The COVID-19 pandemic opened the eyes of the nation to the possibilities of telehealth.
By Shari Roan
In the early days of March 2020, the bulletins circulating among UCLA Health staff were alarming. The COVID-19 pandemic was bearing down on Southern California, as it was on almost every community in the world. Handling the expected influx of patients posed overwhelming dilemmas for hospitals and clinics. The novel coronavirus was highly contagious. Infected patients would require care while non-COVID-19 patients and health care workers needed protection from exposure.
Each day brought more stunning news. While the emergency department (ED) filled with COVID-19 patients, people with the usual conditions typically seen in the ED — heart attacks, strokes, mental health crises — disappeared, apparently too fearful of coronavirus infection to seek care.
Quite suddenly, UCLA Health’s investment in 2018 to launch telehealth capabilities throughout the system looked prescient. Although only sparsely used until then, UCLA Health leaders quickly recognized the time for telehealth had come. “By March 16, we realized this was going to be a broad pandemic, and we needed to get all our physicians on board with video visits as soon as possible,” says Mark S. Grossman, MD, clinical professor of medicine and pediatrics in the David Geffen School of Medicine at UCLA, who helps to oversee UCLA’s telehealth programs. “By the end of March, we had 100 percent of our primary care physicians— 300 providers — set up to do video visits, and all other specialty care doctors were rapidly coming on board with video telehealth capability. The message was that no one with COVID19 symptoms should initially come into the office until screened in a video visit.”
Among the cultural adjustments to emerge from the COVID-19 pandemic in the United States, the increased use of telehealth may rank as one of the most transformative. And if UCLA’s experience is any indication — telehealth visits leaped from 900 in January to 81,000 in April — it will be huge. Telehealth, broadly defined as the use of communications technology to provide health care, has been possible for more than a decade and accessible in most major health care systems around the country for the last several years. But it was used sparingly until tens of thousands of Americans began coughing and running high fevers in unison.
“Expanded use of video visits may be one of the few positive outcomes of the COVID-19 pandemic,” says Daniel M. Croymans, MD ’15 (RES ’18), medical director of quality for the UCLA Department of Medicine. “It may have taken a crisis to get up to par with current technologies and telehealth.”
There are multiple facets to telehealth. It encompasses the transmission of recorded health information between physicians for consultation. For example, a physician in a rural area may ask a neurologist at UCLA to consult, via live video, on a patient who may be having a stroke. Telehealth also includes remote patient monitoring, such as emerging technology that helps people self-monitor their conditions and transmit data back to providers for analysis. But the biggest upside to telehealth may be its unique ability to connect people with health care providers quickly, efficiently, privately and safely. For busy Americans, that may mean the days of taking a half-day off from work to see the doctor for a minor health issue could be over.
Timing is everything. In 2018, UCLA Health implemented telehealth technology systemwide, naming it Connected Health. It was not a revolution. Prior to the pandemic, approximately 200 providers had undertaken the 15-minute compliance training session and were seeing patients via telehealth. Some psychiatrists and their patients favored video visits, and some other physicians preferred video visits to check in on recently discharged patients. In the UCLA Heart Transplantation and Mechanical Circulatory Support Program, a few pioneering doctors and nurses were testing the utility of telehealth with select patients in carefully managed pilot studies.
When the pandemic descended, however, UCLA Health providers flocked to receive training. On March 16, a letter went out to UCLA Health patients to call their physicians before coming to the office or hospital. Video visits were scheduled whenever possible. During the peak weeks of the pandemic, about 17,000 patients were seen via video visits, according to Anne Y. Lin, MD, medical director of UCLA’s telehealth programs.
While the system experienced some technical hiccups — demand was so high at some points, that IT technicians had to increase bandwidth — the advantages of using video visits quickly became obvious: no viral exposure, reduction in the use of personal protective equipment, a time savings for patients and convenience for providers, some of whom could work from home. Using video visits and a remote-monitoring application in UCLA’s electronic health records system, MyChart, “we were able to follow patients with COVID-19 closely to make sure they were recovering well,” Dr. Lin says.
“We’ve gone from a few early adopters to, all of sudden, the majority using it overnight,” Dr. Grossman says. “This was about as quick an adoption of any medical technology as I’ve ever seen.”
Nationwide, telehealth was poised for this moment. Even prior to the pandemic, more than 50 U.S. health systems had telehealth programs in place, according to a March report published in The New England Journal of Medicine. Many small health systems and employer groups already were contracting with private companies for simple primary care visits, such as diagnosing rashes and coughs. A survey by the National Business Group on Health in 2017 showed 95 percent of large employers offered telehealth or were planning to do so. And, according to the American Medical Association 2019 Digital Health Study, physicians who said they use telehealth visits doubled from 14 percent in 2016 to 28 percent in 2019.
The recent growth of telehealth might not have occurred, however, if not for changes in insurance reimbursement that occurred during the pandemic. On March 6, the Centers for Medicare and Medicaid Services (CMS) announced it would begin paying for telehealth services due to the pandemic, including visits for any medical or health condition. Some private health insurers also lifted reimbursement restrictions. On March 30, California Insurance Commissioner Ricardo Lara issued a letter stating that “for the duration of the current COVID-19 emergency declaration” consumers could access telehealth services when clinically appropriate and insurance providers “should immediately implement reimbursement rates for telehealth services that mirror payment rates for an equivalent office visit.”
Prior to the pandemic, reimbursement for telehealth was, at best, a struggle, Dr. Croymans says. For example, in order to reimburse for a video visit, some insurance companies required both the patient and provider to go to a “pre-approved” location to conduct the visit. “The catalyst was missing,” he says. “The catalyst was reimbursement incentives. There wasn’t appropriate reimbursement for these services until March. The lack of reimbursement was almost a non-starter.”
As of July, CMS had not reversed its COVID-19 emergency declaration regarding telehealth reimbursement. If it does, and private insurers follow, reimbursement for video visits may remain a barrier to further growth of telehealth, experts say. The New England Journal of Medicine report noted that only 20 percent of states currently require payment parity between telehealth and in-person services.
However, with the COVID-19 pandemic settling in for a long stay, it may be impossible to reverse course on telehealth. CMS reported that telehealth visits among traditional Medicare recipients soared from about 12,000 per week pre pandemic to more than 1 million a week by late spring of 2020, according to the American Telemedicine Association.
In June, a consortium of 20 national care groups — including Intermountain Healthcare and Kaiser Permanente Federation — announced the formation of a task force aimed at developing recommendations for policymakers on telehealth cost and quality issues.
There’s another reason telehealth is likely here to stay. Patients like it. Lacey Fulcher, 38, is a registered nurse in San Diego. Even prior to the pandemic, she was a busy woman, working long days. For the past several months, however, Fulcher has been able to preserve precious time by using telehealth. Once a month or so, she sits in her car in the parking lot over lunch time and dials in on her smartphone to connect with members of her UCLA heart-transplant team. She laughs at the idea of it, but concedes, “It’s so much easier to have a video check-in. Driving to Los Angeles was exhausting and costly for gas and everything.”
Fulcher was born with a congenital heart condition. For many years, the condition, arrhythmogenic right ventricular dysplasia, didn’t bother her. But about three years ago, the condition progressed significantly, and her heart began to fail. She sought care at UCLA and, in August 2019, she was told she needed a heart transplant. She received a heart after only one day on the waiting list.
Fulcher has recovered well, and she returned to work earlier this year. When the pandemic hit, UCLA called her to suggest she conduct some of her regular follow-up visits via video with her doctor, Ali Nsair, MD (FEL ’10, ’11), director of the UCLA Heart Transplantation and Mechanical Circulatory Support Program.
“These visits are basically check-ins to see how I’m doing,” Fulcher says. Besides Dr. Nsair, several members of her care team assemble in a conference room at the appointed time and connect with Fulcher on Zoom. She still occasionally drives the 125 miles to L.A. for echocardiograms and tests to assess her heart function.
Fulcher appreciates the technology as both a patient and a health care provider. “Even after this pandemic is resolved, telehealth is going to be a huge way we deal with our patients,” she says. “Patients have adapted to it. They had already been asking questions and emailing providers through portals. Doctors like it, too,” she says. “They can do quick check-ups over video and have more time available to see patients who are more critical and to do procedures.”
So far, statistics and studies point to the success of the COVID-19 telehealth experiment. More than three-quarters of Americans say they are interested in using telehealth, according to a recent survey by McKinsey & Company.
Brett Krumrey is an example of the future of medicine — find the best care, wherever that may be, and use technology to facilitate care and reduce the costs. A resident of Canton, Georgia, he conducted two medical consultations, one in New York and one at UCLA, via telehealth earlier this year when he was diagnosed with a colon polyp that was too large to remove during a colonoscopy. He chose Dr. Lin as his surgeon and her colleague Kevin Ghassemi, MD (RES ’07, FEL ’10), as his gastroenterologist because they offered minimally invasive combined endoscopic and laparoscopic surgery. While recovering at his sister-in-law’s house in L.A. during the peak of the spring COVID-19 outbreak, Krumrey again relied on technology. Each morning, he used a UCLA-developed remote-monitoring application in MyChart called PRIME to connect with his care team. He received daily reminders to complete targeted questions that would keep his doctors up-to-date on his recovery and even transmitted a photo of his incisions. “We were able to monitor his progress closely after discharge and respond to his concerns in a timely fashion,” Dr. Lin says. “This application encouraged him to become an active participant in his recovery.”
“During my first surgical consult in Georgia, I had to drive to the surgeon’s office, wait there, fill out forms, wait for the doctor. It was the standard doctor’s visit I was used to,” Krumrey says. “In the future, I’m going to be very reluctant to go to a doctor for some types of visits when I just need to talk to the doctor or just don’t see the need for going in. I intend to make it a criteria for choosing a doctor: Do you do telehealth? It’s a huge time-saver.”
Early data show that patients who converted from in-office to telehealth visits this spring were highly satisfied with the experience, says Megan Kamath, MD (FEL ’18), a UCLA cardiologist specializing in advanced heart failure and transplant. In 2018, the UCLA Heart Transplantation and Mechanical Circulatory Support Program began studying telehealth visits to check on some local patients, as well as those who lived far away from the UCLA medical campus. Dr. Kamath and her colleagues now are conducting studies to determine how the service can be improved and elevated to a regular, reliable option for patients in the future — pandemic or no pandemic. “We have been getting a lot of positive feedback,” Dr. Kamath says. “Patients also have given us constructive pointers on ways to make our platform easier to use and on how we can engage with them better. I think it’s already improving patient health.”
For example, she described a patient who had struggled to make in-person appointments on a regular basis. “This had been going on, off and on, for about two years,” Dr. Kamath says. “Due to the COVID-19 pandemic, we offered the patient the opportunity to do virtual telemedicine visits with us. This is the first time we’d been able to connect with this patient in a very long time. The patient,” who said it otherwise would have been impossible to make it to UCLA for an appointment, “was so grateful.”
Patients appear willing and able to complete video visits. So far this year at UCLA, the no-show rate for telehealth visits is 0.4 percent, compared to 6 percent for in-office visits.
Fulcher says she feels just as “cared for” sitting in her car in San Diego as she did in the medical office building in Westwood. “When you’re a new patient, it might be nice to have a meet-and-greet visit. But with telehealth, I still feel like I’m cared for,” she says. “I feel the doctors are able to take more time. I feel less rushed and can ask more questions because I’m not worried about the traffic and getting home.”
Telehealth may be a way to return to the days when patients could stay with their long-term health care providers despite geographical moves and employment and insurance changes. Fulcher foresees using telehealth to continue her cardiac care at UCLA for years to come. “When you’ve had something like a heart transplant, you have people you’ve trusted for years, and you want to be able to continue your care with them,” she says.
The true measure of telehealth’s growth and future will have to be the quality of care it delivers, says Eve M. Glazier, MD (RES ’07), president of the UCLA Health Faculty Practice Group. “It has to be the right patient, right time, right diagnosis,” she says. “It’s not a cookie-cutter approach. We have to be thoughtful about the tool. “
In the post-pandemic age, telehealth likely will remain useful for second opinions, some primary care visits that involve simple ailments, medication management and consultation and chronic-disease management, she says. It can facilitate post-surgical follow-ups and care coordination when a hospitalized patient is discharged and transferred back to the care of a primary care doctor.
“There is a lot you can see with your eyes, without doing a touch-based physical exam,” Dr. Croymans says. “Video visits allow us to provide excellent — often equivalent — care for many different patient concerns and complaints.”
But many medical visits will remain unsuitable for telehealth, Dr. Grossman says. “Many times, the patient still needs to come in for physical exams, blood draws, vaccinations. Video visits won’t replace physicals or well-child checks. But we have been doing telehealth for a while, and we know it is a safe method for health care delivery in many cases.”
Technological advances may expand the usefulness of telehealth, says UCLA cardiologist David Joseph Cho, MD (RES ’14, FEL ’18). Remote medical monitoring technologies — things like blood pressure cuffs, pulse oximeters, sophisticated thermometers, heart rate monitors and blood sugar monitoring devices — will augment video visits. It’s even possible that future “augmented reality” technologies will be able to assess a patient’s vocal changes, facial expressions and pupils for signs of physiological stress that can help a provider assess his or her patient.
“Solving that quantitative portion is where the future of telehealth needs to go to make it more akin to being in the office,” Dr. Cho says. “But, who knows with technology? There are going to be so many more possibilities with what we can get out of a telehealth visit. It will be interesting to see what the clinic will look like in 10 years. I can say with 100 percent certainty that it won’t be what it looks like today.”
For now, health professionals worldwide are grappling with how to make sure the technology is used appropriately. Multiple studies on telehealth are underway across UCLA and the world, Dr. Lin says. UCLA has launched a digital patient-experience committee to evaluate telehealth and make adjustments to better serve patients. “We are studying the processes and outcomes to guide our best practices,” she says. “Part of our goal is to be sure we are continuing to evaluate care during the pandemic — looking at a disease process and making sure care of a patient using telehealth is equivalent to an in-person visit. We’re hoping to move the needle in understanding how to use telehealth in the best way possible.”
Patients, ultimately, will help decide the future role of telehealth. While almost half of all visits to UCLA in the peak months of the pandemic were conducted via telehealth, by June more patients were returning to the office, Dr. Glazier notes. “We’re seeing telehealth visits falling to a level that will give us a sense of what is more appropriate for this modality,” she says. “I think telehealth will end up at about 10-to-20 percent of all visits.”
There also will be future debates about whether or not telehealth can save money in a national health care system with rampant out-of-control costs. Maria Han, MD (FEL ’15), chief quality officer for the Department of Medicine, suggests telehealth combined with other technologies can lessen several of the burdens that currently plague U.S. health care: economic, logistic and existential. For example, the health care physical infrastructure may shrink. Providers and patients will save time. Health outcomes could improve if people with chronic conditions — poorly managed diabetes, angina, anxiety and the like — can conduct more frequent, timely conversations with their health care providers for problem-solving, education and reassurance.
“I think we’re beginning to see a paradigm shift,” Dr. Han says. “It started many years ago and has been accelerated by the COVID crisis. There is more focus today on value-based health care delivery, and telemedicine has been a great opportunity to deliver care in a way that is convenient and efficient and of high value-added. I don’t think we’ll go back to the way things were.”
Shari Roan is a freelance medical writer and frequent contributor to U Magazine.