On Camera
In his book The Patient Will See You Now, Eric Topol makes several predictions, including that our patients will increasingly use smartphones and other at-home devices to engage in diagnosis and self-management related to their health. Another prediction — contingent to the latter but eluding to a more profound change to the healthcare system — is that care itself will increasingly move to virtual, rather than in our offices. And this transformation is already occurring: Kaiser Permanente has recently claimed that over half of its encounters are virtual.
At Froedtert and Medical College of Wisconsin, we have been offering virtual on-demand visits using a dedicated group of clinicians for over four years. Over this past year, we have begun bringing our own clinics online for video-based visits, starting in primary care, thus offering the opportunity to patients to have a digital-first medical visit with their own doctors and care teams. Rather than having a dedicated team doing only virtual visits (something I will discuss below), I see all of medicine being practiced through a combination of in-person and virtual care, depending on the need.
These video-based visits present a notable change in how we work and interact with our patients and has a learning curve that we must climb. I’d like to share here more about the reasons behind why we are embracing video-based visits, share thoughts about the trends that we are following, and some early lessons about what we have learned along the way.
Technology Advancements
We are in a period of important changes in the way that we are able to practice medicine. In the early days of medicine (such as when my great great grandfather was a country doctor in West Virginia) doctors went to homes to take care of those who were ill, to deliver babies, and to be part of patients’ lives. Over time, as physician schedules became increasingly busy and equipment became increasingly specialized, the care setting moved from the patient’s home to the doctor’s office and to more specialized outpatient care centers. With the current wave of innovation, technology has gradually enabled the reverse: namely moving back to the patient’s home where patients can use technological mediums — i.e smartphones, tablets — combined with the power of cloud computing to facilitate communication with the doctor and even diagnoses (such as using a phone for funduscopic examinations, evaluation of skin findings, and patient-captured electrocardiograms).
The current generation of smartphones equipped with high-resolution cameras and fast internet-connectivity are widely available in the hands of our patients. Coupled with tablets added to the clinical workstations of doctors, video calls become easy, instantaneous, and frictionless for both the doctors and the patients. There certainly is the ‘last mile’ problem of ensuring adequate bandwidth to support smooth video-based, especially to our rural areas or households without broadband or fast cellular connectivity (an area that is an active focus of the federal government).
Demand from Patients is Growing
We continue to see forecasted demand for virtual care. The 2019 Digital Health Consumer Survey run by Accenture shows that time savings, cost transparency, and convenience are becoming important levers for consumer-focused care, and that prospective patients will increasingly choose medical providers that offer digital capabilities (including 49% in 2019 who voiced that video conferencing capabilities would influence their choice of healthcare providers).
Up to 30% of consumer respondents have used some form of virtual care. Even more interesting is the fact that survey respondents who reported that they had major health issues were more likely to seek out virtual care.
Other consumer surveys show similar findings, indicating that people want to engage digitally for their health. Unsurprisingly, those who are younger are prioritizing digital connections, and this is starting to change the landscape of primary care.
My colleague Michael Barnett, in a recent work published in JAMA, identified that commercial telehealth claims have grown at an annual compound rate of 261% between 2014 and 2017, with primary care overtaking mental health as the main reason for using telehealth. Taking a quick look at the graph shows that the absolute volumes still remain fairly low. But is this the start of the tipping point? It’s hard to know for sure, or not, but our belief is that we have to make it easy for patients to engage with us and have their problems addressed.
Part of the equation of adopting new tools and technologies in healthcare is whether or not it is paid and/or covered by payers. For telehealth, government and commercial insurers are starting to work more closely with providers around reimbursement for video-based visits. Medicare by law has traditionally restricted telehealth to explicit use cases, such as physicians connecting to patients in designated remote/rural areas. However, the CMS proposes to enable patients enrolled in Medicare Advantage (1/3 of all Medicare enrollees) to be eligible for video-based visits more broadly.
Experiences to Date with Virtual Care at Froedtert & the Medical College of Wisconsin
We have offered direct to consumer virtual care for four years. We have been developing our virtual care programs for several years, and are increasingly expanding video visits for primary care and soon specialty clinics. Our virtual care capabilities include on-demand virtual care, local clinic primary virtual care for several same-day conditions as well as routine follow-up (through video visits), such as for depression, diabetes, or even hypertension. This complements other remote monitoring services facilitated through the inception virtual care team including tele-observation, E-ICU, tele-hospitalist, and monitoring of our at home digital programs.
Taking a look at our most recent experiences. Through our virtual care on demand services, 40% of visit requests occur outside of our normal business hours on weekdays, and 30% of overall visits occur on weekend days. Our most common use cases include urinary tract infections (22% of all visits), sinusitis, cough and other upper respiratory tract infections (22%), and rashes (9%). While most can be handed within the virtual visit, ~1/5 are escalated to an in-person same-day visit.
Building upon our relationships with payors, we have been able to begin offering primary care based video visits with patients’ own PCPs and/or team members. We began offering these video visits, which are conducted through our patient portal and mobile application, for follow-up visits as well as urgent care visits for appropriate conditions. These video visits are not shorter than in-person visits, but they are much more convenient for our patients, and particularly helpful for reducing the overall time associated with receiving medical care (including time away from work/family obligations and transportation).
Developing New Clinical Skills
While the setting may be different, and technology may introduce some new peculiarities, in my mind caring for people will not and should not change depending on the medium.
The change that we need to go through as clinicians is to grow the skill set of taking care of people through virtual means. There is an interesting perspective in JAMA recently that suggested that a new specialty called the Medical Virtualist would begin to take route, seeing patients remotely. While this may be one future path, similar to how specialist and hospital medicine have gradually taken over the care of acutely ill patients, I see communicating diagnosing and treating patients as part of the course skill set of physicians today. While the setting may be different, and technology may introduce some new peculiarities, in my mind caring for people will not and should not change depending on the medium. But there are likely to be new skills we must use.
- Technology familiarity — so that we are comfortable interacting with patients and can focus on the patient’s problem rather than the technology
- Awareness of what people call the ‘webside’ manner, or “the ability to relate and help” through the use of technology, including the ability to read non-verbal cues and information (This also requires consideration of one’s setting (factors like ambient noise, lighting) and own non-verbal communication)
- Grow observation skills where physical examination may be different, or incorporate the ability for patients to perform parts of physical exams, when necessary, and report or share results
- Awareness and management of conditions that need to be rapidly escalated to other care venues
Looking Forward
We will continue to expand upon this area in our efforts to meet patients where they are. Increasingly we are exploring technologies that make it more frictionless to get needed care, including e-visits and virtual triage tools. We will also be looking very closely at how to help patients solve their problems through asynchronous ways, such as through text-based or chat-based encounters.
I heard a statement recently at a conference I was attending, “We should stop calling it ‘practicing telemedicine,’ and just call it what it is: practicing medicine.” I do think this is the right approach, and ultimately our jobs as clinicians will be to continue to care for patients in ways that best meet their needs, regardless of the medium.
