, but that makes sense for safety. But in other realms, in terms of any blood pressure, cholesterol, antidepressants, antibiotics, if clinically appropriate, can all be prescribed virtually.

Macie Jepson
What stands out to me in what you just said, continuum of care. Important to note, this isn’t meant to be a replacement for your physician.

Brian Zack, MD
So this is about your physician. This is about your ability to navigate your health, your personal journey, and how health systems can be a partner and offer you resources. And virtual care is one of those resources. Some data that came out during the pandemic, just to make an example, is when you go see a primary care doctor or a specialty physician for a scheduled clinic visit, and we assume the normal average time of transportation, parking, walking in the building, checking in, waiting for the doctor or a provider, seeing them, checking out and reverse, going home compared to a virtual visit starting at home, the average virtual visit without significant delay was between 22 and 26 minutes. The average time door to door for an in-person visit was over three hours. This is why people take half days off of work for a doctor’s appointment, or they could take their break, go in a private room and do it from work or home. So the ability to access those services is actually reinforcing that continuum of care and not creating barriers.

Pete Kenworthy
Let’s tie a bow on this. Anything else? Anything we left out or just kind of a takeaway for people here.

Brian Zack, MD
As I think that we’ve said over and over about the value of virtual care in not being its unique, one-time visit, but about the bigger picture and your total health. As patients become more comfortable and more engaged in these options, we actually have changed, and we’re using a term called digital health, which actually means we’re looking at ways technology can be part of this journey beyond the video camera on your computer. We are using text chats to help people follow chronic conditions. We’re allowing patients to use email or e-visits to ask very simple non-complicated questions that don’t require the video. We’re looking at other technology like remote patient monitoring. So if you wear a blood pressure cuff at home or a continuous glucose monitor for diabetes, all of these equipment are now being tied digitally into our electronic medical records as part of your total picture. And we’re making sure that along with virtual visits, all this technology together is allowing our patients to stay healthy at home as opposed to sick at the hospital.

Pete Kenworthy
Dr. Brian Zack, Medical Director for Telehealth at University Hospitals in Cleveland, thanks so much for being with us today.

Brian Zack, MD
Thank you so much for having me.