Why telemedicine is here to stayBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3603 (Published 06 October 2020) Cite this as: BMJ 2020;371:m3603
“It’s arrived with a bang,” says Sam Wessely, a London based GP. “When covid-19 hit, we were instructed to discourage patients from entering the practice physically in order to keep them and the staff safe.” But how were they to support patients remotely?
The obvious answer was telemedicine. Telephone consultations have been in use for over a century1 and video calls were first trialled by doctors in Nebraska in 19642 (using television signals instead of the internet). But while not unfamiliar, neither were in popular use with doctors or patients, and the experience of the technology had been mixed.
Yet the signs are that we have now reached a tipping point, pushed by the pandemic. Across the US alone, nearly half of healthcare consumers are now using telehealth, according to consultancy firm McKinsey—up from one in 10 last year.3
That’s to be expected when physical visits to hospitals and GP surgeries have been limited. Doctors who have long held out against the idea of telemedicine have now seen how it can work and like it. Some of the burden has been shouldered by telephone calls, particularly for patients for whom Skype or Facetime is a step too far. A survey by the Royal College of GPs found that six in 10 appointments in mid-July were conducted by telephone.4 But others are embracing video chats.
“GPs are a pretty conservative profession, and we do tend to revert to what we know,” says Wessely. “What we have now is a new normal. Going back to how we used to consult would be a big change, and we’re going to see many practices around the country employing this remote triage first approach.”
A tale of two practices
Wessely’s practice was better prepared than most. The surgery had been moving towards adopting an app developed by eConsult that helps triage patients. The system asks patients to answer text questions about their illness so a doctor can assess their needs. It was to roll out six weeks before the coronavirus hit, so the practice was able to bring forward the timescale.
The rollout was not without its problems. “Within two days of using it we discovered a flaw in its pathways, and another four weeks later,” says Wessely. In one instance, the system didn’t pick up a patient expressing suicidal thoughts through a pathway designed to process sick notes (the patient was contacted quickly and was fine). Another time, it didn’t highlight the nuance between a child presenting symptoms of potential meningitis and coronavirus in a test of the technology. The system told patients to call 111 and under no circumstances to present to a GP. Wessely says both problems were flagged up to eConsult and quickly remedied.
Four months after the UK’s lockdown was first declared, eConsult seemed to be largely working for them. “As we come out of the first phase and go into the next phase of dealing with coronavirus—delivering care to our patients while avoiding community transmission—we don’t see eConsult as a replacement for face-to-face appointments,” says Wessely. “It’s an adjunct to it.”
In the US, Devin Mann, an internal medicine specialist at New York’s NYU Langone Health practice, says they “had about five years of plans accelerate in a matter of five days.” Like Wessely, long term plans to integrate telemedicine into Mann’s practice were quickly implemented. From an average of 25 to 50 telehealth “visits” per day, NYU Langone quickly expanded to 8000.
“Insurers and regulators allowed us to use the tools we’ve had ready to care for the patients at a distance. The patients remain incredibly satisfied,” he says. Virtual urgent care (defined as “for patients who have minor medical conditions, and not for emergencies”)5 increased by nearly 700%, while non-urgent virtual visits to family doctors increased more than 4300% between 2 March and 14 April.6
Pre-pandemic, Healthwatch England, a patient lobby group, surveyed patients about what they wanted from the NHS. “People were more bothered about how quickly they got to see medical professionals than the method by which they got to see them,” says Jacob Lant, Healthwatch’s head of policy and public affairs.
That said, it would be natural for patients to worry that telemedicine was simply an excuse for inferior healthcare. Early studies, conducted during the pandemic by Healthwatch England, revealed mixed patient feedback. “For some, it’s revolutionised their experience—particularly for those who have regular catch-ups with their GP or consultants for routine matters,” says Lant. “We’ve also heard negative experiences from some groups, including those with learning disabilities or autism, for whom the format isn’t necessarily appropriate.” Patient advocacy groups are also worried about security: health records, particularly when combined with video calls, could become a data management headache.
Jessie Cunnett, head of health and social care at Traverse, an organisation that helps improve health and social care services in the UK, is carrying out similar surveys. “Patients see it as convenient,” she says. “They don’t have to travel or park, and it takes less time out of their day.”
But there is an underlying worry about long term shifts in healthcare. “People were initially willing to do digital appointments because of the pandemic, but how long will that willingness continue?” Cunnett asks. “Some are expressing anxiety that face-to-face appointments will never come back.”
There is another risk too. A US study showed that patients who could afford in-person appointments were continuing to do so, while poorer patients were pushed to digital.7 Whether this is a detriment to health outcomes remains to be seen, but equivalent healthcare it is not.
Here to stay
“We are in extraordinary times. I sometimes use the phrase 10 years of change in 10 weeks,” says Juliet Bauer, former chief digital officer for the NHS and now managing director of LIVI, an online GP provider with a platform that works similar to Skype and Facetime, but also offers a paid-for service to see a private doctor more quickly.
LIVI’s app has seen significant take up from doctors and patients alike: the number of patients accessing it increased five times above normal levels in the early stages of the pandemic—at one point 500 doctors a week were applying to work with the app. McKinsey estimates that in the US alone, the telemedicine industry is now worth $250bn3 (£193bn; €211bn) with health insurers in Germany8 and the US seemingly backing the move to allow virtual consultations to count for claims.9
“The genie isn’t going back in the bottle,” says Paul Testa from New York’s NYU Langone Health practice. What will happen is a more nuanced conversation about where telemedicine can work to streamline the process, and where it can’t.
Mann highlights continuity of care for long term patients, such as monitoring blood pressure or regular check-ups, as areas that could continue digitally. McKinsey’s report predicted that one in four people visiting outpatient clinics could instead be seen online, with a third of home visits carried out digitally.
And with such a rapid expansion, there’s also the question of regulation and standardisation to ensure consistency and quality of the experience, as well as privacy and security. In the UK, the BMA has named four video consultation systems (Accurx, EMIS, TPP, Vision) that the NHS recently made free to access,10 but NHSX advises that Skype, FaceTime, and WhatsApp are acceptable.11 “The consent of the patient or service user is implied by them accepting the invite and entering the consultation,” reads their advice, “But you should safeguard personal or confidential patient information in the same way you would with any other consultation.”
At a time when medical staff are more overworked and under pressure than ever, there is another benefit. “Clinician wellbeing has been enhanced by employing this mode of practice,” says Wessely, escaping what he calls “the tyranny of the waiting room.” Running 10 minutes late has a knock-on effect. “Your behaviour is driven by who’s waiting, and the guilt when you run over is a source of a huge amount of stress in our profession.” Being able to triage patients online and see many through carefully timed video calls, unlocks some of that anxiety.
Commissioned, not peer reviewed
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.