“Hello?” Again I say in my laptop. “How can I help you?”
A 37-year-old woman comes into view of my camera as she picks up the phone and finally starts to join the visit.
“I’m so sorry, I was just collecting my son from school.”
As I wait for my patient who had just left his iPhone, I notice another news article on my screen informing me how much doctors love telehealth. Fr
I can’t blame my patient for making an appointment remotely. When I myself need medical treatment, I hatred I am going to the doctor. It doesn’t feel like it’s designed around what I want, nor does it target the problems I’m trying to solve. And to be sure, virtual care does generally expanding access to treatment.
But as I learned firsthand after the pandemic, there are three major tensions that still need to be resolved before it can work as promised.
Convenient… for who?
Virtual care is very convenient for the patient. They can get it on their terms and in a way that works for their situation. However, this often means that a care provider is waiting for a patient.
Hence the tension. The traditional system is convenient for providers. Patients request an appointment and go through significant processing and preparation. They are optimally and cost-effectively ready for the provider/physician’s time.
Mental health providers reportedly find virtual care more convenient than in-person treatment; after the pandemic, they are slowly returning to personal care. In that case, there is no tension about convenience. But that seems to be the only exception in healthcare.
Which brings me back to my current patient:
“I’m having a bad stomach ache from eating at that disgusting restaurant my husband likes,” she explains to me on Zoom. “I need an antibiotic and something for my nausea.”
As I dig a little deeper, it turns out that she also had several hours of fever, nausea, vomiting, and abdominal pain around the navel and lower right quadrant.
This could to be food poisoning as my patient believes.
Or it could be a life-threatening case of appendicitis.
But there is no way to tell if he needs a CT scan or an ultrasound without doing a physical exam. However, this is clearly not the answer my patient wants to hear.
Which brings me to the second tension
Quality vs satisfaction
“Look, I know it’s just food poisoning,” my patient continues. “I don’t want you to solve some diagnostic mystery. I just want you to prescribe what I obviously need. If I knew it was going to be complicated, I would just stick it out and be fine tomorrow.”
I can hear the frustration in her voice. If she hadn’t contacted me, I never would have raised the possibility that her symptoms were more serious. Instead, she could wait, fend for herself, or end up in the emergency room.
Much of the tedious process for patients in our personal care system exists to ensure that we deliver quality medical assistance. The practice of medicine is to take responsibility for another person’s life. Most providers take this very seriously. This is why virtual care can cause significant anxiety for the provider.
Human touch, however brief, is another advantage of treatment at the clinic. Virtual care can be episodic, with little emotional investment. Patients often believe that what they ask for (antibiotics, antipsychotics, work notes, tests, etc.) will solve their problem. When better and different treatment is needed, it is more effective to explain why in person.
But my patient with either food poisoning or appendicitis is already on call on Zoom.
More virtual care vs. other care
While in-person care has too many barriers, especially those that disproportionately affect disadvantaged groups, virtual care systems need ways to appropriately direct patients to exactly level of care – even if that means asking the patient to make an appointment for an office visit.
Patients and providers are excited about the opportunity to increase access to care. But one person’s access is another’s expense. And payers, especially the government, are concerned that home care programs will increase care and expenses. For example, patients who would otherwise not be admitted to hospital can now be admitted to hospital while they are at home – but still take up limited hospital staff time.
Ultimately, I recommended that my patient call her doctor to schedule a same-day appointment or go to the emergency room. I feel bad that I can’t handle her health anxiety better; she thinks it was a waste of time and money.
Fortunately, there are ways to improve the outcome for both of us.
Reducing stress in virtual care with technology
Providers prefer personal care because More ▼ can be done there: physical exam, EKG, walking test, maneuvers, procedures and laboratory tests. For virtual care to be a much better alternative to all of this, virtualization of more than just audio-video communications will be needed. This means finding virtual counterparts for personal care.
This is where technology can shine. Several promising health technology startups are developing products designed to significantly improve telehealth, including:
- KardiaMobile by AliveCor: A small device that pairs with a smartphone to identify six common arrhythmias.
- Nonagon: Remotely performs multiple examinations including auscultation, ear/throat examination, pulse, pulse ox and temperature.
- Sonavi Labs: Creates an AI-powered digital stethoscope.
- Vastmindz: A company that records vital signs using a phone or webcam. [Editor’s note: Author has no relationship with companies named]
We still need to figure out ways to integrate virtual and physical patient visits with a unified and familiar workflow. When I helped advise the design of a hybrid virtual solution from start-up DecodedHealth, we went to great lengths to ensure that the provider could deliver virtual and personal care with the same workflow without interruption – same registration, same EHR, same documentation, same workflow. I believe something like this will need to become an industry standard to reduce the disruption caused by virtual care delivery while making it more financially viable.
Likewise, we need better telehealth technology where audio/video calls require much less technical support and are customized to improve the needs of providers and patients. Some facilities have a medical assistant who initiates the conversation to make sure the patient is ready. Incorporating biometrics to both verify a patient’s identity and ensure the call technology works are attractive options for startups.
Much more is needed at the systemic level. After helping to advise on a number of these decisions, I realized that better regulatory, compliance and compensation mechanisms are still needed to use virtual care technologies that truly enable better care. The cost of technical integration into our workflows remains daunting. The dynamics of virtual care will also need to become more longitudinal and relationship-based, with fewer episodic pill decisions. Diagnostic and safety mechanisms of virtual care should also be expanded.
I notice that my next patient, a pleasant looking 19-year-old male, is finally logged in and seems ready to go. His file says he has a chief complaint of a rash, so I have high hopes that I can meet his needs in that regard.
If only I could help him get the computer sound working…
Photo: Sorbetto, Getty Images