Ordinarily Trueman Mills makes the trek to his cardiologist by car. He lives in rolling hills at the edge of Allegheny National Forest, about 90 miles from his doctor in Pittsburgh. It is a setting as beautiful as it is inconvenient for patients with congestive heart failure, a condition that in late March caused Mills’ legs to swell into balloon-like shapes he could barely recognize.
Luckily for him, the Covid-19 pandemic came with a big silver lining: His doctor, Ravi Ramani, offered to examine him via video conference. During the visit, the 86-year-old former consultant and car salesman tilted his screen to show the swelling in his legs, prompting Ramani to adjust his medications to help shed the excess fluid.
“I was very impressed by the whole operation,” said Mills, whose legs quickly returned to normal in the days after the visit. “If we get out of this, we might find that a lot more medicine gets done this way, for good or for bad.”
No one has had time to systematically examine how the sudden rise in telemedicine use is affecting patient outcomes. But in the communities surrounding Pittsburgh, where the city quickly gives way to a vast countryside of farms and fading steel towns, a revolution is taking root in the lives of patients like Mills with chronic conditions. They are finding it faster and easier to get care, trading drives that often soaked up three hours for video visits that offer instant access to advice and prescription refills.
Based on the enthusiastic embrace of telehealth, by both patients and their doctors, it seems increasingly likely that these changes will outlast the pandemic, in western Pennsylvania and across the country.
The number of telemedicine visits conducted by the University of Pittsburgh Medical Center (UPMC), the region’s largest provider, has jumped from 250 per day in early March to nearly 9,500 per day last week, a staggering 3,700% increase. Metropolitan areas across the country are seeing similar surges, leaving many providers struggling to keep up with the demand. The trend is especially pronounced among patients with heart disease, diabetes, cancer, and other chronic illnesses that make them more likely to become critically ill or die from Covid-19.
For them, telemedicine during the pandemic is not just a convenience, but a lifeline. Some patients are so fearful of exposing themselves to the virus that they are delaying care and allowing their illnesses to spiral out of control, a dynamic that is causing physicians to preemptively offer video check-ins to those facing the greatest risks.
“The biggest thing I as a clinician rely on is the eyeball test,” said Ramani, who is director of UPMC’s heart failure program. “Just being able to see them, how they are sitting in their armchairs, how their skin color looks — those things are critical.”
His interview with a STAT reporter was interrupted by the sort of phone call he’s been getting a lot lately. An attending physician in an outpatient clinic was calling to notify him that a test had confirmed the progression of a patient’s heart failure symptoms.
A few minutes later, the phone rang again. This time it was the cardiac catheterization lab. The same patient was concerned about being exposed to Covid-19 and wanted to leave the hospital.
“Five years ago, this would have been a no-brainer,” Ramani said, adding that such patients often need hospital care. “What I’m probably going to tell her is: ‘Go home, I’ll have your doc call you on your phone tomorrow and we can do a video visit.’”
Once the crisis is over, the system will begin to rebalance itself, but doctors and patients said it should not return to the way it was before. Many want the increased access to telemedicine to endure beyond the pandemic, so that American health care, with its sky-high costs and mediocre outcomes, will finally become more timely and convenient — and perhaps more effective.
“One of the comments we most frequently get from patients is that they have more face time with the physician during these telemedicine visits than they do when they’re in person,” said Robert Bart, a physician and chief medical information officer at UPMC. He noted that doctors are able to type notes while facing the patient, instead of looking over their shoulders, and they get interrupted less frequently than they do in the office. “The satisfaction rate among patients is remarkably high,” Bart said.
That doesn’t mean there haven’t been technical challenges. Like most providers, UPMC initially struggled to manage huge overnight increases in telemedicine traffic, leading to delays at the start of appointments. Some patients also fumbled around in their first attempts to use the system. “Once they understand how to log into our patient portal and do these visits, the second and third attempts are usually quite straightforward,” Bart said.
Continued access to telemedicine after the crisis will be determined largely by political and financial forces. To support care during the pandemic, the federal Centers for Medicare and Medicaid Services said it would temporarily equalize payment for telemedicine consultations with what physicians are paid for office visits.
The agency also eased restrictions on use of remote care. Instead of requiring rural patients to travel to a local medical facility for a video visit with a physician in the city, it allowed them to get services in their homes. It opened the floodgates even wider by allowing the use of popular platforms such as FaceTime and Zoom.
But the agency has not yet decided whether those policies will continue. A spokesman for CMS said telemedicine is a “great example of services that are creating greater flexibility for beneficiaries” and that the agency is considering which changes should be continued after the crisis is over. The decision, for both private and public insurers, will hinge in part on the impact on patient outcomes during the pandemic, which has become something of a rolling national trial for telemedicine.
“I would say this has been five or 10 years of clinical transformation compressed into a four-week period,” said Bart, who added that doctors in a range of specialties are now racing to document the impact on patient care. “They want to be able to state that they were able to maintain [care] standards via telehealth versus face to face.”
Pittsburgh is uniquely suited as a test case for the expansion of telemedicine. In addition to its vast rural areas, its population is one of the oldest in the country, with about 18% of residents over age 65, compared to about 13% nationally. High rates of chronic disease in that age group mean residents often drive two hours or more for a doctor’s appointment in the city or its surrounding suburbs.
“Patients wait months, despite our best efforts, for a visit with us,” said Lauren Willard, a physician in UPMC’s endocrinology department. “They can have changes in their work or child care schedules that force them to reschedule appointments — and they end up with this period where their chronic disease goes uncontrolled.”
Her department was already moving to expand access to telemedicine services to diabetes patients before the pandemic. But the progress was gradual; endocrinologists were doing about eight telemedicine visits per week. Once Covid-19 hit, the number suddenly jumped to about 500.
“We turned all visits to virtual over two days,” said Esra Karslioglu French, a physician and medical director of the endocrinology department. “We didn’t have to cancel appointments.”
Diabetes care is driven by data, requiring constant monitoring of blood sugar levels and downloads from insulin pumps and other devices. To keep up, UPMC’s doctors use an application called Tidepool to allow patients to share data from dozens of different devices so the information can be reviewed during their visits. That enables them to give on-the-spot advice on how to change their lifestyles or medication regimens to avoid problems.
French said UPMC initiated multiple studies before the pandemic to test the impact of remote care and video consultations. One examines whether the use of Tidepool is associated with better control of blood sugar; another examines whether a follow-up telemedicine visit for hospitalized patients results in fewer re-admissions or visits to the emergency department.
The results of the Tidepool study are scheduled to be presented at the annual meeting of the American Diabetes Association in June, a gathering which has also been converted to a virtual platform.
Meanwhile, French said, a consensus has emerged among UPMC’s endocrinologists: After Covid-19 recedes, they would like to convert about 60% of their sessions to video visits on a permanent basis. “This will also depend on CMS’s regulations,” she said. “But the faculty loves it and finds it very efficient.”
By necessity, the expansion of telemedicine is changing care for patients with illnesses ranging from anxiety to kidney disease to cancer. Many of those patients will need to return to in-person care following the pandemic to get delayed tests and physical exams. But as much as they want the crisis to end, they don’t want access to telemedicine to end with it.
“It’s a very viable way to handle my visit, especially since it saved me from having to go into the hospital,” said Tim Kostilnik, 63, who said a normal checkup to manage his pulmonary hypertension can take two hours door to door. Last week, his doctor offered a video visit in place of his normal trip to the office. “It was easy,” Kostilnik said. “It was over in 15 minutes.”
Other patients who had reservations about telemedicine before the pandemic said their first video visits have warmed them to the idea. Amanda Scifo, 36, was especially focused on careful management of her pregnancy after two prior miscarriages. But she said a recent video visit was a welcome respite from office visits.
“It was really nice. I felt like I had a really good connection with the doctor,” said Scifo. “I really enjoyed being able to see him and ask questions. His eyes were on the screen the majority of the time he was talking to us.”
The video visit was especially welcome after an earlier trip to the office in which Scifo had to have blood work done. The nurses and doctors were covered in protective gear; Scifo was wearing a homemade mask as well, and wasn’t allowed to bring her husband with her. “It was unnerving,” she said. “One nurse we really like had a hazmat suit on and she was like, ‘How are you doing?’ And I said, ‘I’d be better if I could breathe.’”
Once patients and doctors are able to exhale following the crisis, it will take time to study the impact of telemedicine and recalibrate which patients can be managed remotely and which will still need to come into the office. Tracing the outcomes, and comparing them to the standard of care, will likely take months, followed by more work to tweak clinician routines, troubleshoot technology snafus, and ensure that telemedicine is being used appropriately.
But Mills, the patient with congestive heart failure in the Allegheny foothills, said he doesn’t need a randomized controlled trial to know that telemedicine saved him a heap of time and resolved his issue.
“It worked out very well for the problem I was having,” he said. “It’s amazing. You pick up a cellphone and there’s your picture and the man you’re talking to. It’s like he’s in your living room. An awful lot of care can be done with technology. I believe this has a real future.”