TECHNOLOGY IN MEDICINE
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explaining the what, why and how of telehealth to the patients,
to providing technological troubleshooting advice to those
struggling with the system, to the slow process of gathering
the significant amount of health-related data verbally that was
routinely obtained using intake forms.
DR. IT TO THE RESCUE
With telehealth, it became the responsibility of the doctor to figure
out how to resolve information technology (IT) problems even before
the clinical visit. Telehealth visits can have technological issues
not typically seen during in-person visits. Such glitches include the
patient not being able to turn on their camera, microphone or speaker.
I’ve had some patients who I could see through the telehealth
portal, but I had to use the phone to talk to them because the audio
would not come through. Sometimes the visit was going quite well
until the video became glitchy or I couldn’t hear the patient, often
related to either the provider’s or patient’s internet connection.
During these times, they may have been in the midst of a story that
I wanted to know more about, but I could no longer hear them.
Unfortunately, the elderly—our most vulnerable population in
terms of deaths due to COVID-19—are highly susceptible to these
issues. These are the people we have tried to help avoid exposure at
all costs; however, they are also the ones who are the least familiar
with and lack access to the technology. Many of my elderly patients
tried early on to convince me to just see them in the clinic, despite
the risks. These issues have been most prominent to me in patients
in nursing facilities. This population has had some of the greatest
issues with spread of the virus and every time a resident has to leave
the facility, they risk exposing themselves and therefore the entire
facility upon return. I found it disconcerting that my patients in
nursing facilities were refusing to do telehealth visits because of
barriers to technology access or comprehension. Telehealth visits
should be treated the same as in-person visits, with scheduled visit
times, access to technology and personnel assistance as needed.
THE DOCTOR MAKES (VIRTUAL) HOME CALLS AGAIN
People tend to treat telehealth visits a little differently than their
regular visit, and I noticed a few common scenarios.
• The Shirtless Man. I’ve had several men not wearing a shirt
during the visit.
• The Bed Hugger. Several patients have been sitting or lying in
their beds. Many people have been in their bedrooms.
• The Worker and Hobbyist. I had one gentleman who was actively
turkey hunting at the time of his visit (Figure 1). He
had forgotten about the visit, but at least he answered the
call. Evidently, my call did not scare away the turkeys because
he showed his catch to me later. Other patients have been at
their place of employment, whether that be in the office or on
a construction site.
20 LOUISVILLE MEDICINE
• The Car Passenger. Some patients did the telehealth visit while
in their car. I worried that this scenario presented a peculiar
liability. Rarely, a patient would start to drive, at which moment
I had to inform them I would end the visit unless they stopped.
• Camera Confusion. Several people have been confused with the
location of the camera on the device, giving visuals of people’s
foreheads, chins or a single eye alone (Figure 1). Sometimes, the
visits were interrupted by family members asking the patient
about something personal or where to find an item in the house.
• Where’s the Child? Some parents did not realize the child (the
actual patient) was supposed to be on the virtual visit, but
fortunately, the child was often just in the other room since
everyone was “staying safe at home.”
• The On-the-Move Patient. Some people like to move around
when they’re talking to someone. This is no exception when
they’re using telehealth. Unfortunately, some people’s homes
have different connectivity receptions at different areas of the
house. I’ve had to tell these patients to stay in one place because
as they traveled around the house, the audio and video quality
would suffer so much I could no longer see or hear them or
they couldn’t see or hear me.
• The Pill Cabinet Spelunker. I have seen a lot of pill cabinets via
telehealth. One benefit, I suppose, is that the doctor can get
an adequate picture (literally) of the medications the patient
is taking. I found out that one of my patients was taking an
“as needed” medicine twice a day, a twice a day medicine as
needed, and a nighttime medication in the morning. At least
we are on the right track for now.
GREAT EXPECTATIONS
So what does the future hold for telehealth after COVID-19 is
finally behind us? Is telehealth here to stay? Who will use it and
for what situations? Will insurance carriers mandate that doctors
do telehealth visits in certain situations or will they stop covering
them again? Will insurance carriers continue to only contract with
third-party venders for telehealth visits and, if so, what is the impact
of this scenario on patient health from the lack of continuity of care
with a patient’s established provider? Telehealth requires technology
that may incur additional costs, not only for the software format
but also for applications to properly process paperwork and documents
in a HIPAA-secure manner. The visits may be prolonged
or made impossible by technical issues. The clinician has limited
capabilities in regards to physical examination and the inability to
perform minor procedures virtually. These issues are some of the
many topics that should be considered while these decisions unfold.
As the case numbers fall and we return to a semblance of normal,
this is not a time to abandon the technology. We should use this
time to identify the issues and prepare for its increased use in any
potential resurgence of COVID-19, or even the next pandemic.
Reimbursement coverage should encourage continuity of care as