One lesson from COVID has been that some things we thought were impossible are not only possible, but also necessary. Working from home is one of those and another is telehealth. Why have we been making patients come in to see us when many of them would rather stay home because of comfort, transportation issues, risk of spreading/catching disease, or other reasons? Especially when physical presence doesn’t always add value. We’ve relied on in-person visits for lots of reasons, including habit, tradition, money (reimbursement), and the difficulty of changing when no one is demanding change.
But with COVID-19, seeing patients at a distance suddenly became necessary. We quickly figured out how to do it, and in some cases maybe it wasn’t even that hard. Medical practices and systems cobbled together solutions from existing technology, and – in the US – the government helped by adjusting the rules and payments around telehealth. Now that we’ve started doing it, it would be hard to put the genie back in the bottle; we can’t pretend that telehealth isn’t feasible or useful.
So how do we make this temporary change into a permanent one? The conversations, articles, and seminars I’ve seen around telehealth focus on the practicalities: What technology do we need? What are the privacy concerns? How does anyone get paid for this? All good questions. But the focus is on how to make telehealth possible. I’m more interested in asking: how do we make it good?
This is the question we seem to have neglected when it came to the electronic medical record (EMR). It replaced paper charts and had all the capabilities that allowed for healthcare to happen, but it really wasn’t very good. EMRs in general, didn’t and still don’t take full advantage of the digital platform to improve healthcare, and instead remain as slightly improved paper charts. Despite gradual improvement, you don’t have to look hard to find healthare workers complaining about the burden of documentation, poor usability features, and safety problems stemming from EMR design. If you measure the success of EMRs by company profits or number of customers or growth, they may seem successful, but as usable tools that achieve their potential to improve the quality of healthcare, they are far from the mark.*
So how can we make telehealth good from the start?
First and foremost, we have to consider telehealth from the perspective of the customer, from our patients. How can we make telehealth good both in terms of service and quality? Service should be fairly straightforward – care in any form should be convenient and easy to use for people from all walks of life. We should consider both technological and human differences: internet connections, devices, locations, as well as technology expertise, language, culture, age, and ability – both physical and cognitive. In terms of quality, where should telehealth fit it? What types of problems are better to be seen on video? How can we pre-identify these? Is there a place for app- or bot-driven care? If we fragment and distribute the care for faster service (imagine a patient question going to any one of many on-call doctors, like a call center), what do we lose in terms of continuity and connection? In what ways can we mitigate those losses?
When we view things through a small screen, we also tend to lose the big picture. Either because we are interacting through video or through messaging, we lose the ability to see the whole patient – how they walk, their body language, the subtleties of speech and voice. Anyone who has treated patients knows that sometimes the documented “chief complaint” is not the real problem, but it can be easy to miss that in a focused distanced interaction, perhaps the only one with this particular patient.
Telehealth doesn’t always mean video, it may mean chart and message review followed by diagnostic or therapeutic action such ordering of tests, consults, or prescriptions. What happens when we see a chart representation of the patient, rather than a real person in front of us? When radiologists are shown a picture of the patient, the quality of their work goes up, with the the implication that without seeing the patient’s face, the care is worse. While this effect has yet to be proven on a wider scale, it does make sense: it’s easy to forget that the CT or MR images on the screen represent a full person. So what happens when many doctors are treating patients without actually seeing them? How much does that human connection currently add to care, and what happens when it’s gone? Telehealth may be an experiment in depersonalization writ large.
Another change we need to consider is what happens to healthcare workers. Modern radiology is an example of a specialty that has taken full advantage of the digital platform. While productivity has definitely increased, I’m not sure it’s been better for radiologists as people. The practice of radiology has increasingly become devoid of meaningful human contact, first in terms of patients and now in terms of coworkers and colleagues. In my personal experience and in talking with my colleagues, a day spent looking at images with little human contact may be productive, but over time it is more tiring, less fulfilling, and ultimately feels less meaningful. What happens when all doctors and other providers experience the same change? Instead of blithely walking down the same road, we need to be thoughtful in how we plan our schedules, distribute work, design tools, and create balance between computer and human work. Unfortunately, healthcare does not have a stellar record when it comes to this type of planning. Just ask any doctor what they think of “desktop medicine.”
The digitization of healthcare has led to some amazing improvements. It’s also led to questionable change, as our experience with EMRs and in radiology have shown. We can make telehealth great, but we have to be thoughtful about it, and the time to start planning is now.
*Of course I haven’t used every EMR, so if someone uses one they love, please let me know! I’m willing to be convinced.
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