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Telemedicine companies are becoming a crucial first line of defense against coronavirus.

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Inside the telehealth companies rushing to take on COVID-19

Telemedicine is finally having its moment. But this isn't how any of the executives running the companies wanted it to happen.

Every winter, Robin Glass and her team at the telemedicine startup Doctor on Demand brace themselves for the annual flu surge that brings new patients to their platform, seeking virtual visits with their network of physicians.

But those seasonal spikes have nothing on the harrowing threat the novel coronavirus now poses. As the country's strained health care system grapples with the exponential spread of COVID-19 and panic-stricken patients wonder whether they might be infected, telemedicine companies like Doctor on Demand, where Glass is president, are becoming a crucial first line of defense against the virus.


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Already, Glass said the company is seeing a 15% to 20% increase in patient visits compared with a typical flu season. Wheel, an Austin-based startup that vets virtual clinicians for other telehealth platforms, said not only are clients seeing "a remarkable increase" in requests for virtual visits, but Wheel is also seeing a rush of doctors eager to join its network and lend a hand. Even Roman, a telemedicine platform best known for treating men's health issues like erectile dysfunction and hair loss, is triaging patients in eight states and Washington, D.C., with its Coronavirus Telehealth Assessment. The company expects to expand nationally by next week.

After years of slowly insinuating itself into the health care system, telemedicine's moment is finally here — for reasons Glass and other executives in her industry hoped would never come to pass.

"Everyone's starting to realize we just need to reduce any barriers to accessing care, particularly care in a virtual setting that's inherently less infectious and less cumbersome on the overall health care system," Glass said. "As difficult as the situation is, and as much as all of us wish it weren't here, I think it's highlighting a really valuable resource that virtual care brings."

Since the first case was announced in the United States at the end of January, government health officials have been championing telehealth as a core part of the coronavirus response. Major health insurers, as well as Medicare and Medicaid, are waiving co-pays for coronavirus tests and some telemedicine visits. In a press briefing on Tuesday, Vice President Mike Pence trumpeted telemedicine as a way for older patients in particular to "get medical advice without having to go to the doctor or go to an emergency room." Meanwhile, the Centers for Disease Control recently held a conference call with a number of telehealth companies, including Wheel, to help them develop risk assessment protocols for their platforms.

The push is being driven by the need to free up capacity for coronavirus patients who require in-person care, the need to identify people who may have mild cases before they enter a hospital setting, and the need to keep otherwise healthy people away from hospitals and doctors offices where they could be exposed, and therefore expose others, to the virus.

"If we have a modality in place to effectively treat a patient who's a low-risk mild case, it's not just going to be a reduction of one patient encounter at the ER, it's potentially an exponential reduction," said Dr. Rafid Fadul, chief medical officer for Wheel.

Medical experts say this kind of triaging is key as the country's already resource-strapped health care system faces down a still unknowable burden. "There's a certain number of beds, a certain number of workers that can service patients and help them, and when the number of patients exceeds that capacity, you have to make tough decisions, no matter what," Joe DeRisi, co-president of the Chan Zuckerberg Initiative's Biohub, said during a Facebook Live discussion with Mark Zuckerberg on Thursday. DeRisi is part of the team that discovered the SARS virus and is now a professor of biochemistry at the University of California, San Francisco.

Both Fadul and Glass say they were monitoring the virus' spread in China long before it hit the United States, but Fadul recalls the first U.S. fatality in late February as a turning point at the company.

"We were starting to understand the virus a little better," he said. "You start seeing what the trend is going to look like."

Wheel's staff has since been working overtime to train its network of clinicians across the country how to identify who is most at risk and in need of testing. The company has held webinars and disseminated fact sheets to its doctors in hopes of turning them into "COVID-19 specialists," Fadul said.

"It's learning the clinical pathways as to who gets triaged, who gets quarantined, and at what point do you activate the department of health?" he said.

Ro, the telehealth company that operates Roman, is also putting its doctors through a webinar program and developing "sandbox environments," demos that allow them to play out possible scenarios, a spokesperson said.

The companies have all developed risk assessment tools that take into account people's travel history, their symptoms, and their other underlying medical issues that might dictate what type of care they need. Fadul said the ordinarily competitive industry has worked together to ensure these tools are in line with the CDC's protocols.

"You're seeing competition take second place to cooperation," he said.

This work has given telemedicine companies a unique view of the differing levels of preparedness across the country. When Doctor on Demand's care team refers possible coronavirus cases to public health officials — by the start of this week, it had referred about 100 cases — Glass said the response has varied wildly depending on where the patients live.

"There are some places where they're mobilized, they're taking inquiries, and they have a very clear plan of action for how to manage them," Glass said. "There are other places where, when we first call in, we're just getting a voicemail."

Glass declined to name where those places are. But Fadul said, generally, the local health departments in regions with the highest caseloads are "being forced to prepare faster." According to the CDC's website on Thursday, Washington and New York states have experienced the most cases, with 366 and 217 cases, respectively. California, which has 175 cases, and Massachusetts, which has 95, are next.

But because they're hardest hit, some hospitals in these states are also struggling to handle the influx of patients. In Boston, for instance, the city's biggest emergency room was reportedly temporarily overwhelmed by employees of Biogen, who had been exposed to the virus at a single company meeting, and were showing up to try to get tested.

Even in a normal year, winter is always a busy time for hospitals. "Our hospital usually does run quite close to capacity, and many other academic medical centers do, too," UCSF director of clinical communications Kristen Bole told Protocol. This week, she said UCSF set up a special triage structure outside the emergency department to deal with patients with respiratory symptoms. When possible, UCSF is working to have some of those patients taken to other hospitals so that it can keep space for the critically ill and high-risk patients that it specializing in treating. "Many hospitals can handle a coronavirus patient, for instance, but they can't handle brain surgery," she said.

Fadul said telehealth can help shoulder some of the burden for hospitals in places where the virus is widespread. Even a provider in a state like Wyoming or Idaho, who's not at the epicenter of the outbreak, can see patients virtually in the place of doctors on both coasts.

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All of this depends, of course, on patients being digitally literate. Given that the CDC says older people are at higher risk of getting seriously ill from the virus, that could pose a challenge for some patients who are less technologically skilled.

It also depends on the video technology itself remaining stable despite the surge in visits. All of the telehealth executives Protocol spoke with said they're confident their tech stacks can withstand these dramatic spikes. Glass said Doctor on Demand has seen bigger single-day surges occur after past marketing pushes. But the company is working on contingency plans in case that changes, including figuring out ways to get patients through visits faster and to allow providers to call patients back if wait times exceed the current average of five minutes. That's while it juggles onboarding a rush of new employers who are looking to add Doctor on Demand to their insurance offerings.

"We're literally getting calls and emails everyday saying, 'How fast can you set up a relationship with us?" Glass said. "Pretty darn fast."

In the end, though, online consultations can only accomplish so much. Telehealth doctors, like all doctors, are running up against the lack of available tests in the United States. Telemedicine companies can identify cases, but they can't guarantee those patients will get tested quickly, or even at all. And yet, Fadul said, "That doesn't change the fact that the cases need to be identified."

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