I Did Not Expect Telehealth to Be a COVID Silver Lining
By: Megan Elizabeth Bowles Clowse, MD, MPH
In our house, we try to find each day’s silver lining despite the challenges of the COVID pandemic. These have included seeing long-lost family and catching up with old friends on Zoom. Some are predictable: my 16-year-old daughter has more time for her favorite activities, such as reading and drawing. Others are less so: my son is now reading stories multiple times per week with his grandmothers.
One unexpected silver lining in my work as a rheumatologist has been discovering the benefits of telehealth. To be honest, we rheumatologists have always felt that in-person patient visits and careful physical exams were key components of our decision-making and our therapeutic relationships with patients. In our division, we had not pushed for telehealth options prior to the COVID pandemic, thinking that the logistics were too complex, patients would hate it, we’d never get paid for it, and-most importantly-that we would be providing substandard care.
In the middle of March, however, we saw the writing on the wall with the coming social distancing guidelines. Our clinic transformed almost overnight to entirely telehealth-based “visits.” Those first few clinics were a little rocky, as we had to sort out issues related to documentation and billing and navigate technological challenges as we ramped up our use of video conferencing. It was in those first few days, however, that doctors started commenting on the surprising upsides of providing care through telehealth.
Unfamiliar Technology, Unexpected Benefits
One major benefit of telehealth is that it allows us to see patients who otherwise would miss in-person appointments. In the Duke Lupus Clinic, an estimated 20 to 30 percent of our patients don’t show up for any given session. With telehealth, we were suddenly able to cut that to about 5 percent. We always knew that some of our patients, particularly those who live far away and have lower incomes, find it burdensome to drive all the way to Duke University Hospital to get the care they need for their complicated disease. In the past, these challenges often resulted in prolonged absences from care, and our patients have undoubtedly suffered from this. We could see this when they presented to an emergency room somewhere in the state with a severe lupus flare, a severe infection, or kidney failure. We could also see the suffering when they finally were able to get to the clinic, where they would tell us about the long months of chronic pain they’d experienced without a doctor who understood their condition and could provide relief. But at the time, we didn’t think we had a solution for these problems, and the demands of caring for patients who were in our clinic limited our available “bandwidth” for finding patients who might have been falling through the cracks of the system.
“Telehealth allows me to literally meet the patient where she is.”
Because telehealth allows us to talk with patients in their own homes, it has also added an entirely new dimension to the task of reconciling a patient’s list of prescribed medicines with what they’re actually taking. I generally ask the patient walk to the part of her home where she keeps her medications and to read to me what she’s taking. I can generally hear that there is a large collection of bottles in various states of fill. By her level of familiarity with each bottle when she picks it up, I can get a better sense of whether she is taking it regularly. Sometimes I hear the patient taking a bottle directly out of the plastic bag from the pharmacy, something that suggests that she likely hasn’t been taking it recently at all. There’s no question that when I hear her read through the medication bottles, the complexity of the regimen is often overwhelming. I don’t think I could keep track of the number of medications that my patients try to manage and take reliably every day.
Telehealth allows me to literally meet the patient where she is. I’ve had some visits that consisted of patients holding up their cell phones while they sit in the car outside of the store or their work. I see toddlers crawling over their mothers — something that makes me immediately empathize with the challenges of motherhood during a pandemic. And patients are clearly relieved that they don’t have to take off an entire day of work to drive 3 hours across the state for a 20-minute visit in my office.
Meeting Challenges To Enable Better Care
Telehealth definitely has not solved all of our problems, and in some cases it has highlighted gaps that need to be addressed. For example: obtaining laboratory test results from far-flung patients across the state remains an obstacle to care. While patients can in theory get labs tested locally, the logistics of getting them the prescription for these tests and having the results of those tests reported back to me is a major challenge. My favorite approach is to have patients take photos of their lab results and upload them into their electronic medical record for me to review, but this seems like a clumsy solution. An easier fix would be to link up all of the labs across the state so that any doctor who orders them can easily see them as part of routine care.
Telehealth is also definitely a challenge when it comes to building a strong therapeutic relationship with a patient I haven’t met before. I can tell that with telehealth visits, some patient don’t entirely trust my intentions, a problem I rarely encounter during an in-person visit. Patients living with chronic pain, depression, and other disabling and disheartening conditions are, in my experience, harder to care for through telehealth. These patients in particular are in need of empathy and the challenges of slow internet speeds and video buffering make it harder to express this clearly.
Some of our patients would definitely benefit from an “old-fashioned” in-person, physical rheumatologic exam. While all rheumatologists develop tips and tricks over the years that let them tell whether a patient has swollen joints by their description, nothing really compares to putting my hands on their joints, feeling the swelling, noting where and when they’re tender on my exam, and seeing how easy or how hard it is for them to move. It’s true that we can do some of this through telehealth if we have a good video connection and patients are able to show us the areas of their body that are swollen and hurting. I even recently asked a patient to stand on tiptoe so that I could assess the strength in her legs and ankles, as well as any pain she may have feeling. But actually doing formal strength and neurologic testing would have certainly been better.
I think our key challenge now is to figure out how physicians can glean the best of telehealth’s capabilities for our patients, spot and fix remaining gaps, and clearly identify situations where telehealth can help-or hurt. My experience since March has convinced me that including telehealth options as part of long-term management of patients with lupus and other rheumatologic diseases can improve care and provide needed flexibility, especially for those who struggle with consistently making it to in-person appointments. I’m equally convinced that simply discarding telehealth once the COVID shutdowns have eased would do a great disservice to both our patients and our doctors.
Originally published at https://forge.duke.edu on May 6, 2020.
