Dr. Michael Arcarese of Cardiology Associates of Richmond on a telehealth call. HCA Virginia Physicians offer the service in all affiliated practices. (Photo courtesy HCA Virginia)
Dr. Laura Burijon had some time on her hands.
A partner in the Mechanicsville Medical Center Family Practice, she was in self-quarantine for two weeks in March after a trip to Germany was brought to an early end because of the growing COVID-19 pandemic.
The first day in quarantine, she put her time to use by reading up on how the federal government was changing guidelines for remote visits with patients and allowing doctors to bill for the services, a way for health care providers to continue tending to medical needs in lieu of regular in-office visits during the pandemic.
“I knew I would need to help our practice in seeing patients and was, and still am, so thankful for the work that the [American Medical Association and the American Academy of Family Physicians] did on our behalf to loosen previous telehealth restrictions,” she says. “I quickly fired up an old iPhone, loaded some apps, wrote an implementation plan and started telehealth visits March 16.”
Telehealth visits made sense as a way to limit exposure for both patients and staff. The practice implemented telehealth visits by week’s end, using the telehealth interactions for all sick visits and offering it for regular wellness appointments, too. Now, she estimates that about half of patient interactions are done through telehealth.
“Our patients and staff have been very thankful,” she says in an email. “By this methodology, we hope to provide excellent care without imposing mutual risk. Plus, I've seen so many pets that I otherwise would never have met!”
Doctors in Richmond and across the nation have made the switch to telehealth. If you’re in need of the services of a health care provider during this time of shelter at home, it’s likely that your initial encounter will take place via smartphone or your PC. Medical practices are still working out their processes, though, and there are many people without the tech resources or the web connectivity to use the services.
Dr. Michael Blumberg of Allergy Partners of Richmond, also a clinical professor in pediatrics at the Virginia Commonwealth University School of Medicine, says he’s been seeing five to eight patients each day in telehealth visits, using the Zoom platform.
It’s a good tool, but it has its limits: For example, “it’s hard to do a nasal exam on a video screen,” he says. “It’s not going to replace a physical exam any time in the near future,” he says.
Blumberg notes that patients tend to like the sessions and that it’s more convenient when compared with the commute and all that accompanies a trip to the doctor’s office. But the flip side is that telehealth just won’t work for many people, particularly those who lack connectivity. Blumberg notes that all too often, they are the ones who are the sickest, taking the most medications and the most at risk.
His office is trying to divert patients with minor problems to telehealth sessions. He notes that the office doesn’t have enough equipment to properly protect its staff, with less than half the N95 protective masks needed for its 30-member workforce.
For Blumberg's practice, telehealth can provide useful information but has its drawbacks. The person-to-person contact is just not the same over a smart device, and some people may be reluctant to share information. There’s also no way to use some essential equipment in these exams, such as devices to monitor pulmonary function.
“It’s just a whole different way of communicating,” says Blumberg. “It’s better than just talking on the phone at this point, but it’s not a whole lot better.”
It’s hard to replace that one-on-one contact you develop at the office, but with the pandemic and social distancing, you make the best of the tools at hand, according to Dr. Michael J. Petrizzi of Hanover Family Physicians.
It’s hard, for example, to examine a bum shoulder via video, he says, but you adapt. He noted that during a visit where he viewed an 89-year-old’s injured foot, he could see the wound, make a diagnosis and get some vital signs readings courtesy of the patient’s home blood pressure cuff.
“It’s pretty awesome,” he says.
His practice has closed its lobby, and patients who are low-risk may visit in person for physical exams and other hands-on work, waiting in their cars until called. Mornings are set aside for preventive care visits, such as those with acute musculoskeletal complaints.
“They don’t even have to violate the 6-foot thing until they are sitting down and getting their blood pressure checked,” he says. Exam rooms are cleaned before and after each patient’s visit.
Telehealth is a crucial component in maintaining contacts in a time of social isolation for many, such as the elderly and those who have lost a spouse, says Petrizzi. “They can see my eyes focusing on them, and vice versa,” he says, a mental health visit of sorts.
Petrizzi says telehealth is effective, because he has access to a patient’s chart, labs and history during an exam. He says he can often adjust medications or prescribe news ones as needed based on a telehealth session.
“We feel like we have the capacity to do anything,” he says. “It’s a change, but it’s showing a different way.”
He encourages his patients to reach out and give telehealth a try, to convert a scheduled visit to a remote session. It’s necessary, because the longer sheltering in place is needed, the greater the potential for problems as people delay necessary medical care and checkups. If restrictions remain in place through June, by July “there aren’t enough days to do what everyone needs,” Petrizzi says. “We don’t want anybody to be pushed out of their routine care.”
About 80% of medicine depends on the history taking, says Dr. Vimal Mishra, medical director of the office of telemedicine and an associate professor of medicine and health administration for VCU. With a telehealth chat, an astute assessment of how a patient looks via video and chart access, you can generally do a very good assessment of a patient.
“A lot of patients and providers are absolutely fine with it,” he says.
Patients don’t have the hassle of finding transportation to the doctor’s office, don’t have to arrange child care or take time off work. Doctors like the flexibility and the chance to see a different side of a patient.
“It removes the barriers for a lot of patients to being seen,” says Dr. John Cornett of Mechanicsville Medical Center Family Practice. He notes that telehealth is not subject to limitations surrounding the time of day that you’re seen, and it has no geographic limits. It saves money, too.
It also opens a window into a patient’s world. Cornett also notes that he’s met people’s pets, and gets to interact with people in their comfort zones, such as the patient who was at work outdoors at a construction site in safety goggles and hard hat, supervising a crew. “It really gives patients dignity,” he says.
Actually setting eyes on a patient “goes way beyond a phone call,” says Cornett.
Mishra says the technology is also being used in hospitals during the pandemic, a way to limit exposure to staff while still providing care, and allowing some patients to stay in touch with family members. Patients can be monitored without staff repeatedly entering a room and necessitating changes of protective equipment, which is in short supply.
It’s a tool that’s proving useful and that likely will continue to see extensive usage post-pandemic, according to providers. That will depend, though, on whether regulations regarding its usage and payments will be kept in place.
Mishra notes that providers need additional training, in web-side manner, not just bedside manner.
“I think there’s no going back,” he says. “People can see how this tool can enhance health care.”
James River Cardiology began transitioning patients to telehealth visits about three weeks ago, according to Dr. Jaspreet Singh. They realized something needed to be done that Monday, after taking look at a waiting room that was full of patients.
Singh notes that you lose some face-to-face intimacy, but a doctor can accomplish about 95% of what could be done in an office visit without patients leaving their living rooms. He also notes that patients seem comfortable with the transition to telehealth, which can allow for a child or other loved one to participate in a session.
“I’m probably spending a lot more time with them,” he says.
Dr. Greg Leghart, a physiatrist and physical medicine and rehabilitation specialist and chief medical information officer for Sheltering Arms, says that telehealth protects patients and staff, preserves protective equipment, and “works very well for most of our patients.”
The Sheltering Arms professionals have been working out details as they go, Leghart says. “We kind of dove in. Work flows are evolving as we do it.”
They’ve come to a process where patient-access staff take initial steps to reach out to the patient, prep for the call, and make sure that the connection is working and that the patient knows how to use it.
It’s working, and the patients seem to appreciate telehealth, says Leghart. People dislike change, but once they experience telehealth, see that it works and become familiar with it, there will be a groundswell of support for its use post-pandemic.
“I see this as a potential silver lining of the COVID crisis,” he says.
