For the last 17 years Iāve been an adamant fan and promoter of telehealth, predicting that over 80% of patientsā interactions with healthcare providers could be delivered āat a distanceā. And itās only 80% because I have also learned that telehealth, in its most common form as a live audio/video conversation, has its limitations to deliver extraordinary
care.
On the obvious side, telehealth is not going to replace hands-on exams, such as palpations of the stomach. Similarly, dental exams are trickier, too, though for an initial assessment and triage, telemedicine does suffice.
Whatās less obvious are the limitations of telemedicine for the longer term virtual care of patients, mainly because of healthcareās rightful reliance on the aptly named vital signs (pun intended).
One of my favorite quotes is that of Don Berwick, founder of the Institute of Healthcare Improvement, IHI: āEvery system is perfectly designed to get the results it gets.ā What that quote has taught me over the years is that in order to achieve different, better outcomes, one must change the system: the processes, the workflows, the technology, the incentives, the rewards, the policies, the training, etc.
In the rush into telehealth, though, many elements of the system were not changed, were not optimized for the delivery of care at a distance.
The Rush into Telehealth
When healthcare rushed into a full-throttle rollout of telehealth (albeit a lot of it still hiding as ātelephonicā-only telehealth), it was definitely the right thing to do: give patients, who need care or medical advice, access to medical professionals, preferably over video.
Going over test results? Great.
Ordering an interim refill? Got it.
Discussing the implications of delayed surgery? Doable.
Triaging your best care route with Covid-like symptoms? Perfect fit.
Where video-based telemedicine is definitely a great fit is in the behavioral health space - and has been for years. Counselling over video or the phone, including the prescription refills, offers new opportunities for continuity of care, reducing no-shows and improving engagement.
But when we enter the primary care and specialty realm of healthcare, going only by words, by live video of facial expressions and body language is not sufficient clinically in the long run. Ultimately, clinicians rely on access to good data about the clients conditions to make good care decision.
An Engineerās Care Process
My 20 years of working with physicians has taught me that Iām oversimplifying the following (and I mean no disrespect), but todayās modern primary care and specialty care medicine is most often a simple sequence:
- assessing the patientās condition and history
- ordering tests to confirm suspicions or hypotheses
- analyzing and reviewing the results
- developing and discussing a care plan
- following and monitoring the care plan (including in some cases invasive procedures)
While Telehealth is great for steps 1, 3, 4, and 5 (except the invasive part), there are limitations in the assessment of the patientās condition in step 1 and assessment of the difference the care plan makes in step 5.
As Covid-directed physical distancing continues, whatās mostly lacking is an accurate insight into the patientās key vital signs - those that typically would be acquired by the clinic staff in preparation for a patientās visit. For a few visits it was definitely acceptable to āfly in the darkā and go by the patientās vital signsā past performance (which, as we know from the financial literature fine print, is no prediction for future performance). But now, as the health crisis lingers, we need better solutions that still keep patients and staff
safe.
Whatās also missing, regarding step 2, is the coronavirus-safe access to frequent tests such as lab work and imaging. While solutions available for the home exist, the logistics of deploying them to a patientās home make most innovative solutions impractical for scaling.
Preparing a Patient for a Telemedicine Visit
Most healthcare organizations that jumped newly into telehealth in March 2020 merely gave the clinicians a video chat tool (or permission to just use the phone) and told āem to āgo do telehealthā. What was lacking was the whole set of workflows for the scheduling, pre-visit, and post-visit steps that typically make up a complete visit experience in the in-person-care world.
Telemedicine TechCheck
One of the key hallmarks of successful ādirect-to-consumer bring-your-own-deviceā telemedicine that we are practicing during this health crisis is the Telemedicine TechCheck, preferably conducted at the time of scheduling. I have written extensively about his unique but largely unknown practice here, here and here.
While a Telemedicine TechCheck can ensure a satisfying experience regarding the technical aspects of the telehealth visit, the clinical quality of the visit requires more than just a good connection. In addition to access to the patientās medical history, clinicians also need to have access to a most recent set of vital signs.