The COVID-19 pandemic has forced us to redesign how we care for patients in the wake of a dangerous and very contagious disease. Telemedicine and related forms of virtual care have increased access, improved quality, decreased cost, and opened the window for new technologies to support better care. This has been facilitated by decreasing regulatory barriers and paying for virtual visits on par with face-to-face for E&M and preventive care codes. It has also created a way to keep a COVID-vulnerable physician workforce engaged at a time when we most need them.
Slipping on my 40-plus-year-old long white coat, I think about what the COVID-19 pandemic has done for me and the profession.
Certainly, the skies are cloudy and the COVID rain has washed away much of what we took for granted in our work, play, and family lives.
But, at the same time, there has been a silver lining that can inspire us and bring hope. We have improvised and innovated to continue to safely care for our patients and it has presented us with tremendous opportunities to improve access, quality, and cost, while preserving our professional values and endurance.
The sea change shift to telemedicine and, with it, the disintegration of regulatory and payment impediments has opened up a new world of care, with increased access, connection, and the opportunity to improve the way we use technology in the care of our patients.
My years as a primary care pediatrician have reflected the trends in training, growing a suburban practice, and helping to build a pediatric service line in a community hospital begging for patients and leadership. The work week had no beginning or end. It was a continuum of 24/7 access where you rounded at hospitals, had scheduled hours 7 days a week, met patients in the office or the ER after hours, had a dedicated staff, and tried your best to stay current with the clinical and political challenges. We did not question the load or its impact on our lives or our families; it was expected and defined your reputation and success.
One of the most defining, yet challenging, parts of my job was to care for our patients in the hospital. I was lucky to have residents and students, as well as in-house PICU and NICU intensivists, to back me up. Taking care of my patients through their most difficult times created a special connection that resonated with my core professional values. As my group decided to turn our hospital care over to "hospitalists," it was hard for me to let go.
So far, that has worked out and requires a strategic shift in how to deal with more complex patient care issues and needs. Transitions in care are a delicate process that can be best served through planning and communication; when a patient needs to be hospitalized, we outline for them what will happen and the role we will play.
In the COVID-19 world we currently live in, I am acutely aware of my own vulnerability to have a bad outcome if I catch the virus. My age and medical condition have made me very reluctant to resume seeing patients in a clinical setting, no matter how genuine my PPE might be.
However, we have seen the world of practice precipitously turn a relative disinterest in telemedicine into the major platform for patient care. Through the month of March, the transition from office-based practice and revenues to telemedicine was incredible. Yes, it required a crippling pandemic and some regulatory and payment support to get physicians on board with something patients really wanted -- care when and where they want and need it.
I had developed an interest and evolved a program for telemedicine in my office, realizing it really could improve access to care, especially for patients with ongoing conditions that need monitoring but not a 3-hour endeavor through traffic and waiting rooms. And now, I can get paid for that and a lot of other care my patients need, and it does not have to take place in my office. The uptake, effectiveness, and patient satisfaction has been incredible. It also became clear that many families felt that the last place they wanted to be was in a medical facility and if they were going to get a service, it had to be efficient, time conscious, and safe, protecting them from catching COVID-19.
The first focus was taking care of acute problems, then the chronic issues, and as the months passed, it became apparent children were falling behind on their preventive care and immunizations. It did take some very concerted local and national efforts to get CMS and payers to include preventive care in the covered telemedicine services.
Telemedicine has opened many windows in the house of medicine and can really move care and access to a new level. There is abundant research showing that most patients appreciate having access to care through telemedicine and want it to continue. I have transitioned all my clinical work to telemedicine and the experience has been wonderful. I am focused on the encounter, get to see the family in their home environment, and have been able to foster the integration of this care into my patient record and payment routines. While seeing a patient, I can have multiple screens open, providing resources, making referrals, and even searching for information to help with my clinical decision making. I can get so much more accomplished in a visit and, when I ask for a follow-up, there is no hesitation when it does not involve travel and waits.
The one thing I have not been able to do is a hands-on exam. However, I have learned when and how to communicate that there needs to be a physical exam, performed by someone else in my office. I can also highlight in my notes why and what needs to be examined, as well as labs, screenings, and/or immunizations to be done. These specific needs can be reviewed and reiterated by the MA and clinician at the start and all lab and immunizations can be performed. The in-office visit can be very efficient and, if necessary, followed up to address any findings, questions, and test results. So, the concept of the virtual well visit has evolved and is now complemented by a hands-on physical exam performed by the "officist." Although I once railed at the concept of using hospitalists for my patients in the hospital, I have come full circle.
Virtual well care may be the silver lining of COVID-19 that keeps high-risk older physicians working. With more than 20% of the physician workforce at high risk for complicated COVID-19 infection due to age and/or medical problems, we need telemedicine as a regular part of physician practice. That need is compounded by the existing shortage of primary care physicians and the increased medical complexity of an aging population with many chronic conditions. Telemedicine can sustain the workforce and with it the wisdom and experience of doctors who might otherwise retire. Even better, it can be done economically, safely, and efficiently, with their physician providing care from a COVID-free setting.
COVID-19 has created incredible hardships for physician practices and the significance of adapting and embracing change is essential for physicians. Getting back to the office as our communities open up is more figurative than literal. Patients want a telemedicine option, and most are willing to do what you advise if an office or ER visit is indicated. They also are happy to get their preventive care by telemedicine and accept that they may need a hands-on visit in the office. The times when we could see patients on our terms and at our convenience are over. We need to innovate and adapt. We need to make this moment something positive for our patients and our profession.
Russell C. Libby, MD, is the founder and president of Virginia Pediatric Group, which has practice locations in Loudoun and Fairfax counties.