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Physicians Turn to Telemedicine to Treat Patients During COVID-19

Providing ‘safe’ care takes on a whole new meaning during the pandemic

Rebecca H. Reddy, MD
American Board of Pediatrics, Specialty: Pediatrics
Nancy M. McGreal, MD
• American Board of Internal Medicine, Subspecialty: Gastroenterology
• American Board of Pediatrics, Subspecialty: Pediatric Gastroenterology
David J. Mann, MD
American Board of Dermatology, Specialty: Dermatology

As stay-at-home orders were issued to slow the spread of the Coronavirus Disease 2019 (COVID-19) in states across the country this past spring, board certified physicians turned to telemedicine to continue providing medical care for their patients.

Fearful of risking exposure, many patients cancelled in-person appointments and deferred preventive and elective visits. In fact, ambulatory care visits plummeted nearly 60 percent in the wake of the pandemic, according to a recent Commonwealth Fund report. Although the numbers have rebounded somewhat, there are still about one-third fewer visits than before the pandemic.

Rebecca Reddy, MD, who practices at Redbud Pediatrics in Wichita, Kan., with four other board certified general pediatricians, never thought about offering telemedicine services until the number of patient visits dropped by nearly half following the governor’s statewide stay-at-home order on March 16. “We had to do something to see those kids who needed to be seen but would not come in,” she said, knowing that the fear of contagion was not going away any time soon. “And we also needed to do something to help keep our practice viable.” Two days later, the practice launched a telemedicine site. They sent an email blast to all their patients’ families and posted instructions for scheduling a telemedicine appointment to their website. During the shut-down, about half of the practice’s appointments were telemedicine visits, which were offered in the evenings and on weekends. In the past two months, in-person visits have rebounded and now make up more than 75 percent of the visits. All staff as well as patients and family members older than three years of age are required to wear masks in the office.

In mid-March, Nancy M. McGreal, MD, a board certified adult and pediatric gastroenterologist at Duke Health in Durham, North Carolina, noticed an uptick in patient cancellations. She and her colleagues started seeing only urgent patients in clinic and began encouraging other patients to make telephone appointments. The telephone appointments bridged the two-week gap that allowed beta-testing for the video platform to be completed. Although Duke Health has had some form of telehealth for about five years, it was not widely used, she said. Telemedicine visits began on April 6. Today, 99 percent of Dr. McGreal’s appointments are telemedicine visits, noting that a gastroenterologist is always available to see urgent patients at the hospital or in clinic, as necessary.

Within one week of the stay-at-home orders issued for Illinois on March 26, David J. Mann, MD, who practices at Medovate Dermatology in Buffalo Grove with one other board certified dermatologist, implemented telemedicine. Prior to the pandemic, Dr. Mann had planned to launch telemedicine services, so much of the work on the backend had already been completed. Before rolling it out, however, he wanted to streamline the process as much as possible for patients. As an example, Dr. Mann incorporated an interactive request process as opposed to a form to fill out. An email to patients announcing the new telemedicine service provided a short video demonstrating how easy and effective virtual consultations can be. The office remains open one half-day a week for emergencies, urgent matters, and biopsies. It’s important to remain accessible to patients so they don’t feel abandoned during the pandemic, he said. Currently, 85 percent of the practice’s appointments are telemedicine visits.

Pros and cons
In some ways, Dr. McGreal finds telemedicine visits more efficient. There are a lot of variables, such as patients arriving late or problems with insurance, that can derail an in-office appointment. Staying on schedule is much easier with telemedicine. If the patient needs lab tests or imaging scans, she simply emails the order. Picking up on non-verbal clues to tell whether the patient is well or not is easy using telemedicine, Dr. McGreal said. Seeing patients in their homes can provide clues about their lifestyle, which can help to choose more effective treatment approaches.

On the downside, patients can’t always find a private or quiet area for the appointment and may resort to driving around in their car. Information technology (IT) issues, which were more prevalent in the beginning, can be stressful. “When it goes well, it goes great,” Dr. McGreal said. But throw in a poor Internet connection and 15 minutes into the visit “you still haven’t addressed the patient’s needs because you’re working with IT to fix the connection,” she said, acknowledging that there are growing pains with any new technology.

Once the pandemic is over, telemedicine may be a viable option for very stable, established patients with whom Dr. McGreal needs to touch base, maybe write a prescription refill or discuss a new treatment option. In these cases, a physical exam would unlikely change the course of the visit. Other good candidates are those patients who must drive several hours to the office. “We will still need to see people at least once a year in the office and new patients should probably have their first appointment in-person,” she said.

Dr. Mann agrees that telemedicine is best suited for following up with established patients. “Telemedicine will allow me to provide continuity of care, for example, for patients who go away for college,” he said, adding that it can lead to better patient engagement and adherence to treatment. Telemedicine is not, however, ideal for novel diagnoses or problems, especially suspicious lesions. “Looking at a two-dimensional image is not the same as looking through your own eyes, it’s more like looking through a window,” he said. In person, Dr. Mann can look at a lesion in the context of other lesions, but that doesn’t always come through the video screen.

Parents often call Dr. Reddy because they think their infant is in respiratory distress. A telemedicine visit allows the pediatrician to see the infant’s chest. In most cases, the baby is not in distress, she said. But Dr. Reddy can show the parents how to do saline drops and suction the nose out as well as teach them how to look for real signs and symptoms of distress in their baby’s breathing. Being able to see the child’s home environment offers a hidden benefit because it enables Dr. Reddy to caution parents of children with asthma, for example, if she sees doors or windows open during pollen season.

Patients like telemedicine
All three physicians have received positive feedback about telemedicine from most patients. They like the convenience – no long drive, having to take off work or school, or paying for parking, all for a 15-minute visit. Patients seem more relaxed in their home environment, as well. They have adapted quickly to the technology, probably because many were already familiar with FaceTime and more recently with Zoom videoconferencing, Dr. McGreal noted. Telemedicine enables patients to schedule an appointment at their convenience, which increases access to their providers and a sense of empowerment, Dr. Mann said. Families were so grateful and accepting of telemedicine, even with the limitations that it sometimes presented, said Dr. Reddy, who is asked daily by parents if telemedicine will be available after the pandemic is under control.

The physicians are hopeful that insurers will continue to compensate for telemedicine visits and the rules governing its use, which Congress significantly modified during the pandemic, once the virus has been curtailed. “Nobody thought we could make this transition so quickly and yet we have because of COVID-19 to continue to provide quality care to our patients,” stated Dr. Mann, who noted the irony of a technology that has catapulted the delivery of health care into the next century, while harkening back to yesterday. “In a way, it’s like going back to making house calls.”

Rebecca H. Reddy, MD is certified by the American Board of Pediatrics and practices at Redbud Pediatrics in Wichita, Kansas.

Nancy M. McGreal, MD is certified by the American Board of Internal Medicine and the American Board of Pediatrics and is on staff at Duke Health in Durham, North Carolina.

David J. Mann, MD is certified by the American Board of Dermatology and practices at Medovate Dermatology in Buffalo Grove, Illinois.

(Published online on August 7, 2020)

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