One consequence of the present crisis is the urgent embrace of telemedicine, as I recently discussed. Whether the adoption is sustained beyond the crisis period remains to be determined, although use seemed to be increasing overall even before the pandemic hit.
As more physicians and patients find themselves pressed to adopt telemedicine, I thought it might be helpful to better understand what this transition and experience is like, first-hand. So I asked my brother Jonathan, a psychiatrist in Los Angeles and a relatively early adopter of telemedicine, about his experience.
Jonathan is an adult psychiatrist, with a focus on anxiety and affective disorders (depression, bipolar, mood disorders), and a particular expertise in psychopharmacology.
Here is what he had to say.
Timmerman Report (TR): For starters, help us understand what you typically cover with patients in a (pre-COVID) in-person visit?
Jonathan Shaywitz (JS): Most visits are follow-ups, tend to be extremely targeted, about 15-20 minutes long, and focus on medication management, following up on side-effects, for example. There’s no physical exam; the questions are generally subjective.
TR: How did you first get involved in telemedicine?
JS: About six years ago, I was medical director at a Southern California hospital system with two large hospitals, half an hour from each other. At the time I joined, the hospital had already installed a telemedicine capability to enable staff at one location to see emergency room (ER) patients and floor [in-patient] consults from the other hospital – you could provide care from one site while physically being in the other. Most importantly, this allowed the ER staff to get in touch with a psychiatrist right away, so it wouldn’t delay the care of patients, and interrupt the flow of ER patients waiting to be seen. In many ER settings, a common hold-up can be waiting for a psychiatrist to come and evaluate a patient.
TR: When you first heard about this set up, were you skeptical? Interested?
JS: I was both interested and skeptical. I was especially skeptical about the technology, because you are really relying on it. I am at my desk at one site, and on the other end, they are wheeling a robot with a video screen with you projected on it. You are counting on the fact that the robot is available and functioning – plus you need someone to appropriately set up the machine. In my experience, this tended to work very well in the ER – basically because there was a single person responsible, and they were very familiar with the technology. Floor consults tended to be more challenging – depending on the floor, you might not have someone around who really knew how to set up the technology.
TR: Do you feel you were able to do as good an exam remotely as if you had seen the patient in person?
JS: I do. There were no procedures involved. Emergency room patients tended to be especially accepting because they were so happy to see a psychiatrist and not have to wait – there was a real sense of time being an issue. The typical evaluation would be for acute depression, often focused on the question of whether the patient was at risk for self-injury.
TR: Seems like a high stakes evaluation to do remotely – did you feel comfortable, and was it a difficult adjustment?
JS: I did feel comfortable, and it didn’t seem like a difficult adjustment, at least not in this setting, because the exam is so targeted and focused, and the patient is in a well-controlled environment. Floor consults were a little more challenging, both because of the technology issues I mentioned earlier, and also because the consults could be more vague, and less focused.
TR: Did you feel that on these floor consults, you were able to be as effective when you used the robot?
JS: It can be a little more difficult; when you consult in person, you often are dependent on collateral information, such at what you might learn from a family member who’s nearby or waiting outside. It’s harder to get some of that information when you’re using the robot.
TR: You went on to use telemedicine extensively in out-patient psychiatry; what was that experience like?
JS: In the outpatient setting, you can’t control the environment, in contrast to the hospital ER and floor consults. You’re at the whim of the patients, and often they take it a little less seriously. When patients come to the doctor’s office, they tend to be more focused, and in the moment. The big advantage of telemedicine, of course, is the convenience, but this can also mean a patient is multitasking, or not speaking from a conducive location. Many telemedicine doctors talk about this challenge. I’ve had patients who would be talking with their friends, watching television, or just in a crowded place. This is a problem not only in terms of security and privacy, of course, but also, at least as importantly, because the patients tend to be distracted by the environment. Telemedicine doctors try to manage this by setting limits and having boundaries.
TR: So given all this, what’s your view of telemedicine?
JS: I encourage it. Even with all the challenges, it is still better than people not being able to make it to appointments. The overall quality of care you can deliver because of the continuity more than makes up for the occasional challenges of a session.
The overall quality of care you can deliver because of the continuity more than makes up for the occasional challenges of a session
TR: How do you have to adjust your style for telemedicine?
JS: You need to be more structured with patients. You also have to set limits.
TR: For your outpatient interactions, was technology an issue?
JS: No, not at all – we used a HIPAA-compliant app, which worked extremely well.
TR: What about reimbursement – it sounds like that can be a problem for many?
JS: When I first started, some insurance companies would only reimburse for face to face encounters – but that’s really improved now.
TR: And is there a requirement for an initial meeting face to face?
JS: Initially that was true, but it seems to have gotten relaxed over time for many payors. Often, it’s the physician that wants the initial meeting in person.
TR: Finally, what do you see as the future of telemedicine?
JS: Even before COVID-19, telemedicine was skyrocketing. It is the future, especially in areas like psychiatry. Because it’s not procedural, the major factor is convenience – time and geography – and telemedicine allows patients to fit in appointments much more easily. The key needs are checking in and continuity, and telemedicine affords this.