Virtual Visits

Illustrations by Lily Therens
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telemedicine

Telemedicine isn’t new, but it is gaining new uses—and new participants—in the time of COVID-19.

It’s safe to say COVID-19 has upended all aspects of our society. But perhaps the one pushed to reinvent itself with warp speed is the field of medicine. Immediate effort went into treatment options and the chase for a vaccine, of course, but equally critical was limiting the spread of COVID-19 to other patients and staff. How do you safely deliver health care in the middle of a pandemic?

The answer increasingly seems to be video visits, where your doctor’s appointment is via your laptop or iPad—and both you and your physician are beaming in from home.

In fact, telemedicine is gaining in popularity more rapidly than even its pioneers, supporters and pilot programs could have predicted. “Before COVID, we were doing 350–400 video visits a month—and in less than two weeks, we were doing 1,200 video visits a day,” says Mark Avdalovic, M.D., the medical director of virtual visits and eConsults at UC Davis.

Health systems throughout the Sacramento region report the same dramatic upswings, leading proponents to suggest patients and physicians will continue to expand its uses. “Telemedicine may be the silver lining to the pandemic,” says Albert Chan, M.D., Sutter Health’s chief of digital patient experience. “We’ve been on this journey for four or five years at this point, but it really accelerated with COVID. Before COVID, we had 50 clinicians trained (in this technology), and in March and April, we trained 4,600 clinicians.”

Also having an effect on the skyrocketing figures: Insurance plans have temporarily made it easier for health systems to collect the same fees for a virtual visit as a face-to-face appointment and eliminated a cumbersome point-of-service rule. “It has to do with where the patient is—the patient could not be in their home and had to be in a rural setting,” explains James Marcin, M.D., director of the UC Davis Center for Health Technology, who expects many of these restrictions will disappear permanently. “We think it’s going to be harder to put the genie back in the bottle. People will want to have this.”

But is telemedicine for everyone? What are its benefits? Its drawbacks? Will it continue to be popular when the pandemic is over? Sac Mag asked a variety of local experts to weigh in.

In general, physicians are grateful to their teams—who flew into action in response to COVID-19—and to their patients who are willing to try something new. They also would like to see telemedicine keep moving forward. “We don’t want to go back to pre-COVID-19,” says Marcin. “This has created an opportunity to reimagine the models of care we provide.”

Chan agrees. “This isn’t just an extraordinary thing for an extraordinary time, but truly a personalized experience for you and your clinician,” he says. “It’s still all about care.”

father and baby telemedicine

The Pluses

What most people mention first about a video visit is convenience—for both the patient and the doctor. “Even pre-COVID, I was able to provide access to patients at times that were more convenient for their schedules. Patients and providers don’t live 8–5,” says Christine Braid, D.O., the medical director of ambulatory telehealth services for Dignity Health Mercy Medical Group.

Braid, who is also a family medicine physician and a mother, often sees patients from a “remote location” herself—her house. “My commute from my living room to my home office is much shorter than taking a freeway to midtown,” she says, adding it’s fun to show off photos of her young child as well as her own artwork, all while respecting everyone’s priorities. “A patient doesn’t have to take a whole day off work to come to an appointment. And clinicians need a work-life balance, too. Some of my colleagues are soccer dads who coach, but are willing to work evenings and weekends.”

Braid’s longtime patients also tout the ease of video visits, especially if it’s with a physician they already know and trust. “It was very convenient for us. My husband and I both had appointments, so he sat next to me on the couch and we took turns,” says Michelle Chapman, an office manager who lives in Fair Oaks. “You’re not driving around, worried about being late, no sitting in a waiting room. I had my questions answered. It was very thorough, nothing I felt I missed. . . . You really could do this anywhere. You could sit outside or sit in your car.”

There are also clearly segments of the population for whom it’s a real hardship to see their doctor face-to-face, COVID or no COVID. For example, telemedicine was originally intended to give rural communities access to specialists, with provider-to-provider communication set up on hard-wired computer stations in outlying hospitals and clinics. Rural care has continued to be a priority, now most often directly between providers and patients since the advent of laptops and iPhones, allowing a cardiac patient in Plumas County to check in with his cardiologist in Sacramento, for instance.

Another example is if you live three hours away from your provider and have a child who must be put in a car seat with a ventilator, says Marcin, who is also a UC Davis pediatric critical care specialist. “To do that visit in their home is not quite as good as seeing them in person, but when you weigh everything, it’s an overall better way,” he says.

The same is true for elderly people who are frail and may risk a fall leaving their home for an unfamiliar medical campus, as well as people who just don’t feel well. “Especially if you’re sick, you’d rather stay at home and still get care,” says Chan. Staying home also ensures these patients won’t be exposed to another virus on top of the illness they already have—COVID now, but also colds and influenza in a normal season.

The very ease of a video visit may also encourage people to seek care sooner rather than later. “If I can have access to a patient who is ill today, I may be able to keep them out of the hospital,” says Braid.

Finally, there is an obvious use of telemedicine for people with transportation or child care issues or who can’t miss work. Virtual visits also make sense for things that don’t require a physical exam, like refilling a prescription, checking in with a patient after a minor procedure or conducting mental health appointments.

pregnant woman telemedicine

The Minuses

No one is saying, however, that telemedicine should replace all face-to-face interactions with a physician. “The gold standard is seeing a patient in person—with an occasional virtual visit,” says Avdalovic, who is also a pulmonologist and sees limitations to assessing lung and heart health remotely. “(Virtual stethoscopes) are OK, but it’s not the same. We recognize that.”

There is also certain routine care, of course, that must be conducted in person—such as vaccines for children, prenatal visits or gynecological procedures. “I haven’t figured out how to do a Pap smear remotely,” says Braid with a laugh.

Another consideration is for people who don’t have access to technology and are shut out of telemedicine. “We are very concerned about those patients who may not have the option and . . . (about) folks who may not be comfortable with technology,” says Avdalovic. “We want to be sure not to forget about those patients.”

There are also occasional mishaps—as in any delivery system—that range from the amusing to the more serious. For example, doctors admit their patients are sometimes challenged setting up the iPhone camera. “You can get a little dizzy watching them,” says Avdalovic, who recommends a stand for smart devices. “Or they think they’re on the screen but it’s just one eye or a corner of their mouth.” And more seriously, of course, is the possibility of a missed condition. “I canceled my dermatology appointment when I was offered a video visit (during the stay-at-home order),” says Marcin. “I didn’t want my mole diagnosed by a picture.”

To that end, all health care professionals are quick to assure patients that coming in person is safe even during this pandemic—probably safer than going to the grocery store, for that matter, with hospital and clinic staff well-practiced in disinfecting surfaces and maintaining good hygiene. “If a patient needs a physical exam, of course we do them and bring patients in in a safe way—we’ve invested so much in terms of getting systems in place,” says Rob Azevedo, M.D., physician-in-chief for Kaiser Permanente Sacramento. “We encourage patients to reach out to their physician and for the two of them to decide about care: Can it be handled via email, video or a physical exam?”

grandfather and child telemedicine

The Future

Despite some drawbacks, most physicians are eager to explore telemedicine’s uses and predict its popularity will only increase. “This has been an incredible learning period for all this,” says Chan. “And I’m not ready to say what is an appropriate use and what isn’t. Because things we thought we couldn’t do we’re doing.”

Experts also say we are in the midst of an explosion in medical technology, such as cardiac VADs—ventricular assist devices—that have a high risk of infection but can now be linked remotely and alert providers at the very first sign of inflammation. “That early diagnosis is tremendously beneficial,” says Chan. Similar advances allow patients with chronic disease to be monitored at home, passively collecting data on a person’s temperature, glucose levels, or heart and lung function. “There is more and more wearable technology,” says Azevedo. “The world is going to open up. We need to get out of thinking what’s possible and what’s not.”

To some clinicians’ surprise, this technology is also being easily accepted by patients—both young and old. “My 18-year-old son had a video visit and nobody called him to do a mock test run,” says Avdalovic. “And I said, ‘Are you sure you know what you’re doing?’ He looked at me like ‘Are you kidding me?’ It’s just an extension of what he does every day.”

And on the other end, physicians resist making assumptions about older patients. “My parents are in their 80s, and they love it,” laughs Azevedo. Braid also sees a lot of octogenarians jumping onboard. “When I have 80-year-old patients who realize they figured it out, their faces light up with a big smile and I give them a round of applause,” she says.

In fact, it’s not artificial intelligence and robotics that excite physicians the most: It’s the very rich human element of seeing patients in their homes. Medicine has its roots in “house calls,” of course, but for many modern physicians, this is the first foray into treating patients in their own environment. “I have a 2-year-old grandson, and my daughter-in-law did a video visit with his pediatrician, who just happened to be my two daughters’ pediatrician when they were growing up,” says Azevedo. “The girls are both home with us now, because of the pandemic, so they got on the video and said hello. It was a very special thing they wouldn’t have been able to do if the appointment had been at the office. And the pediatrician was so thrilled to see my daughters, now in their late 20s and early 30s.”

Braid has had meaningful experiences herself. “There are patients I’ve had for 15 years, and it’s so fun to . . . look around their house,” she says, adding they often give her a tour or show her photos or objects on a bookshelf. “Video visits are longer than normal appointments, and it’s very personal in their space—they are pulling their doctor into their homes. And it tells me things, gives me an interesting insight.” She gives as an example a couple who were sheltering in place at their daughter’s home and sleeping in bunk beds in their grandchild’s room, clearly visible on video. The husband complained of intense knee pain, and Braid asked if he was taking the top bunk. He was—and climbing the ladder was straining his knee. “In an office setting, I would have had a harder time figuring that out.”

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