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Medicine – Going Where It Has Never Gone Before.

Medicine – Going Where It Has Never Gone Before.

In the Star Trek Voyager TV series, the ship’s doctor was a hologram devised by Starfleet programmers. Using 29th-century technology with a mobile emitter, the doctor was made able to travel the ship. The Emergency Medical Hologram activation was a necessity because of the demise of the ship’s medical crew. The program was originally designed for the physician to function remotely only in emergencies, but because the crew was lost in space, the doctor’s program ran full-time, effectively becoming the Voyager’s chief medical officer. While this Doctor is fictional, a real emergency has required the medical community to pivot to using new technologies to be able to provide medical care seamlessly at a distance during the Covid-19 pandemic. 

The transformation of medical care required a strong stimulus to retool systems, streamline processes, and improve outcomes. Healthcare delivery had become stagnant.  Even the hue and cry about Obamacare did not change the fundamental way physicians delivered care. However, facing an overwhelming adversary, medicine was dragged into the future, and won’t go back. I believe we have changed for the better. 

There have been multiple major innovations applied during the pandemic but the most significant innovation has been the accelerated use of telemedicine. Perhaps the closest to the Star Trek holographic doctor, it has transformed healthcare delivery and will have a lasting impact on medicine. During a time of increased admissions and bed utilization, telemedicine allowed for enhanced discharge planning and reduced length of stay by pushing out-to-home both acute, as well as chronic care management. The pandemic and telemedicine technology accelerated the growth of  hospital-at-home” care programs which enabled patients to receive acute care at home by physicians, nurses, and other clinical staff and provided higher patient satisfaction, improved outcomes and lower costs. There was extraordinary cooperation between providers and businesses to provide access to care. In a time when we all had to distance telemedicine erased that distance between patients and providers, especially in rural areas. By joining providers and patients with specialists and experts of many disciplines it allows a more rapid and efficient way to treat and support patients with their illnesses.

The use of telemedicine allowed medicine to quickly provide acute care for COVID patients: virtual screening of patients needing urgent care, mobile testing sites, remote home monitoring programs for patients, “televigilance” for hospitalized patients to maintain monitoring while preserving provider safety. Digital care allowed nurses and physicians to remotely monitor the status of multiple (up to 100) patients in ICUs in multiple hospitals. My own institution, the University of Miami Health system, developed a program to remotely monitor and care for COVID-19 patients who might otherwise have needed to continue care in inpatient settings. The program involved arming discharged patients with home health devices, which they and their caregivers used to electronically transmit timely health status information. Providers monitored the patients’ vital signs and quickly addressed problems or triaged patients who needed higher levels of care. These innovations are now applied to complex non-COVID patients.

Another innovation that telemedicine offers is linking multiple disciplines in the care of patients. What in the past was the practice of “hallway consults” where physicians talked about patients together with no involvement of the patient, it is now easier through conference calls over “Zoom” lines and can even include the patient in the conversation.

During this time there was the rapid realization digital medicine could be utilized to provide continuity of care for all types of patients. Barriers that had blocked its use in the past fell away: connectivity, privacy concerns, security of records, patient acceptance, documentation, and billing requirements. Regulatory agencies loosened their restrictions on telehealth during the crisis, and payors reimbursed for it as they would any other medical service.  In the beginning, Telemedicine options needed to be user-friendly for patients. The response was to use platforms that the tech community had created prior- doximity, Zoom, Microsoft Team.

 An equal concern was whether providers, particularly physicians, possessed the skill, to be able to communicate effectively with patients through computer screens and phone calls rather than in traditional face-to-face encounters.  Could the compassion, empathy, and intimacy of the doctor-patient relationship be established when there was no “human touch”? What was underestimated was the paramount desire of patients for safe, improved access and directed medical care. Telemedicine literally focused the provider on the patient’s needs and expectations. Families were often included in the encounter for a true patient-centered approach to health care.  Physicians had the advantage of seeing patients where they lived or worked. The encounter was personalized and more transparent. At many sites, telehealth visits soared from < 10% to nearly 70% of all visits. As of July 2021, telehealth utilization has stabilized at levels 38 X higher than pre-pandemic. Providers in every specialty now deliver efficient, comprehensive care to their patients without making them drive to the clinic, find parking, and spend time sitting in waiting rooms. Consumer willingness to accept virtual care has grown significantly. Physicians’ acceptance has also grown—     58 % of physicians continue to view telehealth more favorably now than they did before COVID-19 and as of April 2021, 84% of physicians are offering virtual visits . The highest penetration of telehealth has been with psychiatry (50%).

It is estimated that $250 billion of US healthcare expenditures could potentially be shifted to virtual or virtually-enabled care.  Investment in virtual health as a marker of acceptance continues to accelerate. According to Rock Health’s H1 2021 digital health funding report, the total venture capital investment into digital health, in the first half of 2021, totaled $14.7 billion and the total revenue of the top 60 virtual health players increased in 2020 to $5.5 billion. The pandemic was a unique challenge and created innovations in healthcare delivery from which there is no way to go back now. However, the real way forward will depend on several things. Payers will need to continue to reimburse for telehealth visits at rates like face-to-face care. Tech equity will need to be available to those who do not have access in their communities and homes to use the devices. There will need to be funding and educational resources to help everyone access this or this will become another block to health care delivery for minorities, the elderly, and the poor. Digital innovations will have to continue to evolve perhaps to the level of the Star Trek Doctor so that we can provide even more care where the patients are and with new skills and better outcomes than before.

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