One Month of Working With Telemedicine

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Andrew L. Rosen, MD

“Well, this is weird”
This was what I was thinking when I first did a video call for direct patient care after our office closed down. Although I’ve been connecting with friends and family with FaceTime for years, it was a new experience to use it instead of a medical office visit. Now, after over a month of a complete change in how we practice medicine, it has become pretty natural.

One of the few positive changes to medicine from the COVID epidemic has been the new ability for medical practitioners to utilize telemedicine. Prior to COVID, the government had placed restrictions on allowing doctors to communicate using easy and inexpensive technologies such as FaceTime and Zoom. Furthermore, the government and private health insurers would refuse to pay a doctor for any care that was not delivered in person. The pre-COVID system required all health care to be done only face-to-face. Limited interactions using telephone calls could be utilized for patients but without reimbursement and still required significant time to document the patient encounter.

Since COVID forced Medicare to ‘see the light’ that delivering medical care via telemedicine was not only safer, but worthy of their health care dollars, those restrictions have ended allowing doctors such as myself to now work with patients remotely and be compensated for it.

The Good
I’ve been able to reassure many patients and keep them at home
Since I started these telehealth visits, I have been able to remotely work with many patients and deliver the same level of diagnosis and treatment which I previously was doing in the office. I’ve been able to reassure many patients with minor disorders that they didn’t need emergency room visits or expensive tests. Getting a good history and a basic visual examination of the painful body part has been effective in determining that many conditions aren’t a big problem needing urgent treatment. Without x-rays and ultrasounds to check patients, it can be more challenging, but many conditions can diagnosed without direct testing.

I’ve found some real injuries
So far, I’ve seen several stress fractures due to excessive running, a torn achilles tendon from an over-aggressive home workout and a torn knee cartilage from a deep squat. Many patients require an MRI study performed at an outpatient radiology center that can be ordered and arranged without seeing the patient in person (now, thanks to telemedicine). These type problems can all be treated properly once diagnosed.

I’ve seen some interesting home environments

One of the more interesting parts of telemedicine has been getting to see patients in their home environments. I’ve seen lots of different living rooms, bedrooms and even a bathroom. Getting a look at existing and new patients at home brings back the old days of housecalls (long before my time of course). The presence of inquisitive toddlers and playful cats and dogs has added some levity to the visits which can make online visits more interesting and brings me more into the patient’s lives.

The not so good
Making a definitive diagnosis isn’t always easy when you can’t do a good physical exam or x-rays
Many conditions are fairly easy to figure out from a good history of the problem and a limited video exam. Some problems are more difficult to determine the origin of symptoms without seeing and touching the body part. Telemedicine patients should be informed that diagnoses can be a bit more uncertain with a telemedicine visits.

I can’t do procedures through the video
Barring new robotic injection machines delivered to a patient’s house (science fiction at this point), we still can’t perform procedures on patients with telehealth. Cortisone injections, suturing, application of braces, draining of abscesses are all very useful techniques that can be necessary and enormously useful for treating patients. Telehealth doesn’t allow these techniques but at least they can be discussed and planned as needed.

Insurance companies haven’t completely embraced telehealth yet
Although Medicare covers these visits without any extra effort for practitioners, many insurance companies take up to 30 minutes of staff telephone time to give us the information to tell a patient if they are covered and if there is a copay or deductible. This is just another disincentive for doctors to embrace these visits and could easily be removed with a quick online portal or simply universal coverage mandates.

It’s not always easy or time-efficient

One of the downsides to telemedicine is the (sometimes) lack of efficiency. It takes time to dial, connect with a patient, allow them time to get to a quiet, well-lighted spot. Glitches occur with connecting and sometimes video quality can get terrible depending on patient’s connection speed and location. Photobombing kids and pets are still fun but do distract and take up time. Even arranging post-visit treatments can be more time consuming when I have to contact one of my assistants to remotely get tests or medications ordered or sent to patients. Unfortunately, I can definitely see more patients in the same amount of time in my regular office setting. Telemedicine with any volume of patients will definitely be less productive for health care providers. Theoretically, health insurance should cover this inefficiency with increased reimbursements but that is unlikely.

The Future
Certainly, telemedicine is here to stay for many months as the COVID epidemic evolves. For the long-term future, I hope that telemedicine will continue to improve and adapt as an evolution of the modern medical practice. Visits for routine patients, MRI reviews and some acute injuries could still be very useful and, of course, quite time efficient for patients by avoiding the trip to our office.