PAPERS WE’RE READING: Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm

“Telehealth in the COVID-19 Era: A Balancing Act to Avoid Harm,” written by J. Jeffery Reeves, John W. Ayers, and Christopher A. Longhurst, discusses the impacts, both positive and negative, of the proliferation of telehealth during the COVID-19 pandemic. The authors seek to discuss the benefits and potential pitfalls of telehealth encounters.

Due to lockdowns and physical distancing measures, many healthcare providers moved towards telehealth to provide care while limiting COVID-19 transmission. Consequently, the use of telehealth rapidly expanded during the COVID-19 pandemic, increasing health care access and improving the efficiency of health care delivery during a public health emergency. 

“Telehealth was originally regarded as a form of health care delivery largely reserved for specific, resource-limited settings, but it is now embedded in the daily practice of providers across the spectrum of patient care,” the authors write.

The authors write that the application of this technology rapidly spread across all outpatient settings, “including primary and preventative, medical and surgical specialty, and mental health care” within a matter of weeks. Some specialty clinics even became 100% virtual, equipping themselves with “remote monitoring, access to multi-provider video visits, and virtual translators.” Emergency departments, hospital wards, intensive care units, and interdisciplinary services such as occupational and physical therapy have all started to utilize telehealth. 

“This transition was facilitated by legislative changes designed to enable the ‘good faith’ provision of health care at a distance,” the authors explain. “New reimbursement policies have expanded access to a range of telehealth services offered by medical providers, clinical psychologists, licensed clinical social workers, and other health care workers.”

However, Reeves et al. comment that certain unintended consequences can come with virtual patient care, such as limiting the patient-provider relationship. One potential harm with telehealth is an incomplete or inaccurate physical examination. The authors warn that the inability to conduct an in-person physical examination for certain visits could lead to incorrect diagnoses or alter management plans. 

There are fundamental limitations to a virtual examination, which can be exacerbated by inadequate patient-home environment or space, poor lighting or discoloration resulting in poor visualization, and other technical issues. Additionally, certain aspects of a physical examination cannot be conducted, such as auscultation of heart or lung sounds. 

There are benefits to physical touch that can never be replaced by technology. For example, a physician can reassure patients since they looked specifically at their bodies. Some patients view virtual examinations as wholly inaccurate, regardless of the quality of the examination.

Secondly, “the roll-out of telehealth undermines the patient-provider relationship and the essential humanistic qualities of care providers,” the authors caution. 

The authors explain that a purely digital environment can hinder a trusting and personal connection between the patient and the health care provider. Patient experience studies have consistently reported difficulties in communicating or connecting with providers during telehealth visits. For this reason, pre-existing clinical relationships were considered to be the most appropriate for telehealth, according to a survey of primary care patients during the pandemic.

In addition, the swift expansion of telehealth has resulted in inefficiencies in the delivery of health care, according to the authors. The implementation of telehealth has been speedy, but there is a learning curve. For example, clinics have not been appropriately restructured to support telehealth visits. Medical assistants now play a role like that of front-desk personnel, limiting their involvement in patient care. The authors write that “the existing infrastructure, education, and administrative support surrounding telehealth must be tailored and broadened” to remedy the under-utilization of talent.

Reeves et al. conclude by providing general guidelines for determining the appropriateness of telehealth encounters in the outpatient setting. The authors suggest considering the visit type, patient characteristics, and the reason for a visit. New patient visits, low health literacy patients, or issues likely to require physical examination to aid in diagnosis are several factors that may indicate an in-person encounter would be beneficial. On the other hand, return visits for known patients who have sufficient technologic infrastructure can be conducted safely from afar. 

Acknowledging the many contributions of the telehealth revolution, the authors conclude: “In the future, precision in the approach and delivery of the telehealth patient encounter is essential.”

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J. Jeffery Reeves, MD, is a general surgery resident at UC San Diego Health.

John W. Ayers, PhD, is an associate professor and epidemiologist at San Diego State University. He researches public health informatics and the use of social media data in detecting behavioral health trends.

Christopher A. Longhurst, MD, serves as chief information officer and associate chief medical officer for quality and safety at UC San Diego Health and formerly the chief medical informatics officer at Stanford Children’s Hospital.

Noah Rothstein
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