April 13th, 2020

Telemedicine is now officially here and the results are surprisingly excellent for the issues that are amenable to a FaceTime like audiovisual event. The COVID 19 virus forced this situation upon the medical community as much as it did on the reluctant insurers. The big question moving forward will not be whether providers of care would like to continue this service. It will be whether the powers that dictate insurance reimbursement decide that they want to keep reimbursing at the correct rates as they are doing now or will they go back to the pre COVID days where they would reimburse providers less than is logically reasonable and thus stop the process. The pre COVID days were a study in how not to adopt a patient friendly method of care.

COVID is a true disruptor.

Why they would choose the latter path in my mind is now illogical as this current crisis has proven. For example, I just completed a telemedicine visit for an established child with neuropsychiatric conditions. It went very well as we were face to face discussing his care. He and his mother just saved the 1 hour trip each way plus time surrounding the visit. The time saved is worth something to everyone despite my time spent being identical. It makes the chances almost zero that my patient will be late for the visit which is a huge advantage to all. There is less stress for my patient making the visit in his home comfortable and safe. There are so many wins to be had here that it is time for consumers to petition all insurers to move toward the disrupting changes that COVID has brought us and not revert back to archaic medical care.

We will learn over a very short time which patients need to be face to face in the office and we will make that determination as needed in order to limit patient inconvenience while mandating quality above all. For example, how about a patient presenting for follow up after having a telemedicine visit with an outside provider that is unknown to the current provider of care. The telemedicine provider diagnoses viral pharyngitis without a competent physical exam and no testing for bacterial streptococcus infection. In and of itself, this is not a major problem if in person follow up is mandated to assess for bacterial illness, to assess spleen size and to obtain general exam findings while counseling to avoid contact injury. However, what if this patient has streptococcal pharyngitis, leukemia or lymphoma? That is where a telemedicine case could potentially go south. If the patient is then prescribed steroids or antibiotics over the phone based on the case as stated above, we could see a situation where steroids can mask severe diseases so that they can smolder unknown for a longer time making the outcome more dicey or antibiotics can be inappropriately used for a virus interfering with long term gut health. Etiological context is key and telemedicine is woefully inadequate to provide for etiology in this type of case.

The point of this story is this, we have to be very careful as consumers of care what we ask for via telemedicine without a physical exam and without appropriate testing to ascertain the truth about the illness. Be very specific about what kinds of visits you seek out via telemedicine. Infectious diseases in general are not amenable to telemedicine. Quality is likely to be heavily compromised based on the capability of the system. Please do not ask for antibiotics, steroids or other serious human physiologically modifying medicines without a clear understanding as to why they are needed which often necessitates a physical exam and appropriate testing. These medicines have serious long term side effects and consequences. If your telemedicine provider is interested in making you happy over providing the best care, run away.

Times are always changing. We need to change with them. Telemedicine is one such example where disruption, regardless of cause, can beneficially alter our job, narrative and outcome.

Disruption is often very good if you look at it from the correct perspective.

Perspective is always key,
Dr. M