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A Da Vinci robot being used to help human surgeons operate on a patient. Now, the surgeons in charge can be thousands of miles away.

Photo: Courtesy of Intuitive Surgical
Protocol Manual: Health Care

The pandemic has ushered in the future of health care, and it looks a lot like Zoom

COVID-19 has kept us from the doctor's office, but telemedicine is likely here to stay, experts say.

At a time when people are dying from a highly infectious disease in a worldwide pandemic, patients are staying away from the people who can keep them safe. Doctor's offices and hospitals attract the sick and can become areas that illnesses spread. But it's also due to legislation that ordered citizens to shelter in place in cities and states across the U.S.

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"When COVID started to spread in the U.S., alarms went off in places where we operate physical, in-person clinics," said Andrew Diamond, chief medical officer at One Medical, a primary-care practice group established in 2007, with more than 85 locations nationwide. "It's a familiar story now, but all doctor's offices and hospitals just saw their expected visits disappear entirely."

Four in 10 physicians say their patient loads have fallen since coronavirus struck the U.S., and around 15% say they closed their practices, either permanently or temporarily. But One Medical was better-placed than most to react to the new norm in medicine. Every step of the treatment process — from patient intake and triaging, through to diagnosing illnesses and treating them, right the way to outpatient aftercare — is moving online.

The shift to telemedicine isn't new: For years, telehealth advocates have been pressing to move medicine online where possible. Like many aspects of society, coronavirus has accelerated what was a more measured, longer-term shift from the old ways to the new. Today, even the strongest holdouts against medicine's digital revolution are recognizing the power to connect with patients and keep them healthy while not being in the same room. At the same time, regulators and technologists are rapidly rewriting rules to accommodate the new normal. It's a whole-system rethink of the way medicine works, with potentially enormous implications for the health of everyday Americans.

Surgery via Skype

Huge numbers of scheduled surgical dates have been scrapped as health care providers scrambled to bring more staff to the front line against COVID-19. But for many, operations still need to go ahead: It's literally a life or death situation.

Business has been good for Help Lightning, a telesurgery company founded by Bart Guthrie, a neurosurgeon based at the University of Alabama at Birmingham. Guthrie wanted to be able to support surgery from 1,000 miles away, but wanted to be more of a participant than simply a passive viewer guiding surgeons while watching on a screen. He and CEO Gary York developed what they call a "virtual interactive presence," merging video streams so that remote helpers can aid those conducting surgery in person by gesturing onscreen to where a surgeon should make an incision. Usage has risen more than four times between February and April, according to York.

That remote working has become more important as medical staff on the front line of the battle against COVID-19 fall sick and health care rosters are depleted. Remotely guided and supported surgery is taking place all over the world: a laparoscopic surgery to remove a 2-inch cancerous tumor that had spread to the stomach of a 31-year-old patient took place in London in late May. The surgeon in the operating theater, using the Da Vinci surgical robot developed by Intuitive Surgical, was guided by a colleague who sat in his pajamas (yes, really) 4,700 miles away in Seattle. The Seattle-based surgeon, using a similar technology to Help Lightning developed in the U.K. called Proximie, was able to point to specific areas where the London-based surgeon should make his incisions, his pointing finger overlaid on video footage of the patient's body.

The patient's tumor was removed successfully, and he praised the surgeon who operated on him — as well as the one who stayed up from 1 until 7 a.m. Pacific time to help guide his colleague.

Delivering front-line health services

It's not just in surgery itself that remote technology is offering opportunities. Tech has been used to triage and assess patients, as well as to cut down on the in-person contact that helps curtail the virus. It's also being used to make hospitals work smarter and cut down on waste. Early on in the coronavirus crisis, personal protective equipment was in short supply. "In those cases, some physicians, instead of putting on the gown and mask and going in to see the patient presurgery, did those visits virtually, preserving the protective equipment," York said.

Doctors have also been using telemedicine tech to continue to treat patients remotely during the pandemic. Jim Johnston, a pediatric neurosurgeon at the University of Alabama at Birmingham, has been seeing more than half of the patients at his clinic virtually in recent months. "I don't see it going back because it's an incredible convenience for families and for physicians," Johnston said.

Overall, across the U.S., physicians and other health professionals have seen between a 50 and 175 times increase in telehealth patient numbers during the pandemic compared to last year, according to a report by McKinsey. The report said that about 10% of U.S. health care consumers used telehealth services in 2019 — nearly half are now and 75% are interested in using telehealth more in the future.

There are headaches in this, though. In an attempt to make treatment accessible, many doctor's offices have turned to nonspecialist software like Zoom or FaceTime, which have been used by 56% of health care administrators to connect with their patients. But detailing private medical conditions through unsecure connections on nonmedical software is a potential HIPAA nightmare. State-by-state regulation systems are problematic, too.

"Every state's regulations are different," said Gloria Lau, CEO of Alpha Medical, an online women's clinic that delivers primary care digitally. "Before COVID, there were a number of states where asynchronous telemedicine was fairly difficult." That's an issue, not least because asynchronous medicine is often less traumatic or worrisome for patients, Lau claims. The ability to fill out a medical intake form in your own time can help patients think more carefully about the onset of symptoms and what worries them, as well as reducing anxiety for patients who may often be approaching doctors about mental health issues. Alpha Medical saw a huge spike in patients when coronavirus was declared a pandemic, with volumes on the platform doubling since February, Lau said.

The regulatory struggles have a knock-on effect on medical finances. Physicians worried that video clinics wouldn't be reimbursed by insurance providers, so were wary of conducting them. (They're right to be concerned: One recent report says each primary-care practice could lose nearly $68,000 each this year due to reimbursement issues.) "COVID very quickly reversed a lot of that resistance from a billing standpoint," Johnston said. Since the pandemic, the Centers for Medicare and Medicaid Services temporarily approved more than 80 new telehealth services, and relaxed regulation around telehealth to improve access to care.

Maintaining care, even from afar

While large parts of the economy have been put in stasis for the last few months, it's vital that medicine doesn't stand still. Every day that hospitals worldwide are focusing on treating the COVID-positive patients in front of them, they're not training the next generation of junior doctors and specialists.

The medical-training community can rely to some extent on social media support groups, listservs and other tools, but a large proportion of training today comes from senior doctors getting on planes and flying to talk and demonstrate to students. Given the enormous decrease in the number of flights criss-crossing the globe, that's no longer feasible. The stark realities of the new post-COVID world are demolishing long-held barriers to technological advancement. "I have many colleagues who were less enthusiastic about trying to set this up when they were following the old model of flying back and forth a couple of times a year," said Johnston of his telehealth software. "Now there's no travel, everyone is clamoring for this kind of technology."

"People say a picture is worth a thousand words, and a video is worth 10,000 words, but when you can integrate video with someone else interacting in real time with you, it's worth 100,000 or a million words, in terms of teaching," Johnston said. He is also the co-founder of InterSurgeon, a social network for training surgeons with nearly 500 members across 85 countries. "I'm just very excited that now we've gone through this, people are understanding what they can do with this technology."

That suspicion of digital delivery extends to patients and practicing doctors, too. Alpha Medical's Lau has seen a change in attitudes of patients compelled to move to digital health platforms. "For the more complicated medical conditions, getting people comfortable to see a doctor online previously was difficult," she said. "But during COVID, a lack of access made patients more creative. They got more comfortable with that type of care delivered online." Physicians, too, have softened their opposition to digital practice in general, and asynchronous delivery in particular. For doctors whose physical offices are closed, digital triage and treatment is another revenue stream and a way to practice medicine during a pandemic.

The key question is whether it's an apples-to-apples experience. "That's going to depend a lot on the subspecialty," Johnston said. "This is something that's in progress and each subspecialty is figuring out the safe percentage amount, but I think it's a lot more than we thought before this all started." Whether every doctor's visit will be swapped out for a telehealth call in the future is "the billion-dollar question," One Medical's Diamond said. (McKinsey actually reckons it's more like $250 billion, or a fifth of what Medicare, Medicaid and commercial insurers spend on health visits each year.)

"When there's an out-of-control pandemic ravaging your community and your government has told you not to leave the house except in an emergency, it's got to be almost a one-for-one replacement," Diamond said. "You don't have an alternative."

Opening up access to health care

Coronavirus highlighted an odd contradiction: In a world where we can deliver pizzas and pho to our door through Postmates, large parts of health care, including prescription delivery and rudimentary at-home testing aren't really being delivered digitally.

"Throughout COVID, telemedicine is becoming a household name," Alpha Medical's Lau said. Her company has already offered as much outpatient and ongoing care as possible remotely, even before the pandemic. The company knows an asthma script is going to be on a patient's file for years, if not decades, so it offers shipment through local pharmacies direct to patients' doors. Other, more urgent care conditions, like treatment of UTIs, happen on an ad-hoc basis, so prescriptions have to be filled and collected through neighborhood pharmacies. But the company has long been advocating for a shift in how medicine is transacted away from sterile, stuffy doctor's offices and hospitals to the home. "We deliver various kinds of at-home tests when it's clinically appropriate to deliver it at home," Lau added.

Telemedicine will have varying effects on outpatient delivery: Patient visit data, analyzed by The Commonwealth Fund, a private organization that promotes accessible health care in the U.S., shows that telemedicine went from accounting for 0.1% of all visits to ambulatory-care practices at the start of March, to now being used in 7.4% of visits. At its peak midcrisis, that number reached 13.8%.

That could help rebalance the inequality felt across the U.S. when it comes to accessing health care. A 2019 study showed that the U.S. is one of the most unequal countries in the world for health outcomes, with race and income playing large roles. "Access to care is a lot lower-cost when you can deliver everything digitally," Lau said. "Part of it is about utilization — how much access can you get to the health care system — because we don't have an even supply of physicians," she added. "When you think about patients in certain places, there's definitely a shortage of primary-care providers, and the only way we'll bridge that gap is through technologies like ours."

Next in Protocol's Health Care Manual: Pivoting to COVID-19: How a weekend sprint helped one startup boost adoption

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