By HANS DUVEFELT, MD
After my posts on telemedicine were published recently, (this one on Manly Wellness before the pandemic and this one after it erupted, on A Country Doctor Writes, then reblogged on The Health Care Blog, KevinMD and many others), I have been asked about my views on telemedicine’s role in the future of primary care.
Things have changed quickly, and a bit chaotically, and there is a lot of experimentation happening right now in practices I work or speak with.
Before thinking about telemedicine in Primary Care, we need to agree on some sort of definition of primary care, because there are so many functions and services we lump together under that term.
Many people think of primary care mostly as treating minor, episodic illnesses like colds, rashes, minor sprains and the like. This is an area that has attracted a lot of interest because it is easy money for the providers, since the visits tend to be quick and straightforward and such televisits are also attractive for the insurance companies if they can keep insured patients out of the emergency room. With the technical limitations of video quality and objective data such as heart rate and rhythm, I think this is an absolute growth area for telemedicine. However, with all the other forms but mostly here, fragmentation of care could become a complicated problem. To put it bluntly, if we still expect a medical professional or a health care organization to keep an eye on reports from various sources, such as hospital specialists, walk-in clinics or independent telemedicine providers, they are going to want to get paid for it.
Chronic Disease Management
In actuality, the bulk of the work we do in primary care is manage chronic diseases like diabetes, hypertension, heart disease, obesity, lipid problems, depression, fibromyalgia, asthma and COPD. Many of those conditions are well-suited for telemedicine, at least in between more in-depth periodic hands-on assessments, but a significant portion of patients who suffer from these chronic diseases either lack computer/Internet access or have difficulty using the technology. I still think this is a growth area for telemedicine and in the broadest sense this is really a science-based ”life coaching” in many cases. Here, a good data repository and continuity in the relationship between patient and provider are essential.
Another function of primary care is making sure that patients who believe they need specialty care in fact do, and to facilitate appropriate referrals. So many people don’t know what specialty does what, and this division of labor varies even between counties within a state. A patient who needs allergy testing in northern Maine who asks for a referral could travel 200 miles to see an allergist or 20 to see an otolaryngologist who also does that. And where is a podiatrist a more appropriate referral than an orthopedic surgeon? Sometimes you need to physically examine the patient to know where to refer, but not always.
Another area where telemedicine, in my opinion, has an obvious role is public health – one of my pet peeves as far as things that shouldn’t be the doctor’s responsibility. Once patients are set up for telemedicine, other people besides the medical providers can be involved: The practice can send health reminder messages via patient portals, provide screening and followups, patient education with nurses and other practice staff or even contracted off-site niche resources. Right now (here I go again…) primary care visits are bogged down with mandated public health issues that fit poorly in typical fifteen minute office visits.
Payment Reform – Don’t Revert
It is hard to imagine that we would return to the belief that in person visits will be the only way doctors deserve to get paid for what we do. I think the last several weeks have established in the public mind that medicine isn’t so different from other service industries that we shouldn’t use the available technology for the benefit and convenience of our customers.
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.