In early March 2020, the Washington University School of Medicine in St. Louis embarked on a new experiment in patient care: It began beta testing a telemedicine system. Before then, no virtual medical visits were being conducted there, and the change was expected to be rolled out relatively slowly.
Explore This IssueNovember 2020
But instead, in what has become a familiar experience throughout society during the COVID-19 pandemic, that change came suddenly. Physicians found they could either see patients virtually, or barely see any at all. Payers began reimbursing for virtual visits at the same rate as in-person visits. Like it or not, the era of virtual medicine had arrived.
“There’s nothing like a crisis to force you to innovate,” said Joseph P. Bradley, MD, assistant professor of otolaryngology–head and neck surgery at Washington University.
Innovation under pressure might not sound like a recipe for creating patient contentment with virtual visits. But Dr. Bradley said patients have reported high satisfaction, as they’ve been able to avoid many of the headaches of traditional visits. “It’s the driving to and from appointments,” he said. “It’s the finding a place to park. If I were on the main medical campus for Washington U., they’d have to pay for parking.”
Otolaryngologists around the country report a similar phenomenon. Although many departments had barely dipped a toe in the virtual-visit pool before they were forced to dive in, patients have been almost uniformly happy. Physicians say this has perhaps set the groundwork for a long-lasting change to a much higher percentage of virtual visits, with many types of visits surprisingly feasible without the patient sitting physically in front of a healthcare provider.
A study recently published online in JAMA Otolaryngology found that otolaryngologists provided just 2,127 telemedicine services to Medicare beneficiaries from 2010 to 2018, receiving $88,574 in payment for those services. The number of services per physician in otolaryngology had an annual growth rate of 11%. By comparison, dermatologists provided 3,815 telemedicine service sessions to their patients in the same time period, and had an annual growth rate of 13%.
I thought patients would be really disappointed—I can’t examine them, and I can’t have an intimate connection with them in person. But surprisingly, the emotional connection that I felt with the patient, and vice-versa, was very strong. —Courtney Voelker, MD, PhD
Other specialties have found that telemedicine is a satisfying option for patients as well. A recent study conducted by the University of Michigan in collaboration with the American Academy of Sleep Medicine (AASM) compared the effectiveness of cognitive-behavioral therapy for insomnia through the AASM’s telemedicine platform to in-person therapy for 65 randomized patients. The patients reported no differences between the telemedicine and in-person visits in terms of overall satisfaction with their treatment or their therapist’s warmth and skills (Sleep, published online July 13, 2020).
Patrick Barth, MD, medical director of specialty care at Nemours Children’s Health System and a pediatric otolaryngologist in Wilmington, Del., said that before March, there were many providers who were hesitant to offer telemedicine because they were worried that the logistics would prevent them from providing the same level of care. A few early virtual visit “champions” offered some visits by video, he noted, mostly limited to follow-ups to review sleep studies or X-ray results, or for post-op visits.
In February 2020, Nemours had 1,100 visits by telehealth, Dr. Barth said. By March, COVID-19 shutdowns blanketed the country. And in April, the number of telehealth visits at Nemours had risen to 28,000. Before the pandemic, only about 150 to 200 Nemours providers were offering any visits virtually, but by June, nearly 900 providers had done so. In brief surveys conducted after visits, Nemours patients gave an average of 4.9 out of 5 stars to the experience with the provider, and an average of 4.8 to the platform experience.
“All the pediatric ENT providers were providing telehealth once COVID hit,” Dr. Barth said. “We went from just follow-ups to new patients and seeing the whole breadth of diagnoses in that fashion.”
Courtney Voelker, MD, PhD, chief of otology, neurotology, and skull base surgery at the Keck School of Medicine at the University of Southern California in Los Angeles, led a project examining 500 patient encounters before and after the onset of COVID-19, in which patients and physicians were asked specific questions meant to assess the quality of care, the communication of important information, and whether they thought the medical problem had been handled in a satisfactory way. The preliminary analysis of the data has been encouraging, she said.
Telemedicine is a part of our practice that’s ready for revolution and evolution because patients clearly want it. —Erika Woodson, MD
“The physician satisfaction was a little bit lower across all of those features compared to in-person encounters,” she said. “But the patient satisfaction [data] were really no different across the board from telephone and video encounters compared to those in person. Certain subsets of patients were actually more satisfied with the telemedicine encounter—for instance, those who have difficulty physically accessing the healthcare system for a variety of reasons.”
The researchers also looked at subgroupings and found areas in which progress in telehealth might need to be strengthened, said Dr. Voelker. “It looks like the weak points are elderly patients, because their technology literacy is lower, and patients who have a language barrier and need a translator.”
The Keck School has been addressing these weak points as they are noticed. Through a simple phone call, for instance, an on-demand translator service for telemedicine has been added at USC, to help accommodate the ethnically diverse greater Los Angeles area.
Overall, Dr. Voelker said, the virtual experience has run counter to her expectations. “I thought patients would be really disappointed—I can’t examine them, and I can’t have an intimate connection with them in person,” she said. “But surprisingly, the emotional connection that I felt with the patient, and vice-versa, was very strong.” Patients and physicians have been brought more intimately into each other’s worlds, especially during visits conducted at patients’ homes, she said, and telemedicine has opened up access to healthcare in a novel way to those who have had the most difficulty accessing it in the past.
Adaptation and Success
At the otolaryngology department at the Cleveland Clinic, a virtual-visit platform had been created before COVID-19, but not many providers used it.
“Most of our providers hadn’t been trained on it, hadn’t on-boarded to it, and certainly the platform wasn’t able to pivot to quickly accommodate the volume that we needed,” said Erika Woodson, MD, section head of otology–neurotology, one of telehealth’s early adopters at Cleveland Clinic, and a member of the committee that helped adapt the system for increased use when COVID-19 arrived.
My hope is always that we’re providing at least the same level of care or higher through virtual visits. —Patrick Barth, MD
With too little bandwidth, the platform couldn’t connect well and kept crashing, she said. “You would fight to just get connected with the patient and then the visual and video would be so stilted that you would have to abort the video and use a back-up communication method,” she said. “Much of the time allotted for a visit would end up with our physicians trying to be their own personal help desk.” Across Cleveland Clinic, about 15% of virtual visits couldn’t be completed due to technology issues, she noted, and physicians simply hadn’t been trained to use the system yet.
But it turned out to be a story of adaptation and success. Bandwidth was increased, and physicians and technology officers banded together to ensure that physicians received the training they needed to offer patients the proper care. “We had multiple meetings each week with people from each department,” she said. “It was completely new for most of the doctors and providers—and questions came up every day: Can we prescribe or renew controlled substances? What about patients who are across state lines? How do we bill this? It was a tremendous amount of work on the physicians’ side to translate what we had available into what our doctors, our colleagues, needed to know.”
And despite the initial bumpy road, said Dr. Woodson, surveys have found that patient satisfaction with Cleveland Clinic telehealth was “very, very high.”
“I think patients were relieved to be able to get care,” Dr. Woodson said. “Telemedicine is a part of our practice that’s ready for revolution and evolution because patients clearly want it.”
Physicians have found that not every visit type is suitable for virtual visits. Patients with ear fullness, for example, might need to be seen regardless of the ability or willingness to provide virtual visits, Dr. Woodson said.
“Is it wax, is it fluid, is it sudden hearing loss?” she said. “You don’t know unless you can look in their ear.” Physicians have frequently preferred to not do these types of visits virtually, even if patients like telemedicine appointments, she said. But for other types of visits, such as a scan review, physicians and patients alike have been satisfied with virtual communication.
Dr. Bradley has been surprised at how effectively certain types of cases can be handled virtually. A patient with swallowing dysfunction, for example, will likely need to be seen in person eventually, but much can be done virtually to make it a more efficient experience for both the provider and patient. “The thing that will guide me more than anything else is that patient’s history as well as some type of swallow study,” he said. The first visit for a new telemedicine patient can be used to gather medical history and gauge what type of study should be done, making any in-person visits shorter and more efficient.
A colleague of Dr. Bradley has used telehealth appointments for tonsillectomy cases, with no in-person visits until the day of surgery. “She took a quick look at the tonsils just to make sure there was nothing untoward before going back, but the surgery was booked off the virtual visit,” he said. “In the end, both she and the patient were incredibly pleased with how it went.”
Long-term outcomes data in this new era of virtual medicine still need to be assessed, but Dr. Bradley said he expects them to continue to be positive and that some outcomes, such as that for voice therapy, might even be improved with a greater emphasis on telemedicine. With in-person-only care, for example, a patient who smokes and drinks alcohol referred for hoarseness might have to wait several weeks for an in-person visit, meaning their high-risk status for malignancy might not be caught as early.
Otolaryngologists said they expect the amount of virtual care to stay well above where it was before the pandemic, but that the volume will depend on how these visits are reimbursed. For now, CMS has been renewing the policy of reimbursing virtual visits at the higher rates, but it is unknown how long that will continue.
Even as otolaryngology is proving more capable of expanding virtual visits, caution needs to be taken that some patients aren’t left behind, noted Dr. Woodson. “Rural, elderly, socioeconomically disadvantaged individuals are going to be relatively left in the dust on this—and these are exactly the people we want most to reach,” she said. “If medicine went 100% virtual tomorrow, there are going to be a whole lot of patients I can’t help.”
Dr. Barth added that there could be changes to the way virtual care is delivered once more outcomes are analyzed. “My hope is always that we’re providing at least the same level of care or higher through virtual visits,” he said. “But we’re looking at it very closely because we’ve seen a wider range of diagnoses during COVID through telemedicine than we did previously.”
Thomas R. Collins is a freelance medical writer based in Florida.