What kind of future does telemedicine promise?

A non-COVID newsletter... let's see how this goes

This newsletter installment isn’t about COVID-19.

I won’t be offended if you stop reading now. I understand that COVID news progresses at a rapid pace and that you’re probably only subscribed to my newsletter because of the COVID content.

But other things are happening in the world of medicine and healthcare, and I decided that this newsletter will also touch on them from time to time.

The topic for today is COVID-adjacent, anyway, since pre-COVID this wasn’t really on my radar. I want to talk about telehealth - my initial experience, where it works, where it falls short, and promise for the future.

What’s the difference between telemedicine and telehealth?

They are kind of like squares and rectangles. All telemedicine is technically telehealth, whereas only some telehealth is telemedicine.

Although the terms are often used interchangeably, telemedicine refers to physician visits done via video conferencing platform whereas telehealth can be any type of healthcare access - remote nursing, pharmacy, or health behavior monitoring - in addition to doctor’s visits.

My telehealth experience

When I have telehealth appointments scheduled, I show up at my office and log into the AmWell platform (our telehelth vendor) where I see a list of my scheduled appointments for the day.

When my patient is ready, a pop-up notification appears on my screen with a link to a video chat with the patient. There’s also a phone app with push notifications that come even if the app isn’t open.

The process of logging on and connecting to the platform has been seamless for me.

My patients have had around a 50% success rate. I don’t know if this is because they’re old and not tech savvy, the instructions from my office aren’t clear, the AmWell platform is buggy on the patient side, or some combination of the above.

I click the link, a new window opens with my patient on video chat. It’s really similar to Zoom with buttons for all kinds of different adjustments, although I can’t change my background. There’s a chat box so I can write out instructions to the patient.

We basically have a normal appointment, minus the blood pressure, physical exam, and EKG.

I have the same amount of annoying paperwork in the medical chart, the same number of redundant clicks, the same medication reconciliation, the same documentation of our plan.

I can still order bloodwork, testing, and send patients for referrals.

Where telehealth works

While the experience for the doctor is pretty similar to a normal visit, telehealth is way more convenient for the patient. You get to skip the travel to the office and a huge amount of waiting.

This is particularly useful for my elderly patients and those who have trouble getting around.

The built in chat box has also been surprisingly useful. I find myself in person sometimes writing things down for patients - names of medications, tests, my email - and this streamlines the process.

Our telehealth visits are quick, to the point, and get the job done effectively and efficiently. Most patients don’t have ailments that require a physical exam to address as long as we’re able to obtain bloodwork and other testing.

We’re able to discuss lifestyle in a more in-depth fashion. This means more time spent on nutrition, physical activity, stress management, and sleep hygiene.

Where telehealth falls short

The biggest flaw in telehealth is for the sickest patients.

In particular, congestive heart failure patients don’t have a high quality telehealth experience. The most important part of the assessment in the CHF patient is determining fluid status - are they retaining fluid or do they look dried out? This requires evaluation of something called jugular venous pressure, which, in not just my opinion, is the most important part of the physical exam that a cardiologist performs.

So the lack of physical exam matters for my sickest patients. But for the majority of people, it’s barely significant.

And the others flaws I’ve noticed are probably easily correctable.

I’ve seen that after about 8 minutes, most people start looking at other stuff in their home away from the screen, clearly distracted and ready to be done with the visit.

Maybe I’m just not engaging enough, but my patients don’t seem to get distracted in this way during my office visits.

Like any Facetime or Zoom interaction, there isn’t any eye contact. We both look at each other, but it’s a bit different. For whatever reason, the interaction feels more superficial. I’m sure part of this is my response to the artificial nature of the “visit.”

I do wonder about the long term effects on building the doctor-patient relationship, but I’m not ready to give up on telehealth for this just yet.

Promise for the future, but not quite there yet

I’ve noticed that a surprising number of my patients have a blood pressure cuff at home and are able to give me information about their blood pressure and heart rate at the time of our visit.

This type of home data collection is the next step in the evolution of the telehealth visit. There are a lot of companies already trying to bridge this divide.

AliveCor lets us capture an in-home EKG.

DexCom and Abbott make continuous glucose monitors that give us all kinds of insight into the blood sugar status of diabetics.

We also have even more medicalized invasive “wearables” in the form of the CardioMEMS device for patients with frequent heart failure problems or LINQ cardiac monitoring for patients with unexplained fainting episodes.

I view this sort of at home testing or data collection as the next step in the evolution of telehealth.

The integration of at home data collection with standard medical testing has a lot of promise but also many hurdles to overcome. There’s also the question of whether more data means better data, and a lot of work must be done to ensure that we’re not creating more problems than we solve.

The kernel of possibility for revolutionizing healthcare is visible with the telehealth we have now. If something good has come out of this pandemic, hopefully it will be the increased exposure of telehealth and the innovation this exposure will drive to better care.