The Era Of Virtual Care
In the midst of the COVID-19 pandemic, healthcare delivery was transformed. What was considered futuristic, and only used by early-adopters, has now became mainstream.
I, myself, could have never imagined the magnitude of this digital transformation. A few years ago, I co-authored a chapter titled “Non-Traditional Methods of Care.” (1) Within a book on running academic medical practices, our chapter was the penultimate chapter — a sign of rather its marginalization for a clinician at that time — and covered topics like video visits, asynchronous visits, and telephone-based care. These digital tools were on the outskirts of other forms of care. Colleagues who read it found it interesting and some were enthusiastic about its potential.
And since the pandemic, I started recently sharing that chapter with my colleagues and practice leaders, though made a slight modification. I took a sharpie to the phrase “Non-Traditional” at the top. Now, in the COVID-19 era, the digital tools are just synonymous with care. The chapter became a manual and a handbook for running virtual clinics for both faculty and learners.
Before the pandemic, the main driver for digital transformation was “consumerism”, the concept that consumers were the big change that was going to drive the transformation of health delivery. At Inception Health, we were working towards adapting digital-based care to respond to the trend and support the transformation of our organization. The pace of adoption was growing but still linear. With the pandemic, the change was radical and exponential. Everyone was introduced to some form of virtual care, whether you were affluent or poor, young or old, a futurist or a Luddite. Everyone, all in this change together, at the same time.
In about two week, we increased to about a new normal of ~70% of care provided virtually.
We have embraced the concept that virtual is the best form of PPE, borrowed from Providence’s Aaron Martin. By moving care to virtual, we support the ‘safer at home’ approach by our governor, we reduce patient and staff exposure, and we reduce the need for personal protective equipment.
Virtual Care is the best PPE
The change has happened rapidly. Within a matter of a few weeks, care transitioned to virtual. Essentially, within about two weeks, about 70% of care became virtual. Patients, clinicians, and staff have been adjusting to new concepts, new technologies, and an ever-changing landscape of guidance that has generally been accepting of virtual care as long as it helps the patient.
Here are some of our initial thoughts and lessons that we have learned as we have transitioned to virtual care
Fertile Ground For the First Time
While we were doing virtual, video-based visits prior to March, 2020, the volume was very modest. We were working with only a few payors, which meant it was difficult to market widely or make it part of regular options to all patients. Schedulers would have to look at insurance, visit types, and departments, and if stars lined up, and patients were interested, then a virtual visit would be offered. And not every patient necessarily wanted a virtual visit, unsure about what the experience would be like.
Under COVID-19, the federal government and nearly all private insurers have made changes to cover telemedicine services for their patients, in order to support the safer-at-home governmental physical-distancing policies and reduce risk of disease transmission.
The widespread availability has given patients and clinicians an understanding of the strengths of virtual care. Patients are able to see their doctors on their own terms. We see patients taking calls in their cars, while they are at work, saving trips to the doctors office and time away from other obligations. We have seen patients and have a virtual visit to discuss smoking cessation, while on a “smoke break.” We have seen patients have rashes more quickly diagnosed, with reassurance provided or treatment initiated early on. We have seen patients who were otherwise going to go to an urgent care or emergency department for an evaluation be able to receive guidance either from their own doctor, who knows them, virtually, or from another clinician within our health system to advise them with the benefit of the health record for guidance.
With the rapid expansion of virtual care, we have also seen very rapidly changing regulations and guidance. We have also put to the forefront several of the principal issues related to care in the virtual world, namely what it means to practice when distance/proximity is not required. What will the landscape of interstate licensure need to look like when we have patients who travel across state lines to visit our bricks-and-mortar clinics? (2)
A question that our patients and clinicians are pondering now is whether virtual care is truly an ‘inferior service’ compared to in-person care. Certainly, in-person care enables a wider set of diagnostic capabilities, including but not limited to vital sign measurements, more complete physical examinations requiring auscultation, percussion, palpation where remote technology tools, which do exist, may not be readily available. Of course in person care also does not suffer from technology-induced problems like dropped connections, partially heard sentences, or pixelation on the screen. However, in medical school, we learned that patients tell clinicians to diagnose through their history at least 80% (3) of the time. We can achieve that diagnosis with the history and what video does offer us, ability for inspection and examination, nonverbal communication, and guided self-examinations of patients.
The conversation of whether virtual is an inferior service also reminds me of the late great Clayton Christianson, who described disruptive innovation while at Harvard Business School. The true academic sense of the term disruptive innovation occurs when an incumbent continues to perform the “ platinum” service, while an insurgent provides a generally considered “inferior” service at a lower end of a market. But that insurgent will be more readily adapting to trends, continuing to use advances in technology to refine the service, and may ultimately disrupt the incumbent. It’s like buying glasses now. Buying online, rather than in-person at an optician’s office, couldn’t possibly be a good idea, could it? How will they fit, and how will they look? Warby Parker (who had a nice profile in Adam Grant’s The Originals) started with an inferior buying experience. But they made rapid improvements. They shipped people “try-on” frames for free, enabling people to select frames and then mail them back (reminds me of Netflix). The process was longer certainly than going into a store. When I bought my most recent pair of new glasses, I used the WP app and augmented reality to “try on” glasses virtually, select a pair, snap a picture of my most recent prescription (available through our Froedtert.com patient portal), and click submit. And in a week, there they are.
Friction Has Tremendous Consequences
Care must be equitable, which is a professional obligation first and foremost, to mitigate well-described problems such as disparities of care. But similar to in-person care, virtual care is susceptible to friction of the care process. It just looks different. Friction is resistance from moving through a process, and can sometimes reach a point where it stalls forward progress. Friction has tremendous consequences. It can impede care, and so we (writ large) must continue to examine processes for friction.
As we map out a generic process for obtaining virtual care, we can see where friction can begin to build.
- Downloading and navigating new apps.
- Troubleshooting cameras and microphones.
- Self check-in processes.
These are all areas that could cause failure of a successful virtual visit.
Social determinants of health must also be examined and addressed sources of friction in addition to their broader roles in determining health. Access to smart devices and data plans, and comfort with technology, all shape the path of virtual care.
Lean process improvement, with an eye towards which steps are truly value-added from the patient perspective can shed light on friction. Health care organizations must be willing to reduce friction to ease the path into virtual care even if it means that we must do our work differently.
Lastly, I should point out that in several ways, virtual reduces friction of care for patients. Patients do not need to take as much time off from work, or arrange child-care necessarily for clinical appointments. Transportation is, for many, either difficult to arrange or less reliable than needed.
Primetime for Innovation
COVID-19 has been a time that has required rapid innovation, and we have seen all areas of health care respond. From new lab assays to rapidly emerging clinical evidence, this is a time of unprecedented innovation.
For health care delivery, this is also a time of tremendous innovation. As one of my heros, Dr. Don Berwick, put forth in a recent perspective about our “New Normal,” “Telemedicine has surged; social proximity seems possible without physical proximity…Virtual care at scale would release face-to-face time in clinical practice to be used for the patients who truly benefit from it.”(4)
We have seen the rise in automated technology to assess COVID-19 symptoms, which was particularly helpful in the earlier days when testing was so constrained. We used our partnership with Buoy Health to provide self-service tools on both our website Froedtert.com and our mobile app to help guide patients, and to connect with an on-demand virtual visit to arrange for testing. The future may look more towards even self-service, where able, for diagnostic testing (5), such as Seattle has been doing with mailing testing kits directly to homes. [NB I am an advisor for Buoy]
Patients are innovating to ensure the value of their clinical visits. Patients are collecting and recording vital signs and other remote measurements to make available during clinical encounters.(6)
Patients are also preparing for virtual visits in other ways, including providing some written updates on their health through novel, more bidirectional participation in the OpenNotes / OurNotes programs.(7) This is really cool to see. [Tool]
We are also seeing digital health programs have important roles in care during this pandemic. For example, we have deployed additional health tools to help with patient reported outcomes for all positive COVID-19 patients in our health system who are not admitted to the hospital, or who are discharged home after an admission from the hospital.
We are also continuing to use and expand our digital mental health solutions, a partnership with silver cloud and prescribed through our EHR-integrated digital health formulary powered by Xealth. [NB Inception is an investor in Xealth] A very recent clinical trial showed that it was sure that cognitive behavioral therapy delivered for the Internet was not inferior to in person, and this is a very helpful way to provide mental health services to patients in their homes.8
COVID-19 did not change the essence and the direction of the care transformation underway. It has however catalyzed its pace and removed the final barriers to its adoption. I personally see virtual care as being here to stay. It’s easy to see how the care fits more neatly into the lives of those we serve. The work is really only starting in many ways. We must continue to stabilize our platforms and reduce friction wherever possible. We must also continue to find ways to understand people on even more personal levels to meet them where they are, beyond the literal sense of location.
I am an advisor for Buoy Health.
Inception Health LLC is an investor in Xealth.
1. Weppner W, Crotty BH. Nontraditional Methods of Care [Internet]. In: Lu LB, Barrette E-P, Noronha C, Sobel HG, Tobin DG, editors. Leading an Academic Medical Practice. Cham: Springer International Publishing; 2018. p. 313–23.Available from: https://doi.org/10.1007/978-3-319-68267-9_24
2. Shachar C, Engel J, Elwyn G. Implications for Telehealth in a Postpandemic Future: Regulatory and Privacy Issues. JAMA [Internet] 2020 [cited 2020 May 18];Available from: https://jamanetwork.com/journals/jama/fullarticle/2766369?guestAccessKey=6ad8d832-e34e-46a8-bfd7-f0d2f0aebcd1&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=051820
3. Hampton JR, Harrison MJ, Mitchell JR, Prichard JS, Seymour C. Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients. Br Med J [Internet] 1975;2(5969):486–9. Available from: http://dx.doi.org/10.1136/bmj.2.5969.486
4. Berwick DM. Choices for the “New Normal.” JAMA [Internet] 2020;Available from: http://dx.doi.org/10.1001/jama.2020.6949
5. Nundy S, Patel KK. Self-Service Diagnosis of COVID-19 — Ready for Prime Time? JAMA Health Forum [Internet] 2020 [cited 2020 May 19];1(3):e200333–e200333. Available from: https://jamanetwork.com/channels/health-forum/fullarticle/2763264
6. Bradley SM. Use of Mobile Health and Patient-Generated Data-Making Health Care Better by Making Health Care Different. JAMA Netw Open [Internet] 2020;3(4):e202971. Available from: http://dx.doi.org/10.1001/jamanetworkopen.2020.2971
7. Kriegel Gila, Bell Sigall, Delbanco Tom, Walker Jan. Covid-19 as Innovation Accelerator: Cogenerating Telemedicine Visit Notes with Patients. Catalyst non-issue content [Internet] 1(3). Available from: https://doi.org/10.1056/CAT.20.0154
8. Axelsson E, Andersson E, Ljótsson B, Björkander D, Hedman-Lagerlöf M, Hedman-Lagerlöf E. Effect of Internet vs Face-to-Face Cognitive Behavior Therapy for Health Anxiety: A Randomized Noninferiority Clinical Trial. JAMA Psychiatry [Internet] 2020;Available from: http://dx.doi.org/10.1001/jamapsychiatry.2020.0940