University clinicians see a future for telemedicine

Monday, July 20, 2020 - 7:38pm

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Design by Hibah Chughtai

Adrienne Lapidos commuted to her office for work before the COVID-19 pandemic began in Michigan. But like many others over the past several months, she transitioned to working from home. As a clinical assistant professor of psychiatry at the University of Michigan, Lapidos now primarily sees her patients via video visits instead of in-person.

Though urgent cases are still seen in-person, Lapidos’ department shifted to majority telemedicine in late March. She told The Daily the change was unexpected.

“It pretty much caught all of us by surprise how quickly the transition happened from in-person to video visits,” Lapidos said. “It had been a really major goal to increase uptake of video visits this year, but adoption was not widespread until after COVID started.”

Steven Leber, Medical Doctor and professor of pediatrics and neurology, said video visits are advantageous to patients in selective cases where transportation is a barrier. Leber added moving to video visits also helps with social distancing guidelines.

“Because of social distancing, we’re really limiting how many patients come into the clinic,” Leber said.

Medical School student Lauren Gaston-Hawkins said since medical students were given a directive from the Association of American Medical Colleges in mid-March to pause clinical rotations, the transition to telemedicine was a great idea but difficult to implement.

“At the beginning, I was somewhat neutral about the change,” Gaston-Hawkins said. “I thought it was a great opportunity to propel the use of telemedicine forward, but the transition was difficult since we didn’t have the infrastructure in place previously.”

Gaston-Hawkins noted that even though medical students weren’t incorporated in telemedicine visits until June 8, she’s had the opportunity to help transition prenatal patient visits to video in her department since mid-March. 

Although telemedicine was fairly new to many clinicians, including Leber and Lapidos, the concept was pioneered by Rashid Bashshur, head of telemedicine and professor emeritus of health management and policy at the School of Public Health.

According to Bashshur, telemedicine was first used in 1905 by a Dutch physician to transmit EKG sounds via a telephone. Bashshur was commissioned by the National Science Foundation in the early 1970s to research the capabilities and viability of telemedicine.

“Interest was very meager at that time,” Bashshur said. “But I thought the idea had merit and we had to investigate it to find out what that merit was and (to) see if we want to proceed on that basis.”

Bashshur said inefficient and expensive technology initially made telemedicine difficult to use. However, once technology began to develop, the Centers for Medicare & Medicaid Services began to place constraints on the new concept. Insurance companies did the same. Some restrictions, including only allowing patients from rural zip codes to use telemedicine, were overturned due to COVID-19. As the pandemic began to unravel, Bashshur said there was a wave of new regulations that made it easier for patients to access telemedicine resources.

“The pandemic opened the floodgates of telemedicine because we had to implement mitigation efforts to slow the rate of infection and the separation of people became critical,” Bashshur said. “In addition, keeping health care workers safe from the infection was important.”

Even before the pandemic, Blue Cross Blue Shield of Michigan and the Medicare program expanded their coverage to include telehealth services. Chad Ellimoottil, University faculty and Institute for Healthcare Policy and Invention’s Telehealth Research Incubator member, wrote in an email to The Daily that health insurance companies in Michigan have been generally favorable towards covering telemedicine, even before the pandemic.

Ellimoottil predicts about 20 percent of health care will be delivered using telemedicine after the pandemic.

“Don’t get me wrong, telemedicine use is definitely dropping as in-person care ramps up,” Ellimoottil wrote. “However, this is not because of insurance coverage, it is because of patient preference, clinical appropriateness and resistance to change by some healthcare providers and staff.”

Leber said many barriers to telemedicine remain, including some laws that prohibit interstate telemedicine care.

Leber highlighted that some of his patients require in-person visits and he tries to alternate patients from video to in-person visits. He added video visits haven’t particularly impacted his work, except for performing neurological exams. Leber said clinicians that are more hands-on, like primary care physicians, have not been doing as well with video appointments

“We’re getting better and better examining people by video,” Leber said. “You can test their language skills, you can test their eye movements, you can test facial asymmetry … and in some ways being in a normal home situation makes it less artificial.”

Although Lapidos didn’t notice many changes between video and in-person visits, she said the change has impacted some of her patients in positive and negative ways.

“It’s been paradoxical because it has both radically increased access to mental health care and also decreased access in certain circumstances, too,” Lapidos said. “For example, if somebody doesn’t have access to WiFi, steady internet or a device they could connect with, that will decrease their access to care because there’s less face-to-face care taking place.”

Medical School student Kenzie Corbin told The Daily in an email about her experience with telemedicine as a patient. She agreed with Lapidos and said inadequate internet connection makes telemedicine visits more difficult.

“Wi-Fi could go in and out mid-conversation and it feels more artificial having to speak through a computer screen,” Corbin wrote. “Having a videochat versus just a phone call was much better though and I still felt the empathetic connection.”

Gaston-Hawkins also noticed disparities in internet quality between patients. She said telemedicine relies on high-speed internet, which isn’t universal, and she added it may be difficult to build a patient-provider relationship with new patients over telemedicine.

“I think the biggest concern I have is the potential for widening disparities,” Gaston-Hawkins said. “Older patients are not always as tech-savvy and have some issues with video visits … I think it’s helpful for our patients that come from far away for visits to save some time and money related to travel.”

Corbin is also concerned about patient safety and confidentiality when using telemedicine. She mentioned the home environment may be unsafe for some patients to fully express their concerns with others around them.

“There’s also again the question about confidentiality and safety,” Corbin wrote. “If a patient is in an unsafe living situation, but has to do a telemedicine visit, they may not feel safe or honest to speak about this with others around them.”

Though Leber and Lapidos have had positive experiences with telemedicine, they are still unsure how telemedicine will affect the outcomes of their patients’ care. Bashshur emphasized he isn’t sure of the effects either. He added some problems that may result from telemedicine can include misdiagnosis by physicians.

“We don’t know the blemishes,” Bashshur said. “We know the good things about telemedicine. We may be exaggerating the merit of this modality of care delivery. When necessity dissipates for this technology, once the pandemic ends, people will be facing the facts … and it could contain some risks that we don’t know about yet.”

Bashshur added one of the biggest problems in the future will be the lagging adoption of telemedicine by CMS and insurance companies. 

“Ultimately, the health care establishment won’t be able to deny telemedicine. They can’t,” Bashshur said. “The government can’t either because it has become so common and familiar to everyone, so there will be pressures to maintain it and constrain it. Which one will prevail is very hard to tell, but I’m sure there will be more telemedicine after the pandemic.”

Gaston-Hawkins said she believes in a future for telemedicine, even after the pandemic.

“I think there is definitely a future for telemedicine after the pandemic,” Gaston-Hawkins said. “There are many great advantages to being able to provide care virtually in terms of access. It is definitely specialty dependent … but there is definitely a chance to innovate and rethink health care delivery.”

 

Daily Staff Reporter Michal Ruprecht can be reached at mrup@michigandaily.com.