Telemedicine dominated 2020, but what happens when patients aren't stuck at home anymore?

There was a time, not too long ago, where the only people who knew how to use Zoom were those who spent their days going from meeting to meeting. Then the pandemic struck, and everyone and their mother had to get up to speed on enterprise-grade teleconferencing if they wanted to see their friends and loved ones.

The video revolution of the last year was a massive boon for the health care industry, allowing health care providers to stay in contact with patients who otherwise might have been cut off from care as lockdown orders proliferated. In the U.S., regulators waived their stances on telehealth, and insurance companies set up structures where the e-visits could be billed similarly to in-person visits. All of this happened within a matter of weeks, and it was a prime example of many different groups moving quickly to adapt to the new normal.

But with vaccines beginning to roll out across the country, what will the next normal look like? The groundwork laid long before the pandemic has set the health care industry up for a new, more blended future. When the world opens back up, experts Protocol spoke with said that health care will look different than it does right now, as well as what came before, with telemedicine no longer relegated to the sidelines for clinical care.

Laying the groundwork

The pandemic left many health care providers scrambling to figure out how to get online and connected to patients. But some in the industry saw this revolution coming. "This is not really new or exciting technology; this has all been around for years," Leslie Eiland, director of the endocrine telehealth program at Nebraska Medicine, told Protocol. "I think what prevented us from using it is just the lack of reimbursement models."

The Nebraska Medicine system serves patients hundreds of miles from its home base in Omaha. Eiland said that the endocrine team started its telehealth service back in 2013 to provide care for rural patients who just couldn't easily get into the city to see specialists. "We chose that model because that was our only model," Eiland said. There were restrictions — you had to be from a rural area, and you had to still go in to a local clinic to have the e-visit — but the groundwork was there.

Similarly, other departments at Nebraska Medicine said they had started telehealth programs prior to the pandemic to connect to people who couldn't make it in person. Proleta Datta, a neurologist specializing in epilepsy care, and Jennifer Adams, a dermatologist, both said work began in 2019 for their respective practices to kick off telemedicine efforts. But Adams called the effort an "uphill battle" when it came to getting insurers to pay for telemedicine when in-person visits were more lucrative. Adams helped set up an asynchronous system where patients can reach out to the department with pictures of their body to see if their rashes and bumps are concerning enough to come in. "Tele-derm has been just completely enormous for our department," Adams said.

Paul Testa, the chief medical information officer at NYU Langone, a large health system in New York, also said it was about two years ago that his practice started to dive into telehealth. They started with a virtual urgent care operation to help triage whether people needed to come in to see a clinician. "That was really where we cut our teeth, both in the technology and the process around video visits and telehealth," Testa said.

Testa said that NYU Langone quickly moved to integrate telemedicine visits into its app and electronic health record system, which is provided by Epic. The goal, Testa said, was to ensure that when a patient saw any provider in the system, digitally or in person, they didn't have to tell them information they'd told someone else during an earlier visit. "The data the patients give us is incredibly important," Testa said. "When you tell me your preferred pharmacy is the mom-and-pop pharmacy on 117th and Columbus, I want to make sure you don't tell me that three times."

Prior to the pandemic, though, these virtual visits were used sparingly. Testa said they were primarily used for postoperative check-ins and mental health sessions, and that across the network, there would be about 50 visits per day, with about 500 clinicians set up to do telehealth calls.

Operating remotely

When the pandemic hit, Testa said that NYU Langone's handful of daily telehealth visits ballooned to around 8,000 in the span of about two weeks. But given that the health system had spent the last few years testing and deploying its solution, there weren't too many speed bumps — at least from a technical standpoint. "The technology was in place, and tech scales," Testa said. The only tech hurdle was ensuring that the process for scheduling e-visits was the same as in-person visits, he said. Beyond that, it was really about getting more people onboard.

In that short span of time, NYU trained an additional 4,000 clinicians on the best practices for telemedicine. In some cases, that might've been things like installing software, or even helping to set up their homes to speak to patients privately.

David Cloyed, Nebraska Medicine's director of enterprise applications, said that the health system's Zoom, EHR and asynchronous messaging systems are centrally managed through IT, but that some departments have their own telehealth setups for specialized use cases.

"Zoom and Epic aren't a panacea."

"My team is constantly evaluating other options, because Zoom and Epic aren't a panacea, but there's a cost, and we have to be responsible," Cloyed said. But being able to share information digitally has certainly made life easier, if more distant, for providers in this time. "Before, you'd have this paper chart, and you'd have a shadow chart and now, we're all on the same platform."

But there are obvious limitations to what can be done remotely. While there has been a boom in connected devices for remotely monitoring patients at home during the pandemic, there's still only so much a provider can glean from the data in a vacuum. "Doctors need to put their hands on patients, and patients need to be in the same room with doctors," NYU's Testa said.

I even asked my own doctor during a recent routine telehealth visit how she felt about seeing all her patients on video calls. She told me that even minor reasons for coming into the doctor's office, like refilling a patient's prescription, can be a good opportunity to check in on their health. There are some things, like getting someone's vitals, that can't easily be done over Zoom, but can make a big difference. On the flip side, Testa told me that while testing out a blood-pressure monitor for work during the pandemic, his own doctor discovered he should be on blood-pressure medication through the data the monitor sent. So there are some aspects to care that can translate digitally.

But telemedicine also lowers the barrier to talking to a doctor, both in terms of stress levels and from a socio-economic standpoint. There's no drive to the office, no off-putting exam room, no flurry of white lab coats, no thermometers in uncomfortable places when you're sitting on your living room sofa. Nebraska's Eiland said that a few years back, her team ran a survey for patients using telemedicine visits at a rural community hospital to talk to specialists in the system. The survey asked what the patients would've done had they not been able to do a telemedicine visit, and 40% of respondents said they wouldn't have been able to seek care, Eiland said.

What the future holds

With light beginning to slowly emerge at the end of the tunnel of this pandemic, there will come a time soon when many patients can return to health care facilities. What role will telemedicine play when people don't have to be stuck at home all the time?

"I envision the future as blended care, where the patient has options," Nebraska's Datta said. "As physicians, we can say, 'You know, I haven't seen you in two years, I'm a little concerned about something, why don't you come in? I want to check this out." It's a way, Datta said, for patients to stay connected to their doctors without the need to go in all the time. Both Datta and Adams have patients that they need to check in on routinely who in the past have had to come in. In Adams' case, it might be children on acne medication where she's required to monitor them every month, meaning parents have to take them out of school for the check-in. Telemedicine, even in regular times, could take that burden away. "The patient doesn't have to come in, they could do an appointment over their lunch break or when they have time," Datta said. "And that way, I feel like telehealth medicine will empower both [the] physician and patient to advocate more for their own health."

For others, a digital divide already exists that keeps them from using telemedicine services. In some cases, that's rural farmers with poor internet connectivity, and in others, it's those who don't have access to connected devices. While telemedicine visits can ease burdened health systems by helping doctors triage which patients need to come in immediately, work still needs to be done to bring medical access to those who need it most.

"Those who have had most challenges accessing health care — veterans, the homeless, individual minority populations — we have to think differently about how we reach out to them," NYU's Testa said. "And that means a much more heavy touch in their communities."

For NYU Langone, that's meant demonstrating services available at churches and barbershops, and bringing telemedicine to roughly a dozen schools in Brooklyn, Testa said. In Nebraska, the system is trying to make sure no one is left behind. Eiland said her team is working with biostatisticians to figure out where patients have been coming from, and where telemedicine visits have originated from, to see if there are any blind spots.

There's no one answer to solving geographic and economic disparities with telemedicine, but Eiland suggested one approach to bring conferencing services to more safe public spaces, such as setting up webcams in private areas of libraries or community centers. This would allow patients without internet — as well as those who don't feel comfortable talking at home — to connect with clinicians even if they're hundreds of miles away. "We're asking a lot; this is requiring stable internet, a connected device and a decent level of technological literacy in order to make these visits happen," Eiland said. "And for some people, that's just not possible."

This new blended future could mean quick visits can happen online and aspects of clinical care can be unbundled from clinical settings. But that likely will entail more devices that allow physicians to remotely monitor patients. In some areas of medicine, those devices are already proliferating. "We're seeing a lot more; there's been a whole new set of billing codes to remote patient monitoring," Christina Farr, a health tech investor at OMERS Ventures, said. "That tends to relate to a specific disease: If you have congestive heart failure, you're now pretty commonly sent home with a wireless weight scale, because rapid weight gain in general is a very important thing to be monitoring."

Right now, these sorts of devices are primarily the domain of those who can afford them — or have the insurance. "[They] tend to be developed for the higher-income patient population," Farr said. "And it's a real shame, because these are not necessarily the groups that need this the most."

One remote management company that's trying to make the proposition of using these devices simpler is Current Health. It offers a device that can continuously monitor patients' vital signs, sending them to their health care provider and alerting them when there's an issue. Patients can then use their phones or provided tablets to e-visit with their providers. Current Health takes care of some connectivity and tech-wrangling issues by providing a hub with SIM cards for all major U.S. networks, so that patients can just connect their monitoring device to the hub's Wi-Fi and not have to worry about it again. For patients coming home from operations, or with diseases like COVID-19 that can in some cases more safely be monitored from home, Current Health allows them to spend less time in hospital recovery rooms, according to Adam Wolfberg, chief medical officer at Current Health. "Not only does it give you insight into what's going on with the patient from a vital sign perspective, but it's also an incredible safety net," Wolfberg said.

But for devices like Current Health's to expand to a greater swath of the population, or for telemedicine to keep its place in health care post-pandemic, the experts agreed that it's going to require changes from doctors, insurers and regulators.

For doctors, it'll mean adjusting to fit in both in-office visits and chats throughout the day. "It's very easy to walk into your office in the morning, look at the 20 patients you have on your schedule, your medical assistant has pulled the charts, printed them out of the EHR for you to look at before you walk into the room," Wolfberg said. "We all trained that way, we all know how to do that: Thinking about providing care as a combination of in-person and remote visits is going to require some flexibility."

For regulators, it's going to require making some permanent changes. "We're still working under waivers right now, and we're all very nervous about those waivers not being finalized," Nebraska's Cloyed said. The concern, he added, is that federal and state governments may not move as quickly as needed, and some of the temporary measures put in place last spring could be rolled back, with "our patients being left in the middle."

"Your health care provider is not going to do a prostate exam on Zoom."

Some of those regulatory changes are being made permanent, but the concern over how these services are billed still remains. "My hope would be that we're not burdened by the restrictions imposed on us by an archaic payment system," Current Health's Wolfberg said of the future. "Remote care can be provided where patients gain benefit: The consultation with the specialist who's 200 miles away can be done by telehealth and is not done in person because the specialist won't get paid unless the person shows up in their office."

If patients and doctors agree that there's value in remote care, the hope is that eventually the remaining kinks in the system will be worked out. Regulatory bodies are working on rules to monitor patients that will see them reimbursed to similar amounts as they would be for in-person visits, but the rules are still not as flexible as some telehealth advocates would like. But patients and their providers are still pushing the demand, Nebraska's doctors said. "I like the fact that my patients now have options," Datta said, suggesting that much of the counseling work she does for patients, like consulting with an epilepsy patient who is looking into getting pregnant, can be done online or over the phone. But others, if they want to or have to come in for their care, can do so, too. "Your health care provider is not going to do a prostate exam on Zoom," Wolfberg said.

Telehealth may not hit the heights that the pandemic forced upon it over the last year, but the reasons for speaking with health care providers, while coming in less often, are only likely to increase as a result of its influence.

"The same tipping point that's coming for video visits is coming for remote patient monitoring," Testa said. "There's no putting this genie back in the bottle."