Increasingly, doctors are conducting visits via the internet. What are the benefits — and limits — of telemedicine/ telehealth, and what is its future?

A major shift in health care has occurred because of COVID-19 and it’s likely to continue well after the virus is under control.

The huge change is in the delivery of care from in-person visits to telehealth, which uses advanced communications technology to provide health care services, and especially telemedicine, a category of telehealth that focuses on medical care. By the numbers, the adoption of these methods by patients and providers has been astounding.

Based on a reliable formula, the Arizona Telemedicine Program — housed at the University of Arizona — earlier projected that 40 million telemedicine cases would occur throughout the U.S. in 2020. Instead, one billion cases were reported. “That’s a 2,500 percent increase in a single year,” says Ronald W. Weinstein, M.D., the program’s founder and longtime director.

Arizona’s Medicaid program — Arizona Health Care Cost Containment System (AHCCCS) — logged a 165 percent increase in members using telehealth, from about 184,000 to more than half a million. Blue Cross Blue Shield of Arizona (BCBS Arizona) has seen a 4,800 percent increase in telemedicine use among its 1.7 million patient members.

“That’s a massive growth,” says internist Piyush Gupta, M.D., FACP, vice president of population health and partnerships for BCBS Arizona. “People are happy and excited to use it.”

Connected for Kids

As with many other types of services, patients canceled and avoided making health care appointments when we all were told in March 2020 to stay home to avoid COVID-19, the disease caused by the SARSCoV- 2 coronavirus.

Medical care providers had to figure out how to continue to see their patients. That’s what happened with the Tucson Central Pediatrics and its four physicians.

“At first we weren’t quite sure what to do,” says Carin Eldridge, M.D., a pediatrician who joined the 23-yearold practice in 2018. “Some practices closed for a little while.” Tucson Central Pediatrics rearranged appointments so that well patients didn’t share space with sick kids.

The pediatric office is part of Arizona Community Physicians, a physician-owned medical group with 166 providers across eight specialties in more than 50 locations in Tucson, Oro Valley and Green Valley. It provided an application — — for its members to use for providing telehealth services.

Tucson Central Pediatrics transferred to virtual medical care on March 25 and found a ready and willing clientele to use it. About 20 percent of “visits” to the doctor have shifted to telemedicine using either a laptop with video capabilities or phones for audio calls.

In-person visits are required for feverish patients two years and younger, well-child exams, and youngsters who need vaccinations. Sometimes, telemedicine is used to determine if a child needs to be seen in person.

Dr. Eldridge has found that the convenience of telehealth helps get children, particularly teens, to attend their follow-up appointments. It’s especially important as the doctor tries to address the excessive weight some of these youth have gained — 20 to 40 pounds — since the start of the pandemic.

“Pre-pandemic, it was harder to get patients to show up for follow-up visits like this,” she says. “I’ve had much better luck with telehealth.”

One of Dr. Eldridge’s patient families likes the flexibility of telemedicine. Nerissa Nuñez and her husband have seven children, ranging in age from 11 to two years. She did a remote visit in the summer when one of the kids got a persistent rash.

Nuñez called the office, made an appointment and through email got a link to the telemedicine service. At the appointed hour, she selected the link, which put her in a virtual waiting room. The doctor appeared for the appointment.

“We picked an area in the house with a lot of light (and) I think we went outside and I put the phone up to the rash,” Nuñez explains. She got advice on what to do and then left the meeting 15 minutes later.

Since then, she’s used the service to talk to the doctor about her kids’ allergies. A sore throat required an in-person visit. Nuñez also has been speaking via telehealth with her own doctor for regularly scheduled appointments to manage her chronic conditions.

In-person visits require a lot of coordination, she says. “I would have to figure out how to schedule appointments on days my husband can take off from work,” in order to mind the kids, she observes. Or she would have to get all the kids into the car to make it to an appointment. “It’s so much easier with telemedicine,” she adds.

“I do prefer face-to-face with the doctor in case there’s an issue to get deeply into,” she says.

Decades in the Making

COVID-19 necessitated a great leap forward on the use of telehealth, but in Arizona it’s been around for 25 years since the UArizona College of Medicine opened its Arizona Telemedicine program in 1996.

In the early years, the program created facilities with communications technology that then-University Medical Center physicians used to consult remotely with doctors in emergency rooms, radiology labs and psychiatric settings, among others. It also provided distance teaching and training for medical students.

Some of its high-profile activities included improving much-needed health care to remote areas, especially on tribal lands, and saving lives by reading X-rays shown over video from a hospital emergency room in Douglas.

Teams of doctors and specialists coordinated the transfer of then-Congresswoman Gabrielle Giffords from UMC to a rehab hospital in Houston after she was shot at a constituent event in 2011. They were able to share medical images and other information while protecting her privacy.

The use of telemedicine predictably had increased about 20 percent each year. Then COVID-19 arrived. “The pandemic came along and it turned out to liberate the field,” says Dr. Weinstein. The huge increase in use “represents the effect of the COVID-19 pandemic as an innovation accelerator.”

The program’s training section also has become busier as providers seek technical assistance and training on the use of telemedicine. Between the federal fiscal years (October-August) of 2019 and 2020, assistance requests soared 250 percent. Trainees who completed the program’s courses increased five-fold.

Providers are turning to resources large and small to get up to speed with telemedicine, which requires strong security to maintain medical privacy, as well as systems for keeping records, making appointments and collecting payments.

There are companies that will set up these systems, maintain them and train users. Individual providers who are up to speed on telehealth often are tapped by fellow doctors for advice. Psychiatrist Kristine T. Norris, DO, MPH, is one of them.

“I have had colleagues who asked how I did that,” she says of her practice, which has had virtual-visit capabilities since she opened it in June 2019. “It’s a real need. We don’t want patients to think they can’t get a hold of us because physically we’re not available.”

Behavioral health is one of the easier specialties to adapt to telemedicine because most of the interaction between doctor and patient doesn’t require physical examination. The practice of telemedicine in this field is known as “telepsych.”

Seeing a few patients by video chat or phone calls was not a new technique for Dr. Norris when she moved to private practice. She had been doing something similar as a U.S. Air Force officer serving as medical director of mental health flight at Davis- Monthan Air Force Base for four years. In that capacity, she saw patients who were in Arizona, but not in Tucson.

Paperwork, scheduling and payment are all done online, she explains. Even before COVID-19 disrupted services, she used a combination of video chats, phone calls and texts and office visits to “see” patients. “All of my patients always have had access to me,” she says.

Out of necessity, many more patients switched to telemedicine. About 5 percent of her patients saw her this way before the pandemic. Now 95 percent do. She expects to see some of them return to office visits once COIVD-19 transmission concerns ease, but not at pre-pandemic levels.

“Now, they can see me throughout the day,” she notes as one of the advantages, squeezing in sessions during breaks at work or, for older students, between classes.

Dropping the Call

This ease of use will drive patient desire to continue using telehealth services, but the technology isn’t always simple, nor is it available to everyone for everything.

There are certain examinations that need to be done in person; for instance, looking down a sore throat or into an achy ear, palpating a body to locate an acute pain’s source, examining recent surgery and taking vitals to monitor a patient’s condition or reaction to medication.

There’s also the empathy factor. “Some things get lost in translation,” Dr. Eldridge says. “I didn’t realize how much I rely on body language and facial expressions to understand what a patient or parent needs. It takes a lot more energy to pick up on those cues virtually, and I often feel exhausted after more-involved telehealth visits.”

Lack of strong internet or Wi-Fi service in some communities is concerning because it creates a big divide between haves and have-nots. “We are concerned that the lack of broadband in many rural areas is increasing the disparity of care between rural and urban areas,” says Dr. Weinstein of Arizona Telemedicine.

Such infrastructure deficits shouldn’t deter patients from using telehealth, however. “Many types of services can be conducted telephonically using a regular telephone when video chat is not an option,” explains Sara Salek, M.D., chief medical officer of AHCCCS.

Another technology challenge is that lousy cell service can cut off a “visit,” Dr. Eldridge observes. “There have been lots of video chats where I’ve given up and called the patient instead.”

Dr. Eldridge sees economic disparities in her pediatric practice, too, as some patients can’t get coverage for telehealth services. “It’s been a huge problem and a huge disadvantage from a socioeconomic standpoint,” she says.

Links to the Future

In response to the COVID-19 disruption, state and federal governments issued temporary mandates to ease restrictions on telehealth use for Medicare and Medicaid patients. AHCCCS added more than 150 procedures for which members could receive telehealth services. It also extended coverage for audio-only services. Its increase in provider reimbursement of telehealth services created an incentive for providers to do more of them.

An Arizona bill was winding its way through the legislature that would make these mandates permanent, as well as provide regulations that would expand telehealth. It was introduced by State Rep. Regina E. Cobb, R-District 5, and Joanne Osborne, R-District 13, along with State Sen. Nancy Barto, R-District 15. It had passed the House and was awaiting Senate action at press time.

AHCCCS already had been expanding telehealth coverage before the pandemic hit. It included covering more types of medical specialties and allowing patients to use telehealth at home. Coverage also was extended to a specific service of telehealth, the use of website portals to upload medical information that patients can retrieve any time.

The agency is updating its telehealth policy for implementation in October and will hold meetings on the issue. “We’d love to hear from members” either in the annual member survey or in stakeholder meetings, Dr. Salak says.

Often, companies follow the lead of Medicare and Medicaid in deciding what gets covered. Some private health insurance companies like BCBS Arizona covered telehealth services before the pandemic and will continue to do so even if mandates are lifted.

Coverage is inconsistent across the medical insurance industry. But soon companies may not have a choice but to cover telehealth services. Many patients now know how to use it and understand their benefits. They’ve become comfortable with the technology and the procedures.

Medical practices have made the investment to provide telemedicine. They’ll likely have some significant percent of patients who want to use it.

“I think public pressure is going to force the issue,” says Dr. Weinstein. “Many people are going to pick their physicians because they have access to telemedicine.”

In the early years of telemedicine, the focus was on providing the infrastructure for doctors to confer with other doctors on patient diagnosis and treatment. Now, Dr. Weinstein sees how technology is one step toward direct-to-consumer health care. That may someday include artificial intelligence systems that read diagnostic procedures and make diagnoses; monitoring systems to ensure that patients are taking medications, and search engines that comb electronic medical records to work up a patient’s profile.

There also are online companies that utilize telehealth for patients to use to see affiliated providers.

“Telemedicine has gone mainstream,” Dr. Weinstein says, “and will remain that way. It will join e-commerce, distance learning and work-at-home job activities as the way many people will work in the future.”