3 Tensions to Telehealth and How We Can Resolve Them


“Hello?” I say again into my laptop. “How can I help you?”

A 37-year-old woman comes into my camera view as she picks up the phone and finally starts to engage in the visit.

“I’m so sorry, I was just packing my son off to school.”

While waiting for my patient, who had just put down her iPhone, I notice yet another news article on my screen, informing me how much doctors love telehealth. Oh.

I can’t blame my patient for making a remote appointment. When I need medical treatment myself, I hate going to the doctor. It does not feel like it is designed around what I want, nor target the problems I am trying to solve.  And to be sure, virtual care does generally expand access to treatment.

But as I’ve learned first-hand since the pandemic, there are three major tensions that still need to be addressed before it can work as promised.

Convenient … to whom?

Virtual care is very convenient for the patient. They can receive it on their terms and in a way that works for their situation. However, that often means a care provider waiting for a patient.

Hence the tension. The traditional system is convenient for providers. Patients request an appointment, and go through substantial processing and preparation. They are optimally and cost-effectively ready for the provider/physician’s time.

Mental health providers reportedly find virtual care more convenient than in-person treatment; post-pandemic, they have been slow to return to in-person care. In that case, there is no tension around convenience.  But that seems to be the one exception across healthcare.

Which brings me back to my current patient:

“I have severe abdominal pain from eating at that disgusting restaurant my husband likes,” she explains to me on Zoom. “I need an antibiotic and something for my nausea.”

As I dig a little deeper, it turns out that she also has a few hours of fevers, nausea, vomiting, and abdominal pain around her belly button and right lower quadrant.

This could be food poisoning, as my patient believes.

Or it could be a life-threatening case of appendicitis.

But there is no way for me to determine whether she needs a CT or ultrasound without doing a physical exam. This is clearly not the answer my patient wants to hear, though.

Which brings me to the second tension

Quality vs. satisfaction

“Look, I know it is just food poisoning,” my patient goes on. “I don’t want you to solve some diagnostic mystery. I just want you to prescribe what I obviously need. If I knew it was going to be complicated, I would have just stuck it out and been fine tomorrow.”

I hear the frustration in her voice. If she had not contacted me, I would never have raised the possibility of her symptoms being more serious. She could have instead waited, gotten better on her own – or wound up in the ER.

Much of the tedious process for patients in our in-person care system exists to ensure that we are providing quality medical attention. The practice of medicine is to take responsibility for another human’s life. Most providers take this very seriously.  It’s why virtual care can cause significant anxiety for the provider.

The human touch, however brief, is another advantage to in-clinic treatment. Virtual care can be episodic, with little emotional investment. Patients frequently believe what they want (antibiotics, antipsychotics, work notes, testing, etc.) will solve their problem. When better and different treatment is necessary, it’s more effective to explain why in person.

But my patient with either food poisoning or appendicitis is already on the Zoom call.

More virtual care vs. other care

While in-person care has too many barriers, especially those that disproportionately affect disadvantaged populations, virtual care systems need ways to appropriately direct patients to the right level of care—even if it means asking the patient to make an appointment for an office visit.

Patients and providers are excited about the ability to increase access to care. But one person’s access is another person’s expense. And payers, especially the government, are concerned that at-home programs will increase care and expenses. For example, patients who wouldn’t have been admitted to the hospital can now be admitted to the hospital while at home – but still take up the hospital staff’s limited time.

In the end, I recommended that my patient call her doctor to set up a same-day appointment, or go to urgent care. I feel bad that I could not better address her health concern; she feels it was a waste of her time and money.

Fortunately, there are ways to improve the outcome for both of us.

Decreasing virtual care tensions with tech

Providers prefer in-person care because more can be done there: physical exam, EKG, walking test, maneuvers, procedures, and lab testing. For virtual care to be a much better alternative to all that, it will need virtualization of more than just audio-video communications. That means finding virtual analogs for in-person care.

This is where technology can shine. Several promising healthtech startups are developing products designed to greatly enhance telehealth, including:

  • KardiaMobile by AliveCor: A small device that pairs with a smartphone to identify six common arrhythmias.
  • Nonagon: Remotely performs multiple exams including auscultation, ear/throat exam, pulse, pulseox, and temperature.
  • Sonavi Labs: Creates an AI-powered digital stethoscope.
  • Vastmindz: A company that registers vital signs using the phone or web camera. [Editor’s note: Author has no relationship with companies named]

We still need to figure out ways to integrate virtual and physical patient visits with a uniform and familiar workflow. When I helped advise the design of a hybrid virtual solution from startup DecodedHealth, we spent considerable effort to ensure that the provider could deliver virtual and in-person care with the same workflow without disruption – same registration, same EHR, same documentation, same workflow. I believe something like this will need to become the industry standard to reduce the disruption caused by virtual care delivery, while also making it more financially viable.

Similarly, we need better telehealth technology where audio/video calls require far less technical support, and is customized to enhance provider and patient needs. Some facilities have a medical assistant start the call to ensure the patient is ready. Incorporating biometrics to both verify the patient’s identity and ensure the calling technology is working are attractive opportunities for startups to pursue.

Much more is needed on the systemic level. Having helped advise a number of these solutions, I’ve realized better regulatory, compliance, and compensation mechanisms are still needed to utilize virtual care technologies that truly enable better care. The cost of technical integration into our workflows remains intimidating,  The dynamic of virtual care will also need to become more longitudinal and relationship-based, with less episodic pill-mill solutions. The diagnostic and safety mechanisms of virtual care will need to be expanded as well.

I notice my next patient, a pleasant-looking 19-year-old male, has finally logged into the system and looks ready to start. His record says he has a chief complaint of rash, so I have high hopes I can meet his needs on this one.

If only I can help him get the volume on his computer working…

Photo credit: Sorbetto, Getty Images



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