Where does it hurt?
When doctors at Boston’s renowned teaching hospitals ask patients that question these days, it’s usually in a video conference or telephone call, even when physicians are treating people for life-threatening illnesses such as cancer and heart disease.
Three weeks after Governor Charlie Baker ordered health insurers to cover telehealth in an effort to limit the spread of the new coronavirus, most outpatients at Massachusetts General Hospital, Brigham and Women’s Hospital, and Dana-Farber Cancer Institute are “seeing” their physicians remotely. The trend, experts say, may have lasting implications.
Video conferencing and phone calls last week accounted for roughly 76 percent of outpatient appointments at Mass. General, about 70 percent at Brigham and Women’s, and about 57 percent at Dana-Farber, according to hospital officials. The shift is all the more remarkable given that telemedicine accounted for a tiny percentage of appointments at all three hospitals before Baker’s March 15 order.
“One of the great ironies to me in this story is that prior to the pandemic, the biggest criticism of telehealth was that it was too distant, that it wasn’t intimate enough, that you couldn’t be a hand on the shoulder,” said Dr. Lee Schwamm, a neurologist who leads telehealth at Mass. General. “Now, it’s precisely that degree of distance that has everyone embracing telehealth as fast as they can.”
Such visits are suitable, experts say, if patients are stable and the appointment is set up to discuss symptoms, the results of blood tests and medication regimens, or to provide a limited physical exam through visual observation.
Of course, people with urgent health problems can still see doctors in person and, if necessary, go to the emergency room. And some appointments can’t be done remotely ― such as when patients need chemotherapy infusions or a hands-on examination.
But if outpatients are seeing health care providers mostly for checkups, physicians say, a virtual appointment makes a lot more sense than going to the hospital during the pandemic, even for people with life-threatening diseases — and maybe especially for them.
"It was absolutely wonderful,” said Linda Cohen, a 59-year-old longtime breast cancer patient from Wayland. She made a hasty Zoom appointment with her Dana-Farber oncologist last week to discuss stomach problems resulting from an oral chemotherapy drug she recently started taking. “He got to see me, and I got to see him. From his perspective, he could see that I was OK.”
Cohen said that as a cancer patient with a compromised immune system, she’s particularly vulnerable to the virus that causes COVID-19. She was grateful to be able to discuss her side effects with Dr. Harold Burstein online for 20 minutes and avoid traveling to Boston, parking her car, and having to go inside the hospital. Burstein, she said, prescribed an additional drug to ease her stomach problems.
Robert Zeitlin’s recent annual appointment with Dr. Nandita Scott, his cardiologist at Mass. General, was a 15-minute phone call from Zeitlin’s Beacon Hill apartment. No one was able to weigh him or take his blood pressure, but Zeitlin, 84, a professor emeritus of anthropology at Brandeis University, says he takes his blood pressure on a home monitor anyway. For him, the risks of going to the hospital outweighed the benefits.
“This telephone visit, in my case, was just fine,” he said.
Overall, outpatient appointments at MGH, the Brigham, and Dana-Farber have fallen in the health crisis, despite the surge in telemedicine.
Some doctors and health regulators predict that the rapid switch to telehealth could lead to a tectonic shift that permanently reshapes parts of the doctor-patient relationship after the coronavirus crisis ends.
“Out of the tragedy of the pandemic has come the overnight acceptance of telemedicine and an appreciation of its many advantages,” said Dr. Candace Lapidus Sloane, the longtime chairwoman of Massachusetts Board of Medicine in Registration and a dermatologist by training. “I hope it becomes a permanent part of clinical medicine.”
Baker’s executive order last month required insurers to cover telehealth at the same rate as conventional appointments for outpatients. The state also required hospitals to postpone elective surgeries ― a major source of revenue ― to free up space for COVID-19 patients.
On March 16, the state medical board voted 4-0 to allow a doctor to treat a patient by phone or in a teleconference even if he or she has never seen the person face to face.
Although some doctors have practiced telemedicine for years, a major hurdle was the reluctance of health insurers to cover it at the same rate as conventional medicine, if at all. (Schwamm, the Mass. General neurologist, said he has been able to practice telehealth there for the past five years, in part because the Massachusetts General Physicians Organization and Partners HealthCare, the hospital’s parent company, picked up most of the costs to help doctors learn how to do it.)
Before the COVID-19 epidemic, Harvard Pilgrim Health Care, one of the state’s largest insurers, reimbursed video appointments at 80 percent of what it would have paid out for a conventional appointment, said Philip Tracey, a spokesman for the insurer. Harvard Pilgrim reimbursed telephone appointments only for certain types of behavioral health, such as counseling for depression and substance abuse. It now reimburses all telehealth services the same as face-to-face appointments.
“A lot of people just feel more comfortable with traditional visits,” said Dr. Michael Sherman, chief medical officer for Harvard Pilgrim. “But I have a theory that post-pandemic, a lot of people will learn that they can have effective interactions [remotely], and we’ll see it persist.”
If recent numbers are any indication, that’s a safe bet.
Last week, nearly 76 percent of MGH’s 4,010 outpatient visits on one day were done by video and phone calls, up from less than 1 percent a month earlier, said Mass. General’s Schwamm.
Brigham and Women’s scheduled about 10 virtual patient visits a day before the pandemic, according to Dr. Adam Licurse, a primary care physician and executive director of virtual care at Brigham Health. Last Wednesday, that figure had skyrocketed to 3,256. Overall, he said, about 70 percent of Brigham visits last week were conducted remotely.
At Dana-Farber, none of the approximately 6,800 outpatient appointments in the second week of March were on the phone or video, according to Ellen Berlin, a hospital spokeswoman. Last week, 57 percent of the 5,100 appointments took place remotely.
Teleconferencing has also been expanded for some patients admitted to Brigham and Women’s and Mass. General for COVID-19 or for other diseases, to limit exposure to the virus for health care workers and for relatives of visiting patients, according to physicians.
In the past, when an attending physician, residents, medical students, and nurses made morning rounds to discuss in-patient cases at Brigham and Women’s, as many as 10 people might hover over the patient, Licurse said. Now, often only the attending and chief resident will see the patient in person. They teleconference the examination on an iPad strapped to a portable IV pole to other medical staffers and visitors.
But even physicians who support telehealth say it won’t replace face-to-face appointments.
“Make no mistake, the very nature of medicine is to see a patient in person,” said Dr. Jim Januzzi, a cardiologist at MGH. But, he said, he can easily use a teleconference to review test results with a patient. He can even see how a patient with congestive heart failure is breathing to make sure fluid isn’t building up in the lungs.
Some doctors are still recommending that patients visit hospitals for certain treatments — but closer to home. Dr. Toni Choueiri, an oncologist at Dana-Farber, recently had a longtime kidney cancer patient from Pittsfield receive an immunotherapy infusion at Berkshire Medical Center, where the patient has a local oncologist, rather than drive 2½ hours to Dana-Farber in Boston.
That was fine with the patient, 64-year-old Shaun Tierney. But Tierney said that if Choueiri, director of Dana-Farber’s Lank Center for Genitourinary Oncology, reviews one of his scans and discovers the cancer has spread, he would rather hear that from the oncologist face to face.
“Knowing him, I think he would want to break any negative news to me in person,” Tierney said.
Jonathan Saltzman can be reached at firstname.lastname@example.org