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Dear colleagues and friends,
I am fortunate to receive the baton from Charles Kahi, MD, in facilitating the fascinating and timely debates that have characterized the AGA Perspective series. Favorable reimbursement changes and the need for social distancing fast-tracked telemedicine, a care delivery model that had been slowly evolving.
In this month’s Perspective column, Dr. Hernaez and Dr. Vaughn discuss the pros and cons of telemedicine in GI. Is it the new office visit? Or simply just good enough for when we really need it? I look forward to hearing your thoughts and experiences on the AGA Community forum as well as by email ([email protected]).
Gyanprakash A. Ketwaroo, MD, is assistant professor of medicine at Baylor College of Medicine, Houston. He is an associate editor for GI & Hepatology News.
It holds promise
BY RUBEN HERNAEZ, MD, MPH, PHD
It was around January 2020, when COVID-19 was something far, far away, and not particularly worrisome. I was performing a routine care visit of one of my out-of-state patients waitlisted for a liver transplant. All was going fine until he stated, “Hey doc, while I appreciate your time and visits, these travels to Houston are quite inconvenient for my family and me: It is a logistical ordeal, and my wife is always afraid of catching something in the airplane. Could you do the same remotely such as a videoconference?” And just like that, it sparked my interest in how to maintain his liver transplant care from a distance. The Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communication, information technology, or other means between a physician in one location, and a patient in another location, with or without an intervening health care provider.1 What my patient was asking was to use a mode of telemedicine – a video visit – to receive the same quality of care. He brought up three critical points that I will discuss further: access to specialty care (such as transplant hepatology), reduction of costs (time and money), and improved patient satisfaction.
Arora and colleagues pioneered the Extension for Community Healthcare Outcomes (ECHO) project, providing complex specialty medical care to underserved populations through a model of team-based interdisciplinary development in hepatitis C infection treatment in underserved communities, with cure rates similar to the university settings.1 The University of Michigan–Veterans Affairs Medical Center used a similar approach, called Specialty Care Access Network–Extension of Community Healthcare Outcome (SCAN‐ECHO). They showed that telemedicine improved survival in 513 patients evaluated in this program compared to regular care (hazard ratio [HR]of 0.54, 95% confidence interval 0.36‐0.81, P = .003).2 So the evidence backs my patient’s request in providing advanced medical care using a telemedicine platform.
An extra benefit of telemedicine in the current climate crisis is reducing the carbon footprint: There’s no need to travel. Telemedicine has been shown to be cost effective: A study of claims data from Jefferson Health reported that patients who received care from an on-demand telemedicine program had net cost savings per telemedicine visit between $19 and $121 per visit compared with traditional in-person visits.3 Using telemonitoring, a form of telemedicine, Bloom et al. showed in 100 simulated patients with cirrhosis and ascites over a 6-month horizon that standard of care was $167,500 more expensive than telemonitoring. The net savings of telemonitoring was always superior in different clinical scenarios.4
Further, our patients significantly decrease travel time (almost instant), improve compliance with medical appointments (more flexibility), and no more headaches related to parking or getting lost around the medical campus. Not surprisingly, these perks from telemedicine are associated with patient-reported outcomes. Reed and colleagues reported patients’ experience with video telemedicine visits in Kaiser Permanente Northern California (n = 1,274) and showed that “67% generally needed to make one or more arrangements to attend an in-person office visit (55% time off from work, 29% coverage for another activity or responsibility, 15% child care or caregiving, and 10% another person to accompany them)”; in contrast, 87% reported a video visit as “more convenient for me,” and 93% stated that “my video visit adequately addressed my needs.”5 In liver transplantation, John et al. showed that, in the Veterans Health Administration, telehealth was associated with a significantly shorter time on the liver transplant waitlist (138.8 vs. 249 days), reduction in the time from referral to evaluation (HR, 0.15; 95% CI, 0.09-0.21; P < .01) and listing (HR, 0.26; 95% CI, 0.12-0.40; P < .01) in a study of 232 patients with advanced cirrhosis.6
So, should I change my approach to patients undergoing care for chronic liver/gastrointestinal diseases? I think so. Telemedicine and its tools provide clear benefits to our patients by increasing access to care, time and money savings, and satisfaction. I am fortunate to work within the largest healthcare network in the Nation – the Veterans Health Administration – and therefore, I can cross state lines to provide medical care/advice using the video-visit tool (VA VideoConnect). One could argue that some patients might find it challenging to access telemedicine appointments, but with adequate coaching or support from our teams, telemedicine visits are a click away.
Going back to my patient, I embraced his request and coached him on using VA VideoConnect. We can continue his waitlist medical care in the following months despite the COVID-19 pandemic using telemedicine. I can assess his asterixis and ascites via his cellphone; his primary care team fills in the vitals and labs to complete a virtual visit. There’s no question in my mind that telemedicine is here to stay and that we will continue to adapt e-health tools into video visits (for example, integrating vitals, measurement of frailty, and remote monitoring). The future of our specialty is here, and I envision we will eventually have home-based hospitalizations with daily virtual rounds.
Dr. Hernaez is with the section of gastroenterology and the Center for Innovations in Quality, Effectiveness, and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and in the section of gastroenterology and hepatology in the department of medicine at Baylor College of Medicine, both in Houston. He has no relevant conflicts of interest.
References
1. Arora S et al. N Engl J Med. 2011 Jun 9;364(23):2199-207.
2. Su GL et al. Hepatology. 2018 Dec;68(6):2317-24.
3. Nord G et al. Am J Emerg Med. 2019 May;37(5):890-4.
4. Bloom PP et al. Dig Dis Sci. 2021. doi: 10.1007/s10620-021-07013-2.
5. Reed ME et al. Ann Intern Med. 2019 Aug;171:222-4.
6. John BV et al. Clin Gastroenterol Hepatol. 2020 Jul;18:1822-30.e4.
It has its limits
BY BYRON P. VAUGHN, MD, MS
The post-pandemic world will include telehealth. Technology disrupts business as usual and often brings positive change. But there are consequences. To employ telehealth into routine care equitably and effectively within a gastroenterology practice, we should consider two general questions: “Was the care I provided the same quality as if the patient was seen in person?” and more broadly, “am I satisfied with my practice’s implementation of telehealth?” This perspective will highlight several areas affecting gastroenterology care: lack of physical exam, disproportionate impact on certain populations, development of a patient-provider relationship, impact on physician well-being, and potential financial ramifications. We will all have to adapt to telemedicine to some extent. Understanding the trade-offs of this technology can help us position effectively in a gastroenterology practice.
Perhaps the most obvious limitation of telemedicine is the lack of vital signs and physical exam. Determining if a patient is “sick or not” is often one of the first lessons trainees learn overnight. Vital signs and physical exam are crucial in the complex triaging that occurs when evaluating for diagnoses with potentially urgent interventions. While most outpatient gastroenterology clinics are not evaluating an acute abdomen, in the correct context, the physical exam provides important nuance and often reassurance. My personal estimate is that 90% of a diagnosis is based on the history. But without physical contact, providers may increase costly downstream diagnostic testing or referrals to the emergency department. Increasing use of at-home or wearable health technology could help but requires system investments in infrastructure to implement.
Telemedicine requires a baseline level of equipment and knowledge to participate. A variety of populations will have either a knowledge gap or technology gap. Lack of rural high-speed Internet can lead to poor video quality, inhibiting effective communication and frustrating both provider and patient. In urban areas, there is a drastic wealth divide, and some groups may have difficulty obtaining sufficient equipment to complete a video visit. Even with adequate infrastructure and equipment, certain groups may be disadvantaged because of a lack of the technological savvy or literacy needed to navigate a virtual visit. The addition of interpreter services adds complexity to communication on top of the virtual interaction. These technology and knowledge gaps can produce confusion and potentially lead to worse care.1 Careful selection of appropriate patients for telemedicine is essential. Is the quality of care over a virtual visit the same for a business executive as that of a non-English speaking refugee?
The term “webside manner” precedes the pandemic but will be important in the lexicon of doctor-patient relationships moving forward. We routinely train physicians about the importance of small actions to improve our bedside manner, such as sitting down, reacting to body language, and making eye contact. First impressions matter in relationship building. For many of my established IBD patients, I can easily hop into a comfortable repertoire in person, virtually, or even on the phone. In addition, I know these people well enough to trust that I am providing the same level of care regardless of visit medium. However, a new patient virtual encounter requires nuance. I have met new patients while they are driving (I requested the patient park!), in public places, and at work. Despite instructions given to patients about the appropriate location for a virtual visit, the patient location is not in our control. For some patients this may increase the comfort of the visit. However, for others, it can lead to distractions or potentially limit the amount of information a patient is willing to share. Forming a patient-provider relationship virtually will require a new set of skills and specific training for many practitioners.
Telehealth can contribute to provider burnout. While a busy in-person clinic can be exhausting, I have found I can be more exhausted after a half-day of virtual clinic. There is an element of human connection that is difficult to replace online.2 On top of that loss, video visits are more psychologically demanding than in-person interactions. I also spend more time in a chair, have fewer coffee breaks, and have fewer professional interactions with the clinic staff and professional colleagues. Several other micro-stressors exist in virtual care that may make “Zoom fatigue” a real occupational hazard.3
Lastly, there are implications on reimbursement with telehealth. In Minnesota, a 2015 telemedicine law required private and state employee health plans to provide the same coverage for telemedicine as in-person visits, although patients had to drive to a clinic or facility to use secure telehealth equipment and have vital signs taken. With the pandemic, this stipulation is waived, and it seems likely to become permanent. However, reimbursement questions will arise, as there is a perception that a 30-minute telephone call should not cost as much as a 30-minute in-person visit, regardless of the content of the conversation.
We will have to learn to move forward with telehealth. The strength of telehealth is likely in patients with chronic, well controlled diseases, who have frequent interactions with health care. Examples of this include (although certainly are not limited to) established patients with well-controlled IBD, non-cirrhotic liver disease, and irritable bowel syndrome. Triaging patients who need in-person evaluation, ensuring patient and provider well-being, and creating a financially sustainable model of care are yet unresolved issues. Providers will likely vary in their personal acceptance of telehealth and will need to advocate within their own systems to obtain a hybrid model of telehealth that maximizes quality of care with job satisfaction.
Dr. Vaughn is associate professor of medicine and codirector of the inflammatory bowel disease program in the division of gastroenterology, hepatology, and nutrition at University of Minnesota, Minneapolis. He has received consulting fees from Prometheus and research support from Roche, Takeda, Celgene, Diasorin, and Crestovo.
References
1. George S et al. Stud Health Technol Inform. 2013;192:946.
2. Blank S. “What’s missing from Zoom reminds us what it means to be human,” 2020 Apr 27, Medium.
3. Williams N. Occup Med (Lond). 2021 Apr. doi: 10.1093/occmed/kqab041.
Dear colleagues and friends,
I am fortunate to receive the baton from Charles Kahi, MD, in facilitating the fascinating and timely debates that have characterized the AGA Perspective series. Favorable reimbursement changes and the need for social distancing fast-tracked telemedicine, a care delivery model that had been slowly evolving.
In this month’s Perspective column, Dr. Hernaez and Dr. Vaughn discuss the pros and cons of telemedicine in GI. Is it the new office visit? Or simply just good enough for when we really need it? I look forward to hearing your thoughts and experiences on the AGA Community forum as well as by email ([email protected]).
Gyanprakash A. Ketwaroo, MD, is assistant professor of medicine at Baylor College of Medicine, Houston. He is an associate editor for GI & Hepatology News.
It holds promise
BY RUBEN HERNAEZ, MD, MPH, PHD
It was around January 2020, when COVID-19 was something far, far away, and not particularly worrisome. I was performing a routine care visit of one of my out-of-state patients waitlisted for a liver transplant. All was going fine until he stated, “Hey doc, while I appreciate your time and visits, these travels to Houston are quite inconvenient for my family and me: It is a logistical ordeal, and my wife is always afraid of catching something in the airplane. Could you do the same remotely such as a videoconference?” And just like that, it sparked my interest in how to maintain his liver transplant care from a distance. The Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communication, information technology, or other means between a physician in one location, and a patient in another location, with or without an intervening health care provider.1 What my patient was asking was to use a mode of telemedicine – a video visit – to receive the same quality of care. He brought up three critical points that I will discuss further: access to specialty care (such as transplant hepatology), reduction of costs (time and money), and improved patient satisfaction.
Arora and colleagues pioneered the Extension for Community Healthcare Outcomes (ECHO) project, providing complex specialty medical care to underserved populations through a model of team-based interdisciplinary development in hepatitis C infection treatment in underserved communities, with cure rates similar to the university settings.1 The University of Michigan–Veterans Affairs Medical Center used a similar approach, called Specialty Care Access Network–Extension of Community Healthcare Outcome (SCAN‐ECHO). They showed that telemedicine improved survival in 513 patients evaluated in this program compared to regular care (hazard ratio [HR]of 0.54, 95% confidence interval 0.36‐0.81, P = .003).2 So the evidence backs my patient’s request in providing advanced medical care using a telemedicine platform.
An extra benefit of telemedicine in the current climate crisis is reducing the carbon footprint: There’s no need to travel. Telemedicine has been shown to be cost effective: A study of claims data from Jefferson Health reported that patients who received care from an on-demand telemedicine program had net cost savings per telemedicine visit between $19 and $121 per visit compared with traditional in-person visits.3 Using telemonitoring, a form of telemedicine, Bloom et al. showed in 100 simulated patients with cirrhosis and ascites over a 6-month horizon that standard of care was $167,500 more expensive than telemonitoring. The net savings of telemonitoring was always superior in different clinical scenarios.4
Further, our patients significantly decrease travel time (almost instant), improve compliance with medical appointments (more flexibility), and no more headaches related to parking or getting lost around the medical campus. Not surprisingly, these perks from telemedicine are associated with patient-reported outcomes. Reed and colleagues reported patients’ experience with video telemedicine visits in Kaiser Permanente Northern California (n = 1,274) and showed that “67% generally needed to make one or more arrangements to attend an in-person office visit (55% time off from work, 29% coverage for another activity or responsibility, 15% child care or caregiving, and 10% another person to accompany them)”; in contrast, 87% reported a video visit as “more convenient for me,” and 93% stated that “my video visit adequately addressed my needs.”5 In liver transplantation, John et al. showed that, in the Veterans Health Administration, telehealth was associated with a significantly shorter time on the liver transplant waitlist (138.8 vs. 249 days), reduction in the time from referral to evaluation (HR, 0.15; 95% CI, 0.09-0.21; P < .01) and listing (HR, 0.26; 95% CI, 0.12-0.40; P < .01) in a study of 232 patients with advanced cirrhosis.6
So, should I change my approach to patients undergoing care for chronic liver/gastrointestinal diseases? I think so. Telemedicine and its tools provide clear benefits to our patients by increasing access to care, time and money savings, and satisfaction. I am fortunate to work within the largest healthcare network in the Nation – the Veterans Health Administration – and therefore, I can cross state lines to provide medical care/advice using the video-visit tool (VA VideoConnect). One could argue that some patients might find it challenging to access telemedicine appointments, but with adequate coaching or support from our teams, telemedicine visits are a click away.
Going back to my patient, I embraced his request and coached him on using VA VideoConnect. We can continue his waitlist medical care in the following months despite the COVID-19 pandemic using telemedicine. I can assess his asterixis and ascites via his cellphone; his primary care team fills in the vitals and labs to complete a virtual visit. There’s no question in my mind that telemedicine is here to stay and that we will continue to adapt e-health tools into video visits (for example, integrating vitals, measurement of frailty, and remote monitoring). The future of our specialty is here, and I envision we will eventually have home-based hospitalizations with daily virtual rounds.
Dr. Hernaez is with the section of gastroenterology and the Center for Innovations in Quality, Effectiveness, and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and in the section of gastroenterology and hepatology in the department of medicine at Baylor College of Medicine, both in Houston. He has no relevant conflicts of interest.
References
1. Arora S et al. N Engl J Med. 2011 Jun 9;364(23):2199-207.
2. Su GL et al. Hepatology. 2018 Dec;68(6):2317-24.
3. Nord G et al. Am J Emerg Med. 2019 May;37(5):890-4.
4. Bloom PP et al. Dig Dis Sci. 2021. doi: 10.1007/s10620-021-07013-2.
5. Reed ME et al. Ann Intern Med. 2019 Aug;171:222-4.
6. John BV et al. Clin Gastroenterol Hepatol. 2020 Jul;18:1822-30.e4.
It has its limits
BY BYRON P. VAUGHN, MD, MS
The post-pandemic world will include telehealth. Technology disrupts business as usual and often brings positive change. But there are consequences. To employ telehealth into routine care equitably and effectively within a gastroenterology practice, we should consider two general questions: “Was the care I provided the same quality as if the patient was seen in person?” and more broadly, “am I satisfied with my practice’s implementation of telehealth?” This perspective will highlight several areas affecting gastroenterology care: lack of physical exam, disproportionate impact on certain populations, development of a patient-provider relationship, impact on physician well-being, and potential financial ramifications. We will all have to adapt to telemedicine to some extent. Understanding the trade-offs of this technology can help us position effectively in a gastroenterology practice.
Perhaps the most obvious limitation of telemedicine is the lack of vital signs and physical exam. Determining if a patient is “sick or not” is often one of the first lessons trainees learn overnight. Vital signs and physical exam are crucial in the complex triaging that occurs when evaluating for diagnoses with potentially urgent interventions. While most outpatient gastroenterology clinics are not evaluating an acute abdomen, in the correct context, the physical exam provides important nuance and often reassurance. My personal estimate is that 90% of a diagnosis is based on the history. But without physical contact, providers may increase costly downstream diagnostic testing or referrals to the emergency department. Increasing use of at-home or wearable health technology could help but requires system investments in infrastructure to implement.
Telemedicine requires a baseline level of equipment and knowledge to participate. A variety of populations will have either a knowledge gap or technology gap. Lack of rural high-speed Internet can lead to poor video quality, inhibiting effective communication and frustrating both provider and patient. In urban areas, there is a drastic wealth divide, and some groups may have difficulty obtaining sufficient equipment to complete a video visit. Even with adequate infrastructure and equipment, certain groups may be disadvantaged because of a lack of the technological savvy or literacy needed to navigate a virtual visit. The addition of interpreter services adds complexity to communication on top of the virtual interaction. These technology and knowledge gaps can produce confusion and potentially lead to worse care.1 Careful selection of appropriate patients for telemedicine is essential. Is the quality of care over a virtual visit the same for a business executive as that of a non-English speaking refugee?
The term “webside manner” precedes the pandemic but will be important in the lexicon of doctor-patient relationships moving forward. We routinely train physicians about the importance of small actions to improve our bedside manner, such as sitting down, reacting to body language, and making eye contact. First impressions matter in relationship building. For many of my established IBD patients, I can easily hop into a comfortable repertoire in person, virtually, or even on the phone. In addition, I know these people well enough to trust that I am providing the same level of care regardless of visit medium. However, a new patient virtual encounter requires nuance. I have met new patients while they are driving (I requested the patient park!), in public places, and at work. Despite instructions given to patients about the appropriate location for a virtual visit, the patient location is not in our control. For some patients this may increase the comfort of the visit. However, for others, it can lead to distractions or potentially limit the amount of information a patient is willing to share. Forming a patient-provider relationship virtually will require a new set of skills and specific training for many practitioners.
Telehealth can contribute to provider burnout. While a busy in-person clinic can be exhausting, I have found I can be more exhausted after a half-day of virtual clinic. There is an element of human connection that is difficult to replace online.2 On top of that loss, video visits are more psychologically demanding than in-person interactions. I also spend more time in a chair, have fewer coffee breaks, and have fewer professional interactions with the clinic staff and professional colleagues. Several other micro-stressors exist in virtual care that may make “Zoom fatigue” a real occupational hazard.3
Lastly, there are implications on reimbursement with telehealth. In Minnesota, a 2015 telemedicine law required private and state employee health plans to provide the same coverage for telemedicine as in-person visits, although patients had to drive to a clinic or facility to use secure telehealth equipment and have vital signs taken. With the pandemic, this stipulation is waived, and it seems likely to become permanent. However, reimbursement questions will arise, as there is a perception that a 30-minute telephone call should not cost as much as a 30-minute in-person visit, regardless of the content of the conversation.
We will have to learn to move forward with telehealth. The strength of telehealth is likely in patients with chronic, well controlled diseases, who have frequent interactions with health care. Examples of this include (although certainly are not limited to) established patients with well-controlled IBD, non-cirrhotic liver disease, and irritable bowel syndrome. Triaging patients who need in-person evaluation, ensuring patient and provider well-being, and creating a financially sustainable model of care are yet unresolved issues. Providers will likely vary in their personal acceptance of telehealth and will need to advocate within their own systems to obtain a hybrid model of telehealth that maximizes quality of care with job satisfaction.
Dr. Vaughn is associate professor of medicine and codirector of the inflammatory bowel disease program in the division of gastroenterology, hepatology, and nutrition at University of Minnesota, Minneapolis. He has received consulting fees from Prometheus and research support from Roche, Takeda, Celgene, Diasorin, and Crestovo.
References
1. George S et al. Stud Health Technol Inform. 2013;192:946.
2. Blank S. “What’s missing from Zoom reminds us what it means to be human,” 2020 Apr 27, Medium.
3. Williams N. Occup Med (Lond). 2021 Apr. doi: 10.1093/occmed/kqab041.
Dear colleagues and friends,
I am fortunate to receive the baton from Charles Kahi, MD, in facilitating the fascinating and timely debates that have characterized the AGA Perspective series. Favorable reimbursement changes and the need for social distancing fast-tracked telemedicine, a care delivery model that had been slowly evolving.
In this month’s Perspective column, Dr. Hernaez and Dr. Vaughn discuss the pros and cons of telemedicine in GI. Is it the new office visit? Or simply just good enough for when we really need it? I look forward to hearing your thoughts and experiences on the AGA Community forum as well as by email ([email protected]).
Gyanprakash A. Ketwaroo, MD, is assistant professor of medicine at Baylor College of Medicine, Houston. He is an associate editor for GI & Hepatology News.
It holds promise
BY RUBEN HERNAEZ, MD, MPH, PHD
It was around January 2020, when COVID-19 was something far, far away, and not particularly worrisome. I was performing a routine care visit of one of my out-of-state patients waitlisted for a liver transplant. All was going fine until he stated, “Hey doc, while I appreciate your time and visits, these travels to Houston are quite inconvenient for my family and me: It is a logistical ordeal, and my wife is always afraid of catching something in the airplane. Could you do the same remotely such as a videoconference?” And just like that, it sparked my interest in how to maintain his liver transplant care from a distance. The Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communication, information technology, or other means between a physician in one location, and a patient in another location, with or without an intervening health care provider.1 What my patient was asking was to use a mode of telemedicine – a video visit – to receive the same quality of care. He brought up three critical points that I will discuss further: access to specialty care (such as transplant hepatology), reduction of costs (time and money), and improved patient satisfaction.
Arora and colleagues pioneered the Extension for Community Healthcare Outcomes (ECHO) project, providing complex specialty medical care to underserved populations through a model of team-based interdisciplinary development in hepatitis C infection treatment in underserved communities, with cure rates similar to the university settings.1 The University of Michigan–Veterans Affairs Medical Center used a similar approach, called Specialty Care Access Network–Extension of Community Healthcare Outcome (SCAN‐ECHO). They showed that telemedicine improved survival in 513 patients evaluated in this program compared to regular care (hazard ratio [HR]of 0.54, 95% confidence interval 0.36‐0.81, P = .003).2 So the evidence backs my patient’s request in providing advanced medical care using a telemedicine platform.
An extra benefit of telemedicine in the current climate crisis is reducing the carbon footprint: There’s no need to travel. Telemedicine has been shown to be cost effective: A study of claims data from Jefferson Health reported that patients who received care from an on-demand telemedicine program had net cost savings per telemedicine visit between $19 and $121 per visit compared with traditional in-person visits.3 Using telemonitoring, a form of telemedicine, Bloom et al. showed in 100 simulated patients with cirrhosis and ascites over a 6-month horizon that standard of care was $167,500 more expensive than telemonitoring. The net savings of telemonitoring was always superior in different clinical scenarios.4
Further, our patients significantly decrease travel time (almost instant), improve compliance with medical appointments (more flexibility), and no more headaches related to parking or getting lost around the medical campus. Not surprisingly, these perks from telemedicine are associated with patient-reported outcomes. Reed and colleagues reported patients’ experience with video telemedicine visits in Kaiser Permanente Northern California (n = 1,274) and showed that “67% generally needed to make one or more arrangements to attend an in-person office visit (55% time off from work, 29% coverage for another activity or responsibility, 15% child care or caregiving, and 10% another person to accompany them)”; in contrast, 87% reported a video visit as “more convenient for me,” and 93% stated that “my video visit adequately addressed my needs.”5 In liver transplantation, John et al. showed that, in the Veterans Health Administration, telehealth was associated with a significantly shorter time on the liver transplant waitlist (138.8 vs. 249 days), reduction in the time from referral to evaluation (HR, 0.15; 95% CI, 0.09-0.21; P < .01) and listing (HR, 0.26; 95% CI, 0.12-0.40; P < .01) in a study of 232 patients with advanced cirrhosis.6
So, should I change my approach to patients undergoing care for chronic liver/gastrointestinal diseases? I think so. Telemedicine and its tools provide clear benefits to our patients by increasing access to care, time and money savings, and satisfaction. I am fortunate to work within the largest healthcare network in the Nation – the Veterans Health Administration – and therefore, I can cross state lines to provide medical care/advice using the video-visit tool (VA VideoConnect). One could argue that some patients might find it challenging to access telemedicine appointments, but with adequate coaching or support from our teams, telemedicine visits are a click away.
Going back to my patient, I embraced his request and coached him on using VA VideoConnect. We can continue his waitlist medical care in the following months despite the COVID-19 pandemic using telemedicine. I can assess his asterixis and ascites via his cellphone; his primary care team fills in the vitals and labs to complete a virtual visit. There’s no question in my mind that telemedicine is here to stay and that we will continue to adapt e-health tools into video visits (for example, integrating vitals, measurement of frailty, and remote monitoring). The future of our specialty is here, and I envision we will eventually have home-based hospitalizations with daily virtual rounds.
Dr. Hernaez is with the section of gastroenterology and the Center for Innovations in Quality, Effectiveness, and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and in the section of gastroenterology and hepatology in the department of medicine at Baylor College of Medicine, both in Houston. He has no relevant conflicts of interest.
References
1. Arora S et al. N Engl J Med. 2011 Jun 9;364(23):2199-207.
2. Su GL et al. Hepatology. 2018 Dec;68(6):2317-24.
3. Nord G et al. Am J Emerg Med. 2019 May;37(5):890-4.
4. Bloom PP et al. Dig Dis Sci. 2021. doi: 10.1007/s10620-021-07013-2.
5. Reed ME et al. Ann Intern Med. 2019 Aug;171:222-4.
6. John BV et al. Clin Gastroenterol Hepatol. 2020 Jul;18:1822-30.e4.
It has its limits
BY BYRON P. VAUGHN, MD, MS
The post-pandemic world will include telehealth. Technology disrupts business as usual and often brings positive change. But there are consequences. To employ telehealth into routine care equitably and effectively within a gastroenterology practice, we should consider two general questions: “Was the care I provided the same quality as if the patient was seen in person?” and more broadly, “am I satisfied with my practice’s implementation of telehealth?” This perspective will highlight several areas affecting gastroenterology care: lack of physical exam, disproportionate impact on certain populations, development of a patient-provider relationship, impact on physician well-being, and potential financial ramifications. We will all have to adapt to telemedicine to some extent. Understanding the trade-offs of this technology can help us position effectively in a gastroenterology practice.
Perhaps the most obvious limitation of telemedicine is the lack of vital signs and physical exam. Determining if a patient is “sick or not” is often one of the first lessons trainees learn overnight. Vital signs and physical exam are crucial in the complex triaging that occurs when evaluating for diagnoses with potentially urgent interventions. While most outpatient gastroenterology clinics are not evaluating an acute abdomen, in the correct context, the physical exam provides important nuance and often reassurance. My personal estimate is that 90% of a diagnosis is based on the history. But without physical contact, providers may increase costly downstream diagnostic testing or referrals to the emergency department. Increasing use of at-home or wearable health technology could help but requires system investments in infrastructure to implement.
Telemedicine requires a baseline level of equipment and knowledge to participate. A variety of populations will have either a knowledge gap or technology gap. Lack of rural high-speed Internet can lead to poor video quality, inhibiting effective communication and frustrating both provider and patient. In urban areas, there is a drastic wealth divide, and some groups may have difficulty obtaining sufficient equipment to complete a video visit. Even with adequate infrastructure and equipment, certain groups may be disadvantaged because of a lack of the technological savvy or literacy needed to navigate a virtual visit. The addition of interpreter services adds complexity to communication on top of the virtual interaction. These technology and knowledge gaps can produce confusion and potentially lead to worse care.1 Careful selection of appropriate patients for telemedicine is essential. Is the quality of care over a virtual visit the same for a business executive as that of a non-English speaking refugee?
The term “webside manner” precedes the pandemic but will be important in the lexicon of doctor-patient relationships moving forward. We routinely train physicians about the importance of small actions to improve our bedside manner, such as sitting down, reacting to body language, and making eye contact. First impressions matter in relationship building. For many of my established IBD patients, I can easily hop into a comfortable repertoire in person, virtually, or even on the phone. In addition, I know these people well enough to trust that I am providing the same level of care regardless of visit medium. However, a new patient virtual encounter requires nuance. I have met new patients while they are driving (I requested the patient park!), in public places, and at work. Despite instructions given to patients about the appropriate location for a virtual visit, the patient location is not in our control. For some patients this may increase the comfort of the visit. However, for others, it can lead to distractions or potentially limit the amount of information a patient is willing to share. Forming a patient-provider relationship virtually will require a new set of skills and specific training for many practitioners.
Telehealth can contribute to provider burnout. While a busy in-person clinic can be exhausting, I have found I can be more exhausted after a half-day of virtual clinic. There is an element of human connection that is difficult to replace online.2 On top of that loss, video visits are more psychologically demanding than in-person interactions. I also spend more time in a chair, have fewer coffee breaks, and have fewer professional interactions with the clinic staff and professional colleagues. Several other micro-stressors exist in virtual care that may make “Zoom fatigue” a real occupational hazard.3
Lastly, there are implications on reimbursement with telehealth. In Minnesota, a 2015 telemedicine law required private and state employee health plans to provide the same coverage for telemedicine as in-person visits, although patients had to drive to a clinic or facility to use secure telehealth equipment and have vital signs taken. With the pandemic, this stipulation is waived, and it seems likely to become permanent. However, reimbursement questions will arise, as there is a perception that a 30-minute telephone call should not cost as much as a 30-minute in-person visit, regardless of the content of the conversation.
We will have to learn to move forward with telehealth. The strength of telehealth is likely in patients with chronic, well controlled diseases, who have frequent interactions with health care. Examples of this include (although certainly are not limited to) established patients with well-controlled IBD, non-cirrhotic liver disease, and irritable bowel syndrome. Triaging patients who need in-person evaluation, ensuring patient and provider well-being, and creating a financially sustainable model of care are yet unresolved issues. Providers will likely vary in their personal acceptance of telehealth and will need to advocate within their own systems to obtain a hybrid model of telehealth that maximizes quality of care with job satisfaction.
Dr. Vaughn is associate professor of medicine and codirector of the inflammatory bowel disease program in the division of gastroenterology, hepatology, and nutrition at University of Minnesota, Minneapolis. He has received consulting fees from Prometheus and research support from Roche, Takeda, Celgene, Diasorin, and Crestovo.
References
1. George S et al. Stud Health Technol Inform. 2013;192:946.
2. Blank S. “What’s missing from Zoom reminds us what it means to be human,” 2020 Apr 27, Medium.
3. Williams N. Occup Med (Lond). 2021 Apr. doi: 10.1093/occmed/kqab041.
