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Forced by the pandemic, health care plunges into the digital age

The sudden adoption of telehealth raises questions about what works best and who can be served.

Dr. Melvin Makhni, a spine surgeon at Brigham and Women's Hospital, demonstrated a telehealth appointment with Nicole Dane, a patient who recently had surgery.
Dr. Melvin Makhni, a spine surgeon at Brigham and Women's Hospital, demonstrated a telehealth appointment with Nicole Dane, a patient who recently had surgery.Jessica Rinaldi/Globe Staff

For the past three months, the majority of doctor visits in Massachusetts have occurred far from a doctor’s office. Confined to home amid the pandemic, patients and physicians have been talking on the phone or gazing via video screens, sometimes uneasily, into each other’s living rooms.

This new kind of medicine — called telehealth — swept across the normally change-resistant world of health care with astonishing speed. And it is transforming doctor-patient interactions in ways that will continue to evolve.

Even as other aspects of life went digital, “the health care system lagged behind for years and years," said Barbra Rabson, president and CEO of Massachusetts Health Quality Partners. "All it took was a pandemic and the system changed overnight.”

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Medical practices are gradually opening for more in-person care, but it’s clear telehealth is here to stay. A new phrase has already entered the health care lexicon to describe a skill required for virtual doctoring: “webside manner.”

By all accounts so far, most patients and clinicians readily adapted to the technology and appreciate its convenience. Telehealth seems especially well-suited to mental health therapy.

But worries and questions remain. It’s not clear which other types of visits, and which patients, are most amenable to telehealth, or whether something essential is lost when a doctor cannot physically examine a patient. And will telehealth exacerbate inequities by leaving behind people who don’t have good Internet access?

The data show that a dramatic shift has already occurred. Blue Cross Blue Shield of Massachusetts tallied 770,000 telehealth visits in May, compared with a mere 5,000 in February. Mass General Brigham (the hospital group formerly known as Partners HealthCare) is currently doing 250,000 telehealth visits each month, up from 1,500 a month previously.

Before the pandemic, nearly all doctor visits took place in person. In less than two weeks, in Massachusetts, that flipped to an estimated 60 percent to 80 percent taking place remotely.

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Dr. Joseph C. Kvedar, a Harvard dermatologist and president of the American Telemedicine Association, has spent nearly three decades promoting telehealth to reluctant physicians. He watched in amazement as it took over in two weeks — and without major strife.

“So far no one’s pointed to anything that went wrong,” Kvedar said. “It’s been life-saving. If we had this pandemic 25 years ago, it would have been a much more horrific outcome.”

Telehealth was able to take off so quickly because state and federal regulators issued emergency rules that removed the key obstacles.

No longer did doctors have to buy secure telehealth platforms that met privacy regulations; they could hop on Zoom or Google to confer with patients. Previously, telephone calls were rarely reimbursed, and telehealth visits were paid for at a lower rate than in-person visits. For now, calls and video chats are paid for as if they had occurred in the office.

And amid the pandemic lockdown, doctors who had been too busy or wary to adopt telehealth found themselves staring at empty appointment books. They had no choice but to dive in.

Behavioral health care has proven especially amenable to virtual visits. Of all the telehealth claims to Blue Cross since mid-March, nearly half are for behavioral health services, and the insurer has seen an increase in people seeking such care.

“For behavioral health, this has been a phenomenal boon,” said Dr. Katherine Dallow, the insurer’s vice president of clinical programs and strategy.

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Partly, the numbers reflect a greater need for services during a stressful time. But telehealth has provided an easier and more private way to seek help, avoiding the stigma of walking into a psychiatrist’s office.

While virtual visits clearly make sense for psychotherapy, they obviously can’t work for things like Pap smears and vaccinations.

But for many services, it’s not always clear when doctor and patient need to be in the same room.

“When I’m talking to my patients in the exam room, 80 to 90 percent of the time, I know exactly what they’ve got even before I touch them,” said Dr. Lawrence Garber, an internist and medical director for informatics at the Reliant Medical Group in Worcester. Forcing patients to troop to the doctor’s office every time inconveniences the patient to make things easier to doctors, he said.

Massachusetts Health Quality Partners, a nonprofit concerned with measuring and improving health care, has been interviewing doctors and patients in preparation for a survey about telehealth in the fall. The researchers are hearing mostly positive anecdotes.

“Patients are really grateful that this is an option,” said Rabson, the group’s president. "Sometimes the technology is a little rough around the edges. But it’s helping them stay safely at home.”

Lindsay Rosenfeld, whose 8-year-old twins were born prematurely and have health problems, was relieved that she wouldn’t have to take them into doctor’s offices where they would risk infection. Remote visits also make it easier for her husband to participate without leaving work.

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But the 42-year-old Milton resident sees limitations. A recent checkup for the twins by video seemed equally effective as an in-person visit, but the children missed out on hearing and vision assessments. “Sometimes you do have to go in,” she said.

It’s surprising, though, how much care can happen online. Kim Ouellette’s 12-year-old daughter received treatment for an earache in a video session in their Somerset home. The doctor asked the girl several questions and had her mom shine a flashlight on her ear; in no time she had a prescription for eardrops to treat swimmer’s ear.

Dr. Huy Nguyen, a pediatrician and chief medical officer at DotHouse Health, a community health center in Dorchester, said he finds it helpful to see children in their home environments. On a recent appointment with a 2-year-old, he enjoyed seeing the toddler relaxed and playful, unlike in those stressful office visits.

“He was much more talkative and engaged than when he’s here," Nguyen said.

Elderly people like it too, said Dr. Christopher Garofalo, a family medicine doctor in Attleboro. “The older people, they all know how to get online and do FaceTime, because they’ve got grandkids,” he said. For people who have difficulty moving about or who rely on others to take them to the doctor, a video visit is preferable, he said.

Still, telehealth has downsides. Some clinicians complain that video visits are “too artificial,” and the video quality is often too poor to reveal nonverbal cues, Rabson said.

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Some patients, too, feel viscerally that they need to be there in person. “The laying on of hands really did matter to people,” Nguyen said.

Frank Federico, vice president of the Institute for Healthcare Improvement, a Boston-based nonprofit, questions whether telehealth might increase misdiagnoses or missed diagnoses. For example, Federico said, a physician speaking to a patient seated at a computer wouldn’t know that the patient is unsteady on his feet and at risk of falling.

And there’s a flip side to the convenience issue: For some people, particularly isolated elderly people, the journey to the doctor’s office may be their only opportunity to interact with others.

Federico and others also raise concerns about access to care for people who don’t have good Internet connections and who have limited data or minutes on their phones.

At DotHouse Health, most of whose patients have low incomes, Nguyen found that patients often had smartphones with video capability. About three-quarters of remote visits occur simply as phone calls, he said.

At the Cambridge Health Alliance, which also serves a large proportion of low-income patients, most virtual visits are over the phone. Dr. Kirsten Meisinger, the hospital’s director of provider engagement and regional medical director, said that even patients with video capability prefer not to bother with it. In the first week of June, video was used in only 1 percent of primary care virtual visits.

“Most patients get really stressed by having to figure out all these apps," Meisinger said. “A lot of people don’t want you to look at their house. ‘I have to clean for a medical visit?’”

But Garber, of the Reliant Medical Group, feels he needs to literally see his patients. For example, he asked a patient complaining of difficulty breathing to show him her feet on the video screen. They were swollen, tipping him off to the need to adjust her heart-failure medications.

Reliant is working on lending iPads to patients who lack video technology. Before each visit, the practice would deliver a hot spot connected to the best cell carrier in the patient’s neighborhood, along with an iPad. The devices would be returned.

As the pandemic eases, insurers and regulators are weighing how much to pull back the regulatory floodgates that opened in March. Probably secure websites will again be required, and insurance reimbursements may be less generous.

“This artificial environment we have in the pandemic will not be sustainable,” said Kvedar, of the American Telemedicine Association. He predicted that eventually 20 percent to 30 percent of patient visits will be virtual. “We will have this channel,” he said, “but it won’t be as wide open.”


Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer.