“Chief complaint: My mother is confused and can’t walk by herself.”
I reviewed my video visit schedule recently and was surprised to see this one. Not long before that, I had just encountered, “Chief complaint: Possible DVT.” In traditional circumstances, patients and family members would never consider seeing a doctor via a video visit for these complaints and doctors would refer these patients to an in-person care setting. In pandemic circumstances, these are becoming the norm as they try seeking medical advice and treatment in ways that maintain physical distancing and lower risk of personal exposure to COVID-19.
In a recent SGIM Forum issue, Tepper and Weissman deftly described and then busted myths and misconceptions about video visit integration into routine general medical care.1 To clarify, video visits are a specific subtype of telemedicine: synchronous telemedicine, or real-time, patient-facing video conferencing. Generally, telemedicine also includes e-consults between healthcare professionals (synchronous or asynchronous), remote patient monitoring, and mobile health. Here, I’ll refer to synchronous patient-physician video and telephone visits as televisits.
Since Tepper and Weissman’s perspective, public health measures to limit spread of COVID-19 has turbocharged the widespread patient demand and physician adoption of such visits. Additional contributors include widespread deregulation of physician licensing requirements in the form of emergency licensure reciprocity between states, broader insurance coverage for video and telephone visits, and even waiving penalties for HIPAA violations in relation to using everyday one-on-one communication platforms.2 I have one primary, paid medical license in good standing; since mid-March, as a contractor for one telemedicine platform, I have ten additional state licenses due to emergency licensure orders as of this writing. In traditional circumstances, achieving licensing in all U.S. states costs a physician more than $90,000,3 clearly both a bureaucratic and costly undertaking. But these are not traditional circumstances.
In pandemic circumstances, there is no question in the medical community that televisits are a necessity to support patients who are afraid to seek in-person care and to relieve strained and overflowing acute care clinical settings. Some have non-COVID-19 acute complaints and others need continuing chronic disease management and are having difficulty accessing their usual continuity care. Pre-pandemic, education and counseling were already cornerstones of televisits; these, along with triage, have taken on even more prominent roles as medical decision-making and weighing benefits and risks of diagnostic and treatment pathways must now also account for patients’ personal risk for severe illness from COVID-19 if they are exposed and subsequently infected.
In a previous role, I always felt that video visits implemented as an integrated part of a “bricks-and-clicks” model offered the ideal value-added option for primary care practice, where I already knew patients well.4 An in-person clinic setting still offers immediate collection of more data, like an electrocardiogram, pelvic exam, a urine dipstick, or an x-ray, which allows for alternative diagnostic options to be ruled out and more definitive recommendations to be offered. On the drawbacks of telemedicine in general, other have stated better that it can “interfere with the development of physician compassion and patient trust.”5
However, as this pandemic unfolds, I increasingly believe that narrative and dialogue with patients through televisits can provide a sufficiently compelling and vital part of the overall health system’s emergency response. I still do worry about increasing care fragmentation as a result of standalone televisits, as well as potential information asymmetry or misinformation that enables hoarding of prescription medications and other essential resources. Nevertheless, televisits have a clear role to play now and probably will continue to have a persistent and prominent role in the future, whether they are the current “bricks-or-clicks” stopgap measure or integrated into a “bricks-and-clicks” model. In the meantime, I’m grateful to be able to still help my front-line colleagues by whatever means I have at hand.