Kellu Burch, Granite State New Collaborative
September 18, 2020
Each week, Sandi Elliot needs to take time off work to take her 14-year-old son to a therapy appointment. It takes Elliot about half an hour to drive from her home in Wilmot to the appointment in Franklin. When the pandemic hit and the appointment changed to telehealth, it was much easier for Elliot to get her son to therapy.
“It was also nice that we could be out doing things, and could take a half hour off to do his appointment, instead of planning the day around going to an office,” Elliot said. When the therapist started doing in-person visits again, Elliot and her son opted to stick with video appointments.
The pandemic forced patients and medical practitioners around the country to pivot to remote visits whether they were ready or not. Many doctors’ offices and hospitals turned to telehealth — visits conducted by video-conference or phone — during the early months of the pandemic. In April, 77% of total visits in the Northeast were done remotely, a 300% increase, according to data on more than 1.6 million health records.
But as delivering healthcare during the pandemic became more routine, more people switched back to in-person visits. In July, telehealth made up just 25% of visits, according to the same data set. Still, that’s a significant increase from before the pandemic, when only 1.3% of visits were conducted via telehealth, according to data from the first three months of 2020.
Elizabeth Harrison is a family nurse practitioner at Families First Health and Support Center, a community health center in Portsmouth. She said that prior to the pandemic, another practitioner at the clinic wanted to explore telehealth, but barriers around insurance coverage and healthcare privacy made the transition difficult.
The pandemic encouraged quick legislative and policy action at state and federal levels that helped facilitate the expansion into telehealth. At the national level, requirements under HIPPA, the sweeping healthcare privacy law, were waived to let practitioners offer appointments over platforms like Zoom or Facetime that might not be HIPPA-compliant. The insurance industry moved to cover telehealth at the same level as in-person visits.
In New Hampshire, Gov. Sununu signed HB 1623 into law on July 21. The law requires telehealth parity, meaning that Medicaid and private insurers need to pay the same for telehealth services as they would for in-person services. In addition, the law allowed for phone-based (rather than video) telehealth appointments, and expanded the role of telehealth in treating substance use disorder.
Despite the fact that telehealth visits have dropped from the height of the stay-at-home order, health care providers say that there will be a continued interest in remote doctor visits.
“Now that it’s here, I don’t think it’s going away,” Harrison said.
The benefits of telehealth
Corey A. Siegel, MD, started using telehealth in his gastroenterology and hepatology practice at Dartmouth Hitchcock Medical Center in Lebanon back in 2014. He received funding from The Leona M. and Harry B. Helmsley Charitable Trust to research how telehealth impacted the patient experience. He published research in the journals Gastroenterology and Inflammatory Bowel Disease detailing how telehealth can provide high-value care for patients.
“If the quality is staying the same or better, and cost is going down, that’s a high-value healthcare alternative,” Siegel said.
Oftentimes, patients who come to see speciality doctors at Dartmouth are traveling at least an hour round trip, he said. There’s financial costs associated with time off work, child-care and gas expenses. Telehealth can mitigate those. But Siegel pointed out that telehealth is convenient for everyone, not just people who live far away from their doctor. A local patient who otherwise might need to take time off work for an appointment can simply take a half-hour break and duck into a conference room for a consult.
Harrison and the other practitioners at Families First found that telehealth opened more appointment slots, and also reduced no-shows, which can be costly for a practice. For patients who have transportation challenges, it is particularly helpful.
“They have no excuse to miss their appointments,” she said.
Of course, there are situations where a physical exam is needed, so the goal will never be to rely entirely on remote visits. During the spring, Siegel conducted almost all of his visits remotely, but he still needed to have patients come into the hospital for emergencies, he said. Harrison and Siegel agreed that telehealth is best used for managing chronic conditions and seeing patients who need doctors appointments fairly regularly.
Still, Siegel has been surprised about how well he has been able to connect with patients online.
“Nothing that can take the place of a physical exam,” he said, “But you can do very, very well over video. I’ve had very hard convos about life and death, risky potential outcomes, long term outcomes about their disease. There have been tearful conversations and joyful conversations. Once people are engaged on the platform you can get most of the way there.”
Barriers to telehealth
Telehealth can be particularly important in a rural area like New Hampshire, where patients have to travel far to see their doctors. But rural living also presents a huge challenge, since many residents do not have access to broadband internet that can support a quality video connection.
Mary Oseid, senior vice president for regional strategy and operations at Dartmouth-Hitchcock said that the hospital engages with lawmakers to try to emphasize the importance of the internet in accessing quality healthcare. But, she admits, when it comes to getting patients online, “there isn’t much that we can do.”
“These are issues that need to be solved at the federal level,” she said.
One work-around for some New Hampshire providers is offering telehealth via phone, a service that is now bill-able as telehealth in New Hampshire, with the passing of BH 1623.
In addition, Medicare, the federal health insurance program, only covers some services delivered remotely. The recent New Hampshire bill that requires telehealth parity doesn’t cover Medicare.
Technology challenges emerged for many providers during the switch to telehealth. Dartmouth had already begun offering telehealth services using a HIPPA-compliant portal, but that software was not connected to the hospital’s electronic health records. When the bulk of appointments were taking place remotely, practitioners found it cumbersome to work with both platforms, Oseid said. Because of that, the hospital integrated the two so that doctors can conduct visits right within a patient’s electronic health file. That also makes it easier for patients, Siegel said, since they log into their Dartmouth account and simply click a link to enter the appointment.
In addition, there’s a learning curve for practicing over telehealth. Practitioners need to learn how to use the technology, although most are familiar at this point in the pandemic. More importantly, they also need to learn how to establish rapport and extract important information like family histories remotely. Because of that, the University of New Hampshire is incorporating telehealth education into its classes for nurses and nurse practitioners.
“Communities need more primary care clinicians who are well-versed in telehealth,” said Marcy Doyle, project director Telehealth Practice Center at UNH.
Harrison, who teaches at UNH, said that some students are currently conducting their clinical hours using telehealth, which provides important experience for the future.
“There’s definitely a desire and need for students to learn those skills,” she said.
Finding the new normal
Despite the pandemic’s push into telehealth, the concept of visiting a doctor remotely is still new for many people. With the switch to remote communication in all areas of life, from school to work, more people are willing to give telehealth a try, the practitioners in this story said. Once someone has a positive experience with a report appointment, they’re more apt to try it again, Siegel said.
“Once they do it the first time, then it’s really easy,” he said.
Oseid said that the medical industry overall is still trying to figure out the right balance between in person and remote doctors visits.
That involves educating providers about everything that can be done remotely, getting patients more comfortable with the idea, and making telehealth appointments as easy as possible for everyone. Ultimately, expanding telehealth allows for a more efficient healthcare system, she said.
“It is a really awesome solution for increasing access and improving affordability of care,” she said.
For Dartmouth, telehealth is also about more than just conducting patient-doctor visits online. The hospital offers remote consulting with smaller hospitals throughout the region. Certain beds in this hospital are wired to send patient information directly to Dartmouth, where intensive-care or emergency-room specialists can advise the in-person team remotely.
Ultimately, Oseid said that bedside-decision making assisted by artifical intelligence might reduce the need for these hospital-to-hospital telehealth consulting services, but she expects that the use of telehealth for patient-doctor visits will continue to increase.
“That’s where we’re going to see the most significant growth,” she said.
Right now, the hospital is focused on offering a telehealth option to as many patients as possible in order to gauge interest. Doyle said the Telehealth Practice Center at UNH is also working to understand patient interest in telehealth. If remote appointments are going to become a standard part of care, the patient experience needs to be prioritized, she said.
“We need to have the patient at the center of the conversation: what are the needs of that patient and community?” she said. “How do we align patient needs with quality?”