April 27, 2020

The Doctor is On Line

The Commonwealth Fund just released a study reporting on primary care office visits in the COVID-19 era and it’s disturbing. In-person office visits fell by 60 percent in March and remained down to nearly the same extent in April. While telemedicine substituted for some of these visits, it did not come anywhere near to compensating for the decline. 

Clearly the precipitous fall is disastrous for primary care medicine, which has seen one practice after another furlough physicians or close altogether, but it also bodes ill for patients. While some of those vanishing visits were probably unnecessary or could easily be postponed, there is reasonably good evidence for the efficacy of robust primary care medicine in improving health and increasing longevity. What can we do about this problem—apart from eradicating COVID-19?
The popular answer is to increase the use of telemedicine. Telemedicine—principally video calls by patients to physicians that allow both parties to remain home—have had considerable successes: Jefferson Health has made extensive use of the technology to screen for COVID-19, to enhance prevention and, to some extent, to treat common conditions. The use of telemedicine has been rising dramatically, with some analysts reporting a 50 percent increase since March and others predicting a billion remote visits by the end of 2020. Moreover, the regulatory changes introduced by Medicare to facilitate billing for telemedicine visits have had a major beneficial impact. 

But before we get carried away, we should consider who is not currently using the technology and what adaptations will be necessary to maximize its efficacy. I worry that older people in general and the oldest old in particular are not availing themselves of telemedicine, despite having the greatest need. Older patients who are poor, have little education, or are non-English speakers are at the greatest disadvantage of all. But to assume that the only barrier to effective utilization is lack of access strikes me as naïve: surely new skills and a new approach will be necessary, both on the part of physicians and of patients.

First, the barriers to access. My mother is 94. She is intelligent, she has a master’s degree in social work, and she owns a computer and a tablet, both of which she uses to read her email. But video calling is just beyond her. I’ve tried FaceTime and Zoom. I sat with her (in the days when I was able to do so) and coached her. I’ve attempted to walk her through the process while we are on the phone together. No luck. And she is not unique. Her friends have not been able to master this skill either. Generations on Line, an organization which for decades has been trying to improve digital literacy in the elderly, identifies three obstacles: lack of access (not an issue with my mother or most of her friends), lack of skill, and intimidation. She is convinced she cannot learn to use this technology. “I’m not made for this century,” she tells me and she is not alone in her conviction.

Now consider all the older people who do not have a computer or a tablet. Internet use has been steadily rising in those over age 65 and is now about 73 percent—but among those age 80 or older, it’s only 44 percent. And use falls further with lower income and lower levels of education. 

Then think about those who are hearing impaired—you might imagine that the computer's capacity for amplification would be a benefit of the technology, but for many people with hearing loss, the main problem is discrimination, the ability to distinguish different sounds, and that does not disappear with amplification. Next, throw in non-English speakers. Good systems are available for dial-in interpreters, which works well in the office setting, when the patient and the physician are in physical proximity, but is more challenging when a three-way video call is required. Until these barriers are overcome, telemedicine will be limited to telephone calls in those who are neediest and most vulnerable. 

Even if we could wave a magic wand and all older people would have a computer, smartphone, or tablet and broadband access and the ability to use the device to communicate with their physician, we would still need to address the issue of reaching the doctor in a timely fashion. If telemedicine is supposed to replace urgent care as well as evaluation of new, slightly less acute problems along with chronic disease management, then we will need a systematic way to triage visits. 

If all older people could communicate with the physician via the internet promptly and effectively, there would remain the question of the substance of that interaction. Medical students are taught that a good clinical history results in (presumably correct) diagnosis 80 percent of the time. But a more sophisticated analysis suggests that how likely the history is to prove adequate depends on the prior probability of the condition—that is, if a patient is extremely likely to have pneumonia, then a physical examination or chest x-ray has relatively little to add to the history, but if the chance of pneumonia is small, then these other modalities can add significantly. For telemedicine to be effective, we will need to compensate for the lack of a physical exam and lab tests.

Video adds an important dimension to the visit—physicians can learn a great deal, for example, from observing if the patient is struggling to breathe or has blue-tinged lips. But even in dermatology, physicians rely on touch as well as vision to evaluate a rash. To maximize the effectiveness of telemedicine, patients will need to be able to provide their physicians with critical data. They will have to have a thermometer at home to report their temperature. They should have an electronic home sphygmomanometer to measure blood pressure and, ideally, a pulse oximeter to measure the amount of oxygen in their blood. They should know how to check their pulse (though typically home blood pressure cuffs will do this) and respiratory rate. Obtaining the necessary equipment and learning to use it should be feasible, but it will take time and effort.

Lastly, physicians will need to tailor their approach to a visit to accommodate the strengths and weaknesses of the technological medium on which it is based. A video visit is not identical to an office visit, which in turn is not the same as hospital care. Just as physicians discovered that they could not simply extrapolate from inpatient medicine to the outpatient setting but rather had to learn different strategies for caring for ambulatory patients, similarly they will need to adapt to the brave new world of telemedicine. 

Over the long run, the adaptation will be worthwhile. Better home care can lead to fewer hospitalizations. Fewer hospitalizations means better outcomes for frail older patients: they were at risk of adverse consequences of hospitalization (falls, confusion, decline in self-care ability) long before they were at risk of COVID-19. But we have a long way to go.

No comments: