Every sailor knows of that dreaded spot where the wind dies, the sail goes slack, and the boat starts bobbing back and forth – the doldrums. As I reflect on the ups and downs of telehealth over the past two years, the analogy seems apt to me.
In June of 2020, we were riding the wave of promise, having just experienced mass adoption of telehealth by both patients and providers. At the time, we did not seem to appreciate the lack of competition from face-to-face interactions. Doctors’ offices were shut down, so of course, telehealth flourished. Starting July 2021, we began to integrate telehealth and in-person care into the complete healthcare experience. The success of this integration has been spotty, and the efforts, in most cases, not deliberate. Over the past year, the percentage of health insurance claims submitted for telehealth visits has remained relatively constant, between 4.5 and 5 percent. Is this a victory for telehealth, or are we indeed in the doldrums?
I recently had the pleasure of reading an industry report by ZocDoc, and from that report, some hints surfaced that may explain why we are caught in the doldrums and how to emerge.
But before I go further, I want to acknowledge that, the title of this blog aside, we are not post-COVID. However, I frame the discussion in this way because we now better understand the opportunities and pitfalls of “all telehealth, all the time” (lockdown phase of 2020) and a tepid effort at creating a hybrid delivery system.
Behavioral health as a channel
The first thing that jumps out in the ZocDoc report is the prominence of behavioral health as a channel for telehealth visits. Two charts examined the percentage of virtual and in-person appointments across 18 specialties, comparing 2020 with 2022. In 2022, nearly every specialty except behavioral health is back in the office for most patient interactions. This is true despite continued favorable reimbursement policies.
Another chart compared patient attitudes with physician attitudes, which are almost opposite. For example, 31 percent of patients indicated that it is easier or much easier to build a relationship with their provider via telehealth, whereas 37 percent of doctors said it was more difficult. Further, 15 percent of patients said it wasn’t possible to get the care they expected via telehealth, while 58 percent of providers said it was more difficult or much more difficult to examine patients via telehealth.
To oversimplify, the office is a convenient place for doctors to make diagnoses and communicate care plans. The home is a convenient place for patients to receive care.
In the case of behavioral health, the information the doctor needs to make those diagnoses and form those care plans can be gleaned as effectively from a video interaction as an in-person visit (this explains why behavioral health is such an outlier). For every other specialty, doctors often feel some critical bit of information missing in that video interaction that can only be gleaned from an in-person visit.
This tension between patient convenience and physician comfort has put telehealth in the doldrums.
The way out
So, what is the way out? Simply put, make it more attractive for doctors. Consistent reimbursement is an important piece, but I’ve chosen not to address that here. Instead, what would it take to give doctors more confidence that they wouldn’t be missing diagnostic information in an online interaction? This will vary by specialty, but I can name three categories of technology that, if they became ubiquitous, would assuage this fear:
- Home testing. This set of tools is burgeoning because of the example set by home Covid tests. All manner of innovations are coming to market to allow your doctor to ‘order’ a test and for you to get the results in real-time.
- Home devices. How do we get a device like TytoHome in everyone’s home so when they have an acute illness, they can essentially recapitulate the physical exam in the context of the video visit?
- Digital biomarkers. Several companies have the technology to diagnose your respiratory illness or mental health problem based on the sound of your cough or the tone of your voice.
Before the pandemic, video telehealth was most commonly used for a small group of urgent care complaints (sore throat, earache, pink eye, etc.). Post lockdown, we know it has the potential to be much more. To combat physician complacency with the office environment, we need to surround the telehealth interaction with more data-rich sources so that doctors feel they can do their job.
What technologies should be added to this list?
This piece was written by Joseph Kvedar, MD, Senior Advisor of Virtual Care at Mass General Brigham, and Professor of Dermatology at Harvard Medical School. It was originally published on his blog page, Reinventing Healthcare.