As the world braces for the spread of disease caused by the new coronavirus, public health officials are calling on clinicians and health systems to embrace a set of tools that are technically already within reach: smartphones.
This week, officials from both the Centers for Disease Control and the World Health Organization urged hospitals and clinics to expand their use of telehealth services — also known as remote or virtual care — to help triage the sick and keep the worried well out of already-crowded medical facilities.
In the eyes of many clinicians and public health experts, telehealth’s moment has arrived.
“Telehealth can be a force multiplier that helps protect health workers and extends their reach, and should absolutely be seized upon,” Eric Perakslis, a Rubenstein Fellow at Duke University focusing on data science who previously led the technology efforts for multiple Ebola response programs in West Africa, told STAT.
But there are obstacles to telehealth in the U.S., since its health care system is not well-suited to widely adopt digital health tools.
“The biggest challenges stem from factors that don’t exist in China, like our vast array of private, state, and federal payers with varying reimbursement policies and state-based medical licensing,” Linda Branagan, the director of the University of California, San Francisco’s telehealth program, told STAT.
Those challenges, however, are not stopping some U.S. hospitals and telehealth companies from stepping up to the plate.
At UCSF, digital health tools originally designed for the flu are being turned into triage techniques for coronavirus, and the hospital is proactively reaching out to patients with flu and cold symptoms who had scheduled in-person visits to do video calls instead.
“An outbreak like this shines a light on the value of telehealth,” Peter Antall, American Well’s chief medical officer, told STAT.
Telehealth’s potential: a ‘force multiplier’
On two separate calls this week, Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, and Bruce Aylward, a senior WHO official who led a recent mission to China, pointed to telehealth as one part of a larger strategy to fight the spread of Covid-19, the disease caused by the novel coronavirus.
Messonnier urged American hospitals to look into expanding their use of telehealth services. Aylward said China had successfully done so already, allowing for more streamlined operations and safer care.
“They’ve just moved online a whole bunch of what was done physically to be able to keep the regular health services going, prescriptions turned over, etc., in a very orderly manner,” Aylward said.
China is also seeing a spike in the use of telehealth services. The vast majority of users appear to be healthy people who are using these tools to stay out of hospitals and doctors’ offices.
Telehealth’s most important strength may be its ability to keep healthy people safe: Patients can access clinicians and reliable health information while avoiding crowded hospitals or public transit.
“Telehealth has a lot of inherent properties that are useful in infectious disease outbreaks,” Perakslis said. “It can help keep people contained, map them, and meter the where and how of people going to seek medical care. It can also amplify messages and it can amplify workforces.”
At UCSF, where a handful of telehealth tools were originally put in place to deal with flu outbreaks, features like video visits are already helping combat misinformation about coronavirus and keeping healthy people out of the hospital, said Branagan.
“Many of our clinics are doing active outreach to patients with upcoming appointments that are clinically appropriate for video visits. When a patient reports cold or flu symptoms, the clinic converts the visit to be done via video,” she said.
In addition to screening patients for Covid-19, American Well wants to do more to combat the disease, Antall said. But his company’s efforts are somewhat hamstrung by spotty state laws for telehealth and unclear reimbursement policies that make digital tools a hard sell for health systems, he added.
“The reimbursement challenge still exists for telehealth,” Antall said. “Maybe this emergency will open eyes at CMS [the Centers for Medicare and Medicaid Services] and Congress as to the value of telehealth and why it should be reimbursed with parity to traditional care.”
“Patients are ready for more telehealth than many health systems can provide,” Branagan said.
Other countries beside China are also seizing on telehealth as new cases of the Covid-19 emerge within their borders.
In Canada, officials advised its first potential Covid-19 patient, who later tested positive for the disease, to first call a remote care hotline called Telehealth Ontario before visiting a health facility. After discussing her symptoms with a nurse on the hotline, the patient, a woman in her 20s who had recently traveled to Wuhan, China, was directed to get tested for the virus at a hospital and is currently self-isolating at home.
In Israel, where a major medical center near Tel Aviv recently took custody of the dozen Israeli passengers aboard a cruise ship that had been quarantined in Japan because of Covid-19, the hospital is partnering with at least three telehealth vendors to keep patients isolated while monitoring and communicating with them remotely.
“We have been able to meet all their medical needs without exposing the staff,” Eyal Zimlichman, the clinician overseeing the group’s care, told U.S. News and World Report this week.
Had telehealth been used earlier and more prominently in this way during the Ebola outbreak that began in 2014, Perakslis believes it may have helped save lives.
“The worst situation was because they weren’t prepared, the health care workforce was the first thing to go,” said Perakslis. “That broke the health system down.”
Digital health tools can help prevent such an outcome by quickly disseminating information — keeping people, including health care workers on the front lines, informed.
Digital health tools for real-time tracking and mapping
Digital health tools have other applications in disease outbreaks beyond protecting non-exposed people and health care workers.
Telehealth can be used to map the spread of an outbreak and identify hot spots, document communications between health care workers and patients, and quickly obtain patients’ consent in an ethical way. It effectively buttresses the work of epidemiologists and other health workers to more intelligently track and monitor cases in real time.
“All these things that are really important epidemiology tools are also things that have come along naturally with the way basic [telehealth] technology works,” Perakslis said.
In the case of coronavirus, conditions on the ground are changing almost daily, meaning that the providers who stay on top of the virus’ spread are also those who are constantly revising their guidelines and best practices. This is something that digital health tools also naturally lend themselves to, Perakslis added.
American Well, for example, has already changed its regulations for providers three times in the last six weeks, according to Antall.
“You need to be nimble to provide quality care,” he said.
Being nimble may prove critical for U.S. health systems preparing for an influx of coronavirus cases. Most of them, according to Perakslis, are not adequately prepared to handle infectious diseases at scale.
“Most medical facilities are reasonably well-prepared to handle an isolated case of infectious disease. They’ve got an isolation ward. They can take that one person who got off a plane. But what about when you get 200 people? This is where telehealth is something that should be seized upon.”
Still, telehealth has its limits as well. For Covid-19, which appears to be primarily a respiratory illness, many clinicians are looking into patients’ lungs to get an adequate assessment of their condition. Digital tools can’t really be used to do something like that unless patients already have the equipment at home.
For now, companies like American Well are assessing patients’ respiratory systems by looking at how they’re breathing and listening for things like wheezing, wet-sounding breathing, or wet cough.
“When we feel a patient needs more, we refer,” Antall said.