The threat posed by COVID-19 has upended daily life all over the globe. The switch from pre-COVID normal to COVID abnormal was jarring, but as time goes on, some of those changes will persist as the new normal.
Telemedicine, for example, was a long time coming, became outpatient medicine’s new ballgame practically overnight, and now may be here to stay. While it won’t solve all of healthcare’s pre-existing problems, telemedicine is a good strategy for social distancing and is helping many people engage in needed care.
COVID-19 suddenly shifted physician office visits to telemedicine, but other forces—convenience, access and cost savings—have been nudging healthcare toward using virtual interfaces for decades. It took a pandemic to break the logjam of entrenched power, habits and reimbursement policies. Now liberated, consumer power and patient preference will be hard to suppress. Focusing on patient-centered care and catching those who fall between the cracks must be a priority going forward. Assuming that a permanent version of recently relaxed regulations is enacted in the future, telemedicine will become part of the norm.
Two essays about “self-service” medicine—a particular type of telemedicine—published on the Health Affairs blog highlight an example from the less acute end of the spectrum and raise important questions about future development of telemedicine. The essays were published in mid-February and late March, with no mention of the role telemedicine was beginning to play regarding COVID-19. Reading them feels a bit like taking a trip back in time.
In the first of the Health Affairs essays (published on February 19, 2020) Anupam Goel and Santanu Nundy ask if “self-service” medicine is “an idea whose time has come.” The offer Hims, a start-up that offers to treat erectile dysfunction, acne and male pattern baldness as an example of self-service. Hims asks prospective patients—obviously, men in a narrow demographic—to enter medical history and symptoms in an online profile. They are then connected by phone to a physician who completes the exam, assigns a diagnosis, discusses treatment options and, if appropriate, prescribes medication. Drugs are delivered directly to the patient’s home.
Katelyn Smalley, a PhD candidate in health research in London and previously a policy analyst at the Centers for Medicare & Medicaid Services, responded in March with observations and questions that apply to the prospects for telemedicine’s role going forward:
- Will the kind of self-service medicine Goel and Nundy highlight “exacerbate our already fragmented health system and work at cross-purposes with efforts at integration”?
- How will healthcare episodes delivered by telemedicine be integrated into the patient’s medical record?
- What happens when a consequential medical error occurs? Who is responsible?
- We already know from past experience and research that some patients are better suited and equipped to take charge of their own healthcare in the way that some telemedicine services require. Should clinicians try to evaluate which patients are most likely to be successful or run into trouble? How? If patients need education and training, who is responsible for providing it?
- How important is the in-real-life relationship between patient and clinician to the effectiveness of care? If the answer is, “It depends?” who evaluates when and if to choose among the solutions in the telemedicine toolkit?
- There is a role for artificial intelligence in telemedicine, which Smalley says “has the potential to accelerate the capabilities of digital health care.” There is already evidence that AI algothrims can introduce bias in health care delivery, so this needs careful tracking and study.
The most significant, cross-cutting question for telemedicine is, “What can it do for the patient?” What is the impact on outcomes and patient experience? It will be years before we have evidence-based answers to those questions, and the challenge of responding to the coronavirus outbreak is more pressing at the moment. Meanwhile, as always, if thoughtful engaged patients and their providers stay focused on working together toward better health and patient-centered care, they will often find that telemedicine can be an effective tool.
