Telehealth is Here, But Is It Here to Stay?

I recently saw a clever ad, a spoof on a Merriam-Webster dictionary entry defining telehealth:

“The provision of healthcare remotely by means of telecommunications technology. Synonyms: convenient; virtual doctor; accessible care. Antonyms: long waits; copays; deductibles; impossible to do from your La-Z-Boy.”

During these COVID times, a lot of things have changed. We’ve had no choice but to work, learn, and shop from home. That list of home-based activities has also come to include getting medical care. Although telehealth – seeing your doctor on the computer screen – existed before the pandemic, it is now big business. According to GBMC’s Medical Director of Primary Care and Population Health, Dr. Robin Motter-Mast, GBMC’s telehealth project was put into place a year before COVID hit hard and was prepared to help patients. In February, GBMC charted 59 telehealth visits; by May, there were approximately 18,000.

Telehealth is certainly convenient, but is it effective? Dr. Motter-Mast feels that, although there are times when a patient needs to be seen, such as for abdominal or chest pain, telehealth is a very valuable preliminary tool. And it is the wave of the post-pandemic future. By now, many people have participated in this new form of doctoring, whether as a patient or a healthcare provider. I asked some of them in Baltimore and around the world to share their telehealth experiences.

Rash Decisions

Surie had a baby during Pesach. Ordinarily, she would have had an office visit once a week during her ninth month and then every two to three days after passing her due date. But in the midst of Corona, she ended up speaking to her doctor on the phone. “All that shlepping in the ninth month – why is it necessary? And if these visits are so important, then why did my doctor call me only twice throughout those five weeks?! And why did those conversations take less than two minutes?! Could it be that so many visits are the only way for doctors to make their money from insurance, or, do they really prevent problems? B”H, I had a good experience with no complications, but I wonder if people have had more complications due to telehealth.”

Pediatrician visits have also been increasingly virtual. Yocheved Gross shared, “My baby had an ear infection and was on Amoxicillin. After a few days he got a rash; it was an allergic reaction. The doctor said she will look at it via a video meeting. When I logged in and the doctor started talking from the screen, my baby got scared and burst out crying! I had to turn him away from the computer. I was eventually able to show the doctor the rash, but the doctor couldn’t see the rash well enough so we still had to go into the office.”

Another mother corroborated these limitations. “Trying to show our pediatrician my 18-month-old’s diaper rash on Zoom was awkward and didn’t quite work, but the doctor and I had a good laugh because of the awkwardness of the situation, especially with a non-cooperative toddler.”

When SB’s two-year-old had a cold and a cough, she scheduled a telehealth visit. She was a bit surprised as he had had numerous ear infections and breathing problems in the past that had led to hospitalization with a lung infection. “The pediatrician started by asking the usual questions,” recalls S.B. “I had to lift his onesie so the doctor could see his breathing. It all seemed fine; the doctor thought he had some allergies and suggested Zyrtec or Benadryl. I put him in for his morning nap, and he woke up two hours later with a croupy cough, very rapid breathing, and throwing up phlegm. I took him into a steamy shower, which did little. The doctor suggested we take him to the ER. We called the doctor back and asked if we should try the nebulizer with albuterol. She agreed. We tried it and it helped a lot. Then a steroid was prescribed. B”H, he didn’t have to go to the ER, and the rapid breathing went away. But two weeks later, he has yet to be seen by the doctor as a follow up!”

What the Brits Think

In the UK, Doreen Wachmann says her general practice (GP) – a patient’s first port of call – has improved tremendously since the lockdown. “Before, you could wait for up to two weeks even for a telephone appointment. Now with the app, “Ask My GP,” you get an answer to online inquiries within minutes. It frees up GP time from having to see so many people and is better for many patients with questions that do not need face-to-face encounters.”

Elsewhere in the UK, Mrs. Meyer shares that she had a major spinal issue several years back, but because she came in via the ER rather than being officially on some surgeon’s list, she never received a proper follow-up. Just before the COVID outbreak, she asked her GP to be referred to a spinal specialist at her local excellent hospital. “Of course, by the time the referral came through, nobody was going anywhere, so I had a telephone consultation,” says Mrs. Meyer. “The doctor gave me a full half-hour or more (unheard of!) and made up for every bit of the previous five years’ neglect. He was incredibly sympathetic and understanding, and I didn’t have to waste time going in – though he did say he didn’t feel comfortable not seeing his patient and has given me a face-to-face appointment sometime this fall. It’s been great not having to go to follow-up appointments which are terrific time-wasters. They may be necessary (sometimes I have my doubts) but not going is bliss!”

The Israeli Telehealth Experience

When Raizy Shlesinger’s daughter called Kupat Cholim, instead of going to the doctor, she was offered a tele-appointment. She readily agreed; at that point, she didn’t want to go out to the clinic. A nephrologist called her at the predetermined time. “My daughter found him extremely attentive and helpful,” relates Mrs. Shlesinger. “She felt like he was there for her – even more than the in-person doctor who is more focused on his computer screen than on the patient in front of him. When the doctor looked at her ultrasound, he reassured her that her kidney was enlarged only because she had drunk so much water before the test.”

The mother of another Israeli telehealth patient asked me rhetorically, “Antibiotics prescribed without seeing the patient’s throat is probably the most popular experience, isn’t it? I gave my daughter the medicine anyway, but it felt silly. We are the type of people who try hard not to take antibiotics. We take a throat culture, if needed, to avoid taking an antibiotic for a viral infection. We go again and again to the doctor – and he’s okay with that – to see if it’s just a seasonal virus or a case of real infection.”

All You Need Is a Sphygmomanometer, Thermometer, Scale, and Pulse Ox

Dr. Chavi Eve Karkowsky, formerly of Silver Spring, is an OB/GYN with a subspecialty in high-risk obstetrics (maternal-fetal medicine) practicing in New York City. She oversaw many of the prenatal care modifications at her institution during COVID, which invested in new equipment to accommodate telehealth patients.

“At the beginning of March, when it became very abruptly clear that it would not be safe for our patients, we very quickly moved to a telemedicine model. But because of the nature of the work we do, in-person visits were required as well,” explains Dr. Karkowsky. “Things like ultrasound, inpatient care, and labor and delivery can’t be done with telemedicine very well, and we just have to lay hands on pregnant women every so often. So, we had to keep both our inpatient and outpatient practices going, which was really a challenge. Most other disciplines either shut down or did only telemedicine.

“Most of us were using our own iPhones and computers, but since then our institution invested in a platform, software, cameras, and other things that make it work. It also invested in reliable blood pressure cuffs (sphygmomanometers) for our patients to use at home and in software for everybody. We are getting more and more equipment as time goes on.”

Among Dr. Karkowsky’s high-risk patients’ telehealth perks are the avoidance of a 30-minute bus ride and a 40-minute wait to see her. “In some ways I think it has increased access,” notes Dr. Karkowsky, “and in some ways it has made things really difficult. A lot of my patients don’t have unlimited data or reliable Wi-Fi; some don’t have their own phones – they only have a phone when their husband is home.”

In addition, many of Dr. Karkowsky’s patients don’t speak English. Although getting a translator on video is possible, it is complicated. “I’m worried about that,” says the doctor. “They don’t need any more barriers to care. We are presently trying to figure out if access to care is being increased or decreased via telehealth – and how much of it we should keep in a post-COVID world.

“I actually enjoy tele-med; I can get a lot more done on tele-video than I think any of us thought. So much of the work we do in medicine today, like counseling, can be done over a video conference. I prefer in-patient visits, but video is preferable to a phone call, for both me and my patients, in creating a connection and having a functional conversation. If the patient has a blood pressure cuff, a thermometer, a scale, and a Pulse Ox, I can do most of her care at home. There will always be exceptions, like those who don’t work well over video or who have cardiac anomalies and whose hearts and lungs I need to listen to, each visit.”

Remote OT

When Riki Markowitz, OTR/L, moved to Israel in 2013, she looked at options for practicing occupational therapy that made more than minimum wage in the country’s socialized medicine health system. She was one of the first OTs hired by a company that added OT to the online speech therapy services.

“It definitely took a lot of creativity and problem solving to provide services remotely,” remarks Riki, “but it’s doable and, against all odds, productive! In the past, any time I was asked about my job, I took a deep breath before trying to explain how it was even possible to provide OT services through an online platform. Recently, I was telling someone about when I worked as an OT online, and the person just nodded and the conversation continued! No shock or skepticism. Teletherapy has become pretty normal. I would never want to trade seeing clients in person, but love that there is an option to see clients virtually when the need arises.”

Back in the States, Talia Schuss, OTR/L, recalls her journey into virtual therapy. “After several years of working with children with autism as a ‘virtual OT,’ I noticed a gap in access to ABA therapy services for these families. The lack of ABA therapists in more rural geographic locations, coupled with long waiting lists in the bigger cities, leaves many families waiting months and even years for ABA therapy, the most commonly recommended therapy for children with autism.”

Talia and her husband, Chaim, launched Latitude Therapy with the goal of making ABA therapy accessible to children and their families, no matter where they live through the use of a HIPAA-compliant video conferencing platform. Their therapists live throughout the U.S.

How does ABA therapy work through a screen? In short, Talia says, “with the help of a supportive and involved family, a combination of the standard direct ABA therapy model and a family training-only model. Fortunately, Talia and Chaim are often able to help families utilize their insurance to cover these services, even when they live in a different state.

“The field of ABA therapy is ever evolving, and as COVID-19 has brought the world to a halt, many people have come to appreciate the benefits of telehealth,” concludes Talia. “I think that post-COVID we will see a new openness to the concept of telehealth ABA therapy, both from funding sources and from families – and with that openness will come an increase in access for so many families in need.”

Psyched for Telehealth

Although Dr. Michelle Friedman’s general psychology practice provided telehealth on an as-needed basis back in 2015, when COVID hit, she informed her malpractice insurance company – which was already covering telehealth visits – that she was switching her entire practice to the secure telehealth platform Doxy.me (“Docs, see me”). She did not have to spend a penny on new technology – her MacBook computer is equipped for it.

“I don’t find it hard, although my colleagues and I have run into glitches,” admits Dr. Friedman, “like the time the patient entered my ‘virtual waiting room’ before I logged on and he went unseen for a while. After that, I told him if he doesn’t see me to call.”

Dr. Friedman notes that telehealth has worked out well for almost everyone except her patients who are either not tech-comfortable or don’t have a computer – typically, those in a lower socio-economic group and/or the age 80-plus population. “Some of these patients are even refusing telephone sessions,” she says. “I encourage people to set something up – especially the more vulnerable ones, like those struggling with bipolar depression who are, at times, suicidal. Those patients have been doing well with telehealth.

For those with severe symptoms of anxiety, depression, schizophrenia, or schizoaffective disorder, telehealth can still be an effective mode of treatment, Dr. Friedman tells me. It is important to observe patients closely and add additional sessions to monitor any changes in mental status. Even subtle changes can be the beginning of a ‘storm’, i.e., a decline that may require a change frequency of treatment, medication, or, possibly, a hospitalization.

Whether conducting psychotherapy in the office or on a telehealth platform, clinicians need to be sure they are engaged in their own self-care. It also involves consultation with trusted colleagues in the form of a consultation group and/or a private consultant. “I never know when I will need to bounce an idea off of a clinician,” says Dr. Friedman. “Isolation in clinical work, like isolation in our personal lives, makes providers more vulnerable and less able to operate at our best.”

Research has shown that telehealth is as effective as face-to-face psychotherapy and that the retention rates tend to be higher. “You don’t have to find a parking space,” says Dr. Friedman. “You just pull out your phone or computer instead. It is also more anonymous. Sometimes, parents meet me in their closet, for privacy – I am not kidding. I have had a number of sessions in people’s cars, too.

“Working with children and young teens is a little different. I have to make sure we are connecting. I can’t get on the floor and play cards with them as I typically do in my office. There are interactive video games, but then you are too busy playing and you can’t see your patient. I am experimenting; that’s where some of the creativity comes in.”

Dr. Friedman notes that mental health needs have increased since March. “Anxiety is up, depression is up, and a lot of uncertainty is up. It is very likely that at some point, somebody is going to be in crisis, especially during COVID. The isolation can bring on a lot of things – if you don’t have good coping or support, you are even more vulnerable. We are here to help.”

Dr. Friedman’s colleagues have tried to convince her that telehealth is the “best thing since sliced bread,” but she feels the in-person appointment is the safest and best way to go because of a potential emergency situation. If hospitalization is needed, she has the patient there with her and could call 911, providing support in the meantime.

Although her telehealth sessions are going well, Dr. Friedman looks forward to the day when she can meet with her patients in person. “I miss some of the subtle things you just can’t pick up on camera, like body language and even watching somebody walk into the office and situate themselves – there is so much data that is lost,” concludes Dr. Friedman. “On the other hand, I’ve gained data, because now I am in people’s bedrooms. One person sits on her bed, another lays down because she is so tired all the time. I’ve gotten to meet their dogs, cats, and hamsters, and they have gotten to meet my dog, Lola. We definitely are getting to see each other in a different light!”