by Carrie MacMillan, Kathleen Raven, Kathy Katella, Colleen Moriarty, Yale University
We are being told to stay home and practice social distancing during the COVID-19 pandemic, but where does that leave people with routine doctor appointments? What about someone who notices a lump in her breast? Or has worrisome digestive problems? Should these patients still see their doctor, and, if so, how?
<p>At Yale Medicine, <a href="https://medicalxpress.com/tags/patients/" rel="tag" class="textTag">patients</a> can still see their specialists—whether it's their cardiologist, urologist, Ob/Gyn, dermatologist, pediatrician, oncologist, and others—for a telehealth video visit.
What is telehealth?
“Telehealth” refers to the broad category of electronic telecommunications technologies, including things like smartphone apps, while “telemedicine,” or video visits, are specific to remote doctor-patient services, allowing you to receive health care and services from your provider who is in a different location.
To participate in telemedicine, patients need to download the MyChart app to their device (smart phone or tablet). When the appointment time comes, the patient and provider log in and talk to one another over a video connection.
The platform is completely compliant with HIPAA, the federal law that protects patient privacy, says Pamela Hoffman, MD, medical director for Telehealth Services for Yale Medicine and Yale New Haven Health System. “It provides the safety and security that patients deserve. For instance, videos are not recorded,” Dr. Hoffman adds.
To maintain social distancing protocols, all Yale Medicine appointments that can be handled via telehealth are currently being converted to telehealth. The transition has been quick, Dr. Hoffman says. YM has had experience with telehealth, with some doctors doing these visits for several years now, but the services have expanded dramatically in recent weeks. For example, Dr. Hoffman said that there were 34 video visits scheduled on one particular day in the pre-COVID-19 era, whereas in a single day this week, more than 1,500 video visits were scheduled.
If someone is uncomfortable with a video visit or doesn’t have a device that can support it, a telephone consult is another option. But Dr. Hoffman says a video visit is preferred, because it allows for better interactions between patient and provider.
“If patients have any concerns about doing a video visit, they can talk to their provider about it, or even whoever calls to schedule the appointment,” she says. “We know that these visits work well, and we don’t want people to wait for in-person visits because we don’t know when those will take place. This is the new normal.”
As for insurance coverage, Dr. Hoffman says video visits are covered just like a regular appointment would be. “Right now, we don’t want that to be a hindrance to getting care,” Dr. Hoffman says.
We asked Yale Medicine specialists in different disciplines to discuss how they’ve adapted to Telehealth.
Telehealth and cardiovascular medicine
Yale Medicine Cardiology ramped up its telehealth visits quickly, knowing that heart patients—along with pulmonary and immunocompromised patients—are at especially high risk for complications if they are infected with COVID-19, says cardiologist Joyce Oen-Hsiao, MD. She says almost 95% of Yale Medicine’s cardiac patients are now using telehealth.
“It’s just like talking to grandkids over FaceTime,” she says of the video visits. “It’s a little bit of a different platform, but essentially it’s the same thought process.”
Patients should treat video visits the same way they would an in-office appointment, Dr. Oen-Hsiao says, adding that the doctors are seeing the patients at their designated appointment time and are moving from one patient to the next, just as they would in the office. Patients shouldn’t postpone any visits just because they are telehealth, and they should bring up the same issues as they would in the office, she adds.
“We run through their medications, ask them how they are doing, discuss symptoms, and ask them to check their blood pressure if they have a monitor at home,” she says. “It’s very helpful for the patient, not only so they can stay in touch with the doctor, but also to make sure they have enough refills, so they will not be in danger of running out.”
Cardiologists using telehealth have identified potential complications in patients they see over video, which helps them prevent serious problems and hospital stays, she says. Dr. Oen-Hsaio has picked up on changes patients may not notice themselves, as she did when she saw that a patient was using different muscles to breathe. (If patients start to have a build-up of fluid in their lungs, it is harder for them to breathe, which means that instead of using mostly the diaphragm to take a breath, they will start using muscles in their neck to help take a breath.)
“If physicians can see their patients on video, we can notice if a patient is struggling to breathe more,” she says. She asked another patient to hold the phone down to her legs so she could diagnose “pitting edema” (a build-up of fluid that leaves a “dimple” after pressure is applied to the area) and prescribe medication.
While the goal is to avoid office visits, “If there are major issues, the patient may be asked to come in,” Dr. Oen-Hsiao says. As always, it’s important to call 9-1-1 if there are symptoms that could signal a heart attack: chest discomfort (pressure, squeezing, fullness, pain) in the center of the chest that lasts more than a few minutes, or comes and goes; discomfort in one or both arms, or the back, neck, jaw, or stomach; shortness of breath with or without chest pain; or other signs that could include a cold sweat, lightheadedness, or nausea.
Telehealth and Ob/Gyn
In the past, physicians from Yale Medicine Obstetrics, Gynecology & Reproductive Sciences had used telehealth very little, says Hugh Taylor, MD, chair of the department. But the service is now working very smoothly for many Ob/Gyn patients, he says.
“Naturally, there are things we can’t do remotely, such as when a physical exam is needed, or for ultrasounds. But in many cases, it works beautifully,” Dr. Taylor says. “Patients feel safer using telehealth given the risks out there, and they can get the same medical care they would have received in the office. It saves them gas and travel time. That’s helpful, because some of our patients have had to travel great distances for care.”
Currently, Ob/Gyn physicians are only seeing patients in person who are pregnant and need to be monitored, and those with urgent needs, including cancer patients or women who have had a miscarriage. “We are deferring routine annual exams in healthy people until the risk goes down,” Dr. Taylor explains. “And for those who do come in, we are screening them at the door and taking temperatures and spacing people out by six feet in the waiting room.”
It’s also a way to keep appointments running on time. “In the office, so many things can throw off all the appointments in the day. One person can be late because of a traffic jam, and it has a domino effect,” Dr. Taylor says. “I was on time for every video visit I did the other day.”
Telehealth and pediatrics
In the past, telehealth was not widely used in pediatrics, except for some surgery and neurology patients. “For surgery, we had done some brief follow-up visits post-surgery. Instead of having a family come in, we could check the wounds via telehealth and save them the visit, and that worked well,” says Anthony Porto, MD, MPH, a Yale Medicine pediatric gastroenterologist and vice chair of ambulatory operations in the Department of Pediatrics.
Now, nearly all non-urgent appointments are moving to telehealth, and the transition is going smoothly, Dr. Porto says. “We were concerned about continuity of care if we delayed visits until we could meet face to face, and we are finding this to be very seamless,” he says. “Kids are very engaged, sometimes more engaged than they are in the office, because we are using technology that is second nature to them.”
The only difference for pediatrics in terms of MyChart is that for patients under age 13, a parent has to sign a digital proxy to see information for their child.
And if patients and families prefer—or if they don’t have a device that allows for a video visit—a telehealth appointment can be done over the phone.
“We want to keep as many people at home as possible. The patients who do need to come in are more likely to be immunocompromised, and they still need to come to our infusion sites in Trumbull, Greenwich, and New Haven,” Dr. Porto says.
For now, Dr. Porto says he is trying to embrace the positive parts of this difficult time. “I think families and providers alike will see that telehealth is the future, and we are just going to keep enhancing its services,” he says. “As a parent myself, it’s nice to know you could have certain visits after school on the phone and leave in-person visits for new cases or others where it is preferred.”
Telehealth and orthopaedics
Before the current crisis, Yale Medicine Orthopaedics & Rehabilitation’s Jonathan Grauer, MD, says his department had not fully embraced telehealth visits.
That’s changing. “There is a lot we can do through telemedicine or telephone encounters. For example, with a video visit, we can ask a patient about how much they can they move their arm, and see it. Or, if someone has an incision site they are worried about, they can show us,” says Dr. Grauer, an orthopaedic spine surgeon.
No elective surgeries and procedures are being done right now; all are being deferred, to be rescheduled when life begins to return to normal. “Not only is this for the safety of patients and medical teams, but we anticipate shortages in personal protective equipment (PPE), and we want to conserve these as much as possible right now,” Dr. Grauer explains. “This is hard because something may be considered elective medically, but when someone is in pain, they may not see it that way. Nonetheless, we can’t have an elderly person come in and then get sick, or give someone an elective procedure and later on be short on masks and gowns because of it.”
This experience with telehealth has made Dr. Grauer realize there will probably be a greater place for it in orthopaedic care going forward. “You can get a lot from a telehealth visit instead of waiting three weeks for an in-person appointment.”
Telehealth and urology
By the time COVID-19 arrived in Connecticut in early March, Yale Medicine’s urologists were already testing telehealth visits with a small percentage of patients who had undergone surgery recently through a pilot program. “We had a handful of physicians who were familiar with it,” says Diana Glassman, clinical program director of urology.
By mid-March, urology physicians were seeing almost all patients online. “When we launched our pilot program, we had to spend a lot of time convincing patients this was a good idea,” Glassman says. “Since last week, we haven’t had to convince anyone.”
For now, a wide variety of appointments can be accomplished through telehealth, Glassman says. “Most of our assessment of a patient’s health comes from reviewing radiology images and looking at lab results, and those can be done before the telehealth visit starts,” she says. Based on information from those sources, doctors can change medications, or decide to keep everything the same.
Patients can discuss any symptoms that may be concerning them. So far, patients have been able to show physicians their stitches, or sutures, from surgery and how wounds are healing, Glassman says. For those with catheters collecting urine in a bag, doctors can request to look at the urine for signs of blood or clots. “It’s not glamorous, but it works,” she adds.
Two groups of patients are keeping their in-person hospital or office visits: bladder cancer patients who need to continue their treatments, and patients with an emergency. For example, people who have urinary retention—which means they are unable to completely empty their bladder—are being seen, Glassman says. “We want those patients to come in so we can be proactive and keep them out of the emergency room,” she says.
The biggest challenge Glassman and her team faced with video visits has already gone away. “We’ve seen a change in the public’s understanding of the value of staying home. Now the understanding is there,” she says.
Telehealth and dermatology
Sara Perkins, MD, a Yale Medicine dermatologist, says skin conditions such as acne, psoriasis, and rosacea can be assessed and handled via video visits.
“Because dermatology is such a visual field, I think in some ways we are particularly well-suited for this,” Dr. Perkins says. “Every patient is getting a call and being offered to convert to a video or phone visit. I think patients are appreciative of having their questions answered without having to go to the office.”
Patients can also upload photographs into MyChart, which is sometimes preferable for doctors to assess a spot on the skin or some other problem a patient may be worried about. And if a patient has something that looks like a precancerous lesion, for example, the plan may be to first try a topical medication and then make an appointment in person.
Routine appointments, including total body scans for moles, and cosmetic procedures, are being postponed for now.
“In most situations, it is alright to wait for your total body skin exam for a few months. If a patient has a spot that’s changing, hurting, bleeding, or otherwise concerning to them, that lesion should be evaluated. They can send me a photo and I can see the lesion over the video, hear how it changed—and when—and determine the urgency of when you need to be seen,” Dr. Perkins says.
Dr. Perkins stresses that telehealth is a worthy tool for dermatology. “If you have a skin concern you’ve been putting off, or you wanted to schedule an appointment but one wasn’t available for months, this is an opportunity to re-engage and schedule a video visit,” she says.
Plus, through telehealth doctors can still write prescriptions, which patients can fill via home delivery or drive-through pharmacies.
Telehealth and cancer
To show just how quickly Smilow Cancer Hospital at Yale New Haven changed previously scheduled in-person visits to telehealth ones, Anne Chiang, MD, Ph.D., its chief network officer, shares this metric: “Last week, in some parts of Smilow, we had more telehealth visits than in-person visits,” she says. “The fact that we made that transformation in a short time period means that everyone is working together to make patient care a priority.”
Dr. Chiang notes that patients who need to receive treatment in the hospital, such as chemotherapy or immunotherapy, are still scheduled to go in. Another group of patients who are continuing to be seen in-person are ones who are very sick, as well as those who need lab tests completed, she says.
But many cancer patients who had follow-up visits scheduled before the COVID-19 pandemic can continue to see their physicians through video visits. “We can talk with patients about test results that have come back, and for patients managing pain medication, we can discuss how well the medication is working and make adjustments if needed,” says Dr. Chiang, a lung cancer oncologist. “We can see the patient and examine rashes or bruises—there are a lot of aspects of the physical exam that are observed and not felt.”
Telehealth initiatives, launched over a year ago, allow Smilow patients cared for in New Haven or at one of the 15 care centers located throughout the state—with one in Rhode Island—to discuss the results of genetic testing, answer questions about palliative care, and provide second opinions on cancer diagnoses, Dr. Chiang explains.
A little less than a year ago, Dr. Chiang helped a patient enroll in a clinical trial through the Smilow Waterford Care Center located near her home. “She felt comfortable having the appointment from her home and she was so grateful that she was able to enroll in the clinical trial,” Dr. Chiang says. “After this pandemic, I think we will find that being able to do video visits is an easy way to communicate and allows our patients to stay at home more often.”
Being able to do that, Dr. Chiang says, is “a wonderful thing.”
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