COVID Has Made the Office Visit a Dinosaur
Douglas Eby, MD, MPH, CPE, VP Medical Services, Southcentral Foundation, Alaska Native Medical Center
Edward McGookin, MD, MHCDS, FAAP, Chief Medical Officer, Coastal Medical, Inc.
Jill Duncan, RN, MS, MPH, Executive Director, Institute for Healthcare Improvement (IHI)
The office visit has been central to modern medicine. Long-held truths include the necessity of meeting with patients in person, lining up patients to see them in order, and care team members efficiently doing their part to maximize the physician’s precious time and skills. COVID has shown that this choreography is often unnecessary. Once basic evaluation has occurred and a relationship of trust is in place, weaving medical expertise into patients’ lives when, where, and how they want it with no delay — and using ongoing virtual conversations — has proven to be better in many ways. Suddenly, the office visit no longer seems central to caring.
Visit-based medicine comes at a significant cost to patients. Visits take time from work, a particular difficulty for those who most need clinical support and a burden that falls hardest on lower-income families. Patients travel, check into a front desk, wait, and go through a fairly long standardized ritualized process with various staff before sitting alone in a room on an exam table, waiting, again, for the precious few minutes with the clinician expert. Often, the professional, not the patient, drives the encounter,(1) which is directive and produces a plan designed mainly by the professional. Given the effort and inconvenience of coming to an office visit, it is no wonder that patients expect laboratory tests, radiology images, medications, and specialty referrals. And, given the implicit power relationships, it is also understandable that many patients “fail” to fully adhere to what clinicians “prescribe,”(2) being labeled “noncompliant.”
The COVID crisis has dismantled all of this with respect to location, cost, convenience, and power. No-show rates for virtual visits have dropped to nearly zero.(3) High-quality virtual medical care proceeds without nearly as many labs, radiology tests, and referrals to other specialties. Patients seem satisfied with simple suggestions of interventions, since their investment in the virtual visit is small and additional virtual visits are easily available if these suggestions do not work. Exceptional telehealth is not visit-based, rather reorients the total system creatively with many ways of connecting and supporting toward putting people truly at the center of care, with readily available relationships and services exactly where and when they need them, in familiar settings.
Behavioral health and addiction telehealth decrease potential stigma and have lower barriers to getting started at the moment of readiness. Parents with medically complex children — or just many children — avoid the hassles of transportation. Therapists of all types are now providing video visits in the home setting, where life happens, and the applicability and efficacy of these therapies significantly improve as a result.(4) Appropriate use of home monitoring devices has soared, improving self-care and home-based chronic condition management. The delivery of medications, equipment, and self-learning materials to patients’ homes has greatly improved, optimizing care plans while diminishing the barriers of complexity associated with getting to a medical appointment.
Specialists forced into virtual care environments by the pandemic are discovering that they can expand and leverage their circle of influence and impact by working through generalists rather than requiring in-person visits before giving medical advice. Cognitive-based specialists, in particular, are rediscovering joy in work by providing many quick solutions through generalists and reserving their clinical time for individuals with truly complicated needs who require more attention.(5) Specialty care is an area rich for even further explosion of efficacy as video and voice platform sophistication and use of AI-supported evaluation expand rapidly.
When people do require face-to-face encounters, the pandemic has driven innovation in the shape and design of the visit, itself. Greatly expanded use of smart phones has all but eliminated the need for front desks and waiting areas. Registration updating can be done virtually, and individuals can wait in their vehicles until summoned by phone to enter the clinical space. During the pandemic, support functions such as immunizations, blood pressure measurement, throat swabs, finger-sticks, other specimen collection, and blood draws are conducted in drive-through tents or parking lots. Medications and supplies are delivered by mail or courier. Follow-up counseling, changes to care plans, and further inquiry are all done virtually, using the ubiquitous smartphone.
Enabling these system transformations to become permanent will require full alignment of payment methods and quality measures, and wholesale adoption of these changes by the medical institutions, clinical staff, and tens of millions of patients and families who have been trained for centuries to use the medical system specific ways. It is remarkable that even in long-standing single payor systems the office visit-based paradigm remains central, as does the overall medical model with which it is closely associated.(6) But around the world, the COVID-19 pandemic has thrown the centrality of the office visit, and its classic workflow, into serious question.
In 2019 in the US, prior to COVID, members of the Institute for Healthcare Improvement (IHI) Leadership Alliance (Alliance) convened The Office Visit Is a Dinosaur (OVID) working group. The 53 Alliance member organizations had already established principles for health care redesign that included “Move Knowledge, Not People” and built on decades of IHI and Alliance members’ health care transformation work.(7) This working group recognized that the traditional office visit is an outdated, physician- and institution-centered construct in a modern age when the Internet and technology are affording new possibilities. Stuck in a fee-for-service paradigm that has been driving high volumes of visits, few clinicians or organizations have been brave enough to scrap the traditional primary delivery structure.
But this has changed. In a matter of weeks, the current pandemic has demonstrated that the office visit is no longer as essential as previously thought and might also be dangerous to health. With coronavirus widespread, patients, families, and clinical staff all conclude correctly that congregating humans in medical settings is actually dangerous. The COVID crisis has forced rapid, dramatic innovation in health care, creating the opportunity to question the centrality of the office visit for many patients and many needs. The office visit may now share the same fate as the dinosaur, driven to extinction by compelling factors in its environment.
1. Nutting PA, Crabtree BF, McDaniel RR. Small primary care practices face four hurdles — including a physician-centric mind-set — in becoming medical homes. Health Aff (Millwood). 2012 Nov;31(11):2417–2422. doi: 10.1377/hlthaff.2011.0974.
2. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011 Apr;86(4):304–314. doi: 10.4065/mcp.2010.0575.
3. Peters AL, Garg SK. The silver lining to COVID-19: avoiding diabetic ketoacidosis admissions with telehealth. Diabetes Technol Ther. 2020 Jun;22(6):449–453. doi: 10.1089/dia.2020.0187. Epub 2020 May 5.
4. Torous J, Jän Myrick K, Rauseo-Ricupero N, Firth J. Digital mental health and COVID-19: using technology today to accelerate the curve on access and quality tomorrow. JMIR Ment Health. 2020 Mar 26;7(3):e18848. doi: 10.2196/18848.
5. Wright JH, Caudill R. Remote treatment delivery in response to the COVID-19 pandemic. Psychother Psychosom. 2020;89(3):130–132. doi: 10.1159/000507376. Epub 2020 Mar 26.
6. Tsai TH, Huang N, Lin IF, Chou YJ. Variation in the 11-year trajectories of medical care seeking behaviors in diabetes patients under a single payer system: persisting gaps to be filled. BMC Health Serv Res. 2019 Aug 19;19(1):580. doi: 10.1186/s12913–019–4399–0.
7. Berwick DM, Feeley D, Loehrer S. Change from the inside out: health care leaders taking the helm. JAMA. 2015;313(17):1707–1708. doi:10.1001/jama.2015.2830.
Corresponding author:
Jill Duncan, RN, MS, MPH, Executive Director, Institute for Healthcare Improvement (IHI)
Email: jduncan@ihi.org
