Despite the hubbub around telehealth for the past 2-plus years, I still hear providers (and some patients) talking about it in absolutes. Some unattributed quotes:
“My patients prefer to see me in person.”
“I can’t make a diagnosis without the physical exam.”
“Can the doctor take good care of me over video?”
As we look at telehealth adoption in mid-2022, it is stuck in the doldrums. A clear, long-term reimbursement policy would go a long way to putting the wind back in our sails, but there is more to it.
In the meantime, let’s get back to those quotes that oversimplify care into absolutes — either in-person or virtual.
The process of care delivery can be boiled down to three steps:
- Your doctor gathers information about your health and/or illness.
- She formulates a diagnosis or list of possible diagnoses — these two steps can repeat several times until a lead diagnosis is arrived at.
- She formulates a care plan and shares it with you, the patient (this can involve prescribing medication).
Follow-up care represents a slight variation in this process, especially if the diagnosis is not in doubt:
- Your doctor gathers information on how you responded to the care plan.
- If a new therapy is required, she shares information about that with you.
We have already clearly identified the value propositions of telehealth: access to care and improved efficiencies (with either the same or better quality). Patient convenience is another, though underappreciated, value.
Finding the best option
We can use this set of filters to sift through the workflows above to come up with examples where in-person care is required, in-person is optional, and telehealth is the better choice. For example, does the information gathering by the doctor require touching the patient? If not, I’d argue that telehealth gets the green light since the other steps (formulating a diagnosis and sharing the care plan with the patient) can almost always be done virtually. You can apply this exercise yourself, thinking about care experiences you’ve been a part of as a patient or a provider.
Here are a few shortcuts that might be applied:
- Is the diagnosis evident to all (e.g., a woman desires contraception; a teenager has new onset acne)?
- How important is the emotional connection with the patient when providing the care (in some cases, the need for a doctor is very transactional, and convenience wins out over emotional connection)?
- Follow-up care is almost always an easier sell for telehealth because the relationship with the patient is established.
This is a call to action to my provider colleagues to apply this formula to your practice and come up with scenarios in three categories: in-person required, telehealth optional, and telehealth preferred.
The presumption has always been that in-person care is generally better. Still, sometimes, if we consider the value of access or patient convenience, we could accept telehealth as an alternative.
Taking economics out of the picture, the value proposition that tips the scales is quality. Are there examples where we can extend access, provide patient convenience, and do so at a higher quality than in-person?
Here are several examples of virtual care interactions that fit those criteria:
- Starting with my specialty, follow-up visits for patients with acne, as well as psoriasis, and atopic dermatitis patients who are clear of disease and stable on therapy.
- Behavioral health visits, especially follow-up visits for patients with anxiety, depression, and ADHD. Behavioral health professionals tell me that they gain more insights about these patients via virtual visits by getting a window into their home and that the patients are ‘more themselves because they don’t have to endure the tribulations of traveling to the office.
- Visits with allergists who are better able to get a sense of what allergens might be present in the home environment.
- Titration of blood pressure medication for newly diagnosed patients, provided they have a calibrated home blood pressure monitor.
- Ongoing management of patients with type II diabetes who have connected glucometers.
I know there are many more. What examples can you come up with?
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.
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