Turn Healthcare Workers Loose with Outpatient Telemedicine-Let Them Decide its Fate; No Top-down Decisions on What it Can and Cannot Do.

Telemedicine was used extensively for the first time by thousands of physicians, nurse practitioners, and other clinicians during the recent SARS-CoV-2 pandemic. Eager to continue providing care for patients while much about coronavirus was still unknown and many clinics lacked resources, clinicians embraced telemedicine. Health professionals and patients alike were impressed by the opportunities presented by this novel format and how responsive and adaptable the venue was in meeting the challenges of the pandemic. However, things are now slipping backward, fueled by mistaken ideas about telemedicine's applicability and accuracy. In addition, there have been misguided rulings and regulations brought about by organizations mindful of controlling patient-provider interactions and the monetary stream. This commentary seeks to address these issues. Author SAK is an infectious diseases physician who has used telemedicine to provide care to incarcerated men and women in the Arizona Department of Corrections since 2006, and more recently provided telemedicine care to HIV patients throughout the state who otherwise would have been forced to physically attend in-person clinic with all the risks that entailed. JBJ serves as the director of the ambulatory medicine clerkship for the College of Medicine and is an attending physician for internal medicine residents’ clinics. RR is a pulmonologist, intensive care, and sleep physician and editor of the Southwest Journal of Pulmonary and Critical Care. Although all of us are staunch advocates of telemedicine, we acknowledge its limitations as well. We recently reported on HIV telemedicine clinics conducted over 3 years of the SARS-CoV-2 pandemic involving over 900 patient visits.1Klotz SA Chan CB Bianchi S Egurrola C York LD. The genie is out of the bottle: telemedicine is more effective than brick-and-mortar clinics in the care of HIV-infected outpatients.Am J Med. 2023; 136: 360-364Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The most striking fact was the quality of outcomes achieved compared with in-person appointments. Utilizing telemedicine, 98.6% of the patients maintained sustained viral suppression, the goal of antiretroviral therapy. Previously, our best rate was a response of 91% sustained viral suppression for patients physically attending clinics in-person.2Klotz SA Bradley N Smith S Ahmad N. HIV infection-associated frailty: the solution for now is antiretroviral drugs: a perspective.J Int Assoc Provid AIDS Care. 2019; 182325958219831045Crossref PubMed Scopus (6) Google Scholar This remarkable achievement of nearly 99% sustained viral suppression was attained using telemedicine alone. Although success was in large part due to the strength and durability of current antiretroviral medications, patients needed to regularly attend telemedicine clinics to ensure consistent adherence. It was through use of this modality that regular interactions with a caregiver were feasible. Telemedicine was the ideal venue for accomplishing regular visits involving assessment and planning. It lends itself to short virtual visits backed up by occasional laboratory tests that serve as proof of treatment efficacy (for example, viral load and CD4 cell count) without in-person interaction, thus mitigating risks and personal inconvenience that accompany in-person appointments. A pharmacist and clinic director joined the caregiver for appointments lasting 20-25 minutes. Similarly, studies have shown effective use of telemedicine for the diagnosis and management of obstructive sleep apnea, most extensively to improve adherence to positive airway pressure therapy.3Shamim-Uzzaman QA Bae CJ Ehsan Z et al.The use of telemedicine for the diagnosis and treatment of sleep disorders: an American Academy of Sleep Medicine update.J Clin Sleep Med. 2021; 17: 1103-1107Crossref PubMed Scopus (36) Google Scholar During the chaos early in the pandemic, medical residents were re-assigned to wards and intensive care units while their outpatient appointments were canceled indefinitely. Medical students on ambulatory medicine clerkship developed a new clinic that enabled them, with faculty supervision, to perform outpatient telemedicine to hundreds of patients, most of whom were previously underserved. At graduation from medical school, students mentioned their telemedicine coverage of outpatients was the first time they felt genuinely valuable in medicine. Despite efforts from the clinical organization to move outpatients to exclusive in-person visits, patients from that clinic are still demanding the option of telemedicine visits. For many of these people, issues of leaving work, finding childcare or transportation present significant impediments to making an in-person appointment. Many clinical conditions are currently addressed through telemedicine, and many more could be. A complaint by many physicians is that since telemedicine is not in-person, the caregiver cannot physically examine the patient. Although some medical problems will be resolved only with in-person visits, it is surprising how many complaints can be effectively and accurately addressed during a virtual visit. An important key is for the caregiver to use “surrogate markers” in place of data normally collected during an in-person assessment. Readily accessed parameters such as blood pressure, heart rate, pulse oximetry, weight measurements, and blood samples do not require a patient to physically visit a clinic, and, in fact, the tools to collect vital measurements are sold at community pharmacies and online. With the availability of tools such as ultrasound for collecting physical data by the general public, the need for patients to visit a clinic may become increasingly unnecessary. Instead, data collection by the patient or community health worker could prove useful. For some patients in-person contact can be therapeutic by itself. In such cases and where a physical exam is required, a hybrid model of telemedicine augmented by in-person visits can be employed. It is said that digital literacy is not widespread among those born before 1980, who are referred to as “digital immigrants” as opposed to the younger, “digital natives.”4Prensky M. Digital natives, digital immigrants part 1.Horizon. 2001; 9Google Scholar If that were in fact true, older patients would primarily use brick-and-mortar clinics. However, in our study of HIV telemedicine, we did not find that to be the case even though most of the patients were older than 40 years of age.1Klotz SA Chan CB Bianchi S Egurrola C York LD. The genie is out of the bottle: telemedicine is more effective than brick-and-mortar clinics in the care of HIV-infected outpatients.Am J Med. 2023; 136: 360-364Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Patients not attending telemedicine clinics were the same patients who failed to keep in-person appointments. Computer literacy (or telemedicine skills) among these patients appeared to have little to do with age, rather it was a willingness to try telemedicine. Hospitals and clinics communicate with patients almost exclusively by e-mail and smartphone messaging. Virtual clinic appointments can be sent by e-mail or smartphone. It is helpful if the clinic manager contacts patients by telephone prior to the visit to iron out any potential connection issues. Failing all else, a telephone visit is acceptable (and actually preferred by some patients for its anonymity). A significant hurdle to the widespread adoption of telemedicine is concern over reimbursement disparities between the virtual service and “hands on” assessment. Moves to decrease reimbursement for clinician time and expertise based on whether the patient is present in 3 dimensions or 2 significantly reduces enthusiasm for use of telemedicine in healthcare organizations. The truth is that in-person clinic visits are probably over-compensated for what they accomplish, and telemedicine visits are significantly undervalued and undercompensated. A recent report shows state-by-state laws regarding telemedicine parity. In summary, “21 states have implemented policies requiring payment parity, 6 states have payment parity in place with caveats, and 23 states have no payment parity.”5Augenstein J, Marks J. Manatt, Phelps & Phillips, LLP. Executive summary: tracking telehealth changes state-by-state in response to COVID-19-April 2023#2. Available at: https://www.jdsupra.com/legalnews/executive-summary-tracking-telehealth-6432678. Accessed April 27, 2023.Google Scholar Time will disclose what all of this means in practice. The limited coverage of broadband and technical impediments may pose problems for video connectivity in rural or tribal communities, and telephone visits remain a mainstay for many geriatric patients.6Woodall T Ramage M LaBruyer JT McLean W Tak CR. Telemedicine services during COVID-19: Considerations for medically underserved populations.J Rural Health. 2021; 37: 231-234Crossref PubMed Scopus (39) Google Scholar However, increased government support for broadband expansion and technology adaptations are rapidly addressing these obstacles. In-person clinic visits are costly for both the provider and patient with respect to time, money, and effort needed to bring them together. However, the medical staff needed for an in-person visit can now join a virtual visit from different sites thus providing team care. Time utilization by healthcare providers is more efficient with telemedicine; attendance at virtual clinics by outpatients (the show rate) is significantly higher than the show rate for patients in brick-and-mortar clinics.1Klotz SA Chan CB Bianchi S Egurrola C York LD. The genie is out of the bottle: telemedicine is more effective than brick-and-mortar clinics in the care of HIV-infected outpatients.Am J Med. 2023; 136: 360-364Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Failing to implement telemedicine widely will result in patients losing the virtual option for medical care, leaving them unnecessarily burdened with in-person visits. Outpatients prefer telemedicine over brick-and-mortar clinic visits,1Klotz SA Chan CB Bianchi S Egurrola C York LD. The genie is out of the bottle: telemedicine is more effective than brick-and-mortar clinics in the care of HIV-infected outpatients.Am J Med. 2023; 136: 360-364Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar as it is more convenient and less expensive and, transportation and office space are not required. Clinicians must be free to construct their outpatient Telemedicine visits in such a way as to meet the needs of the patient as well as the clinician. The last thing clinicians need is top-down decisions and rules of how to perform telemedicine. Let the practitioners figure it out. Timely, efficient visits using telemedicine are major contributing factors to achieving patient satisfaction.