Telegeneeskunde is niet genoeg

Telegeneeskunde is niet genoeg

april 16, 2020 0 Door admin


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It’s 2020, and millions of Americans—now bound to their homes—still don’t have reliable internet access. In a pandemic, that’s a public health crisis.

These days, Dr. Susan Kressly begins appointments by thanking patients for inviting her into their homes. Like many other doctors during the covid-19 outbreak, Dr. Kressly, a pediatrician in Warrington, Pa., has begun practicing medicine over phone or video — even though in-person visits are essential in pediatrics, for good reason. “In young kids, it’s very much like tele-veterinary medicine,” she laughed. “They’re turning the phone upside down and licking it. And they’re not very good at accurately reporting their symptoms.”

Even if it’s delivered by screen or speaker, pediatric care remains critical during a pandemic where families find themselves homebound, she said. Without daily school lunches, some children lack access to adequate nutrition. Previous recommendations for maximum daily screen time have become laughable. And minors, like all of us, are struggling with anxiety, sleeplessness, and fear of the future. On top of it all, Dr. Kressly worries patients without at-home internet won’t be able to connect with pediatricians during the covid-19 pandemic. “We have to take into consideration what technology is available to the family,” she said, “and we have to do the best we can with what they have.”

Over the past month, healthcare providers from psychiatrists to family physicians have rushed to telemedicine through video conferencing or healthcare apps. Treating homebound patients virtually can soften the blow of an infectious disease outbreak like Covid-19, experts say, by reducing traffic to hospitals and doctor’s offices already struggling with limited resources and higher infection risks. It works the other way, too; telemedicine allows quarantined doctors to work from home. “If we’re talking about social distancing in order to alleviate our healthcare centers, telehealth is going to play a major role,” said Christopher Ali, a University of Virginia media studies associate professor and faculty fellow with the Benton Institute for Broadband & Society who focuses on connectivity.

But how is telemedicine supposed to work for the tens of millions of Americans who lack reliable, affordable, at-home broadband (the minimum threshold of acceptable upload and download speeds)? Ali says the answer is simple: “Telehealth is impossible without broadband. The two are synonymous.” He and others are sounding the alarm that internet inequity is now a public health crisis, as rural and urban households that lack—or can’t afford—at-home, high-speed internet are being left out of the massive, pandemic-driven shift toward telemedicine. “Before, the digital divide was a serious problem. It is now a life-and-death problem,” said Angela Siefer, Executive Director of the National Digital Inclusion Alliance, an advocacy group. “This is not rocket science. If someone doesn’t have internet, or a computer, or know how to use an app, they’re not going to use telemedicine. And if they’re not, they’re either leaving home or not receiving care.”

It’s proven difficult to accurately measure the width of this country’s digital divide. The Federal Communications Commission—which spends about $8 billion annually on connecting the disconnected—reported in 2019 that 21.3 million Americans lack cable, DSL, fiber, or wireless access to broadband speeds. In February, when a broadband availability tracking firm manually checked the FCC’s accounting, it doubled that figure to about 42 million Americans. According to Microsoft, it’s even more dire than that: as many as 157.3 million can only access download speeds below the FCC’s current minimum threshold, 25Mbps. Technology policy researcher John Horrigan estimates more than 18 million households across the country (some or most of which contain more than one person) lack broadband. “That’s 12 percent of the population who simply do not have internet access at home or with a mobile device,” Horrigan said. “But there are more dimensions than ‘you have it or you don’t.’”

For one, the digital divide plagues both rural and urban areas. In rural America, where 2018 Pew Center data suggests only 58 percent of residents have home broadband subscriptions, the issue is often infrastructure-related: Providing fast internet in remote, sparsely populated places means investing in expensive fiber or cell tower installation for the benefit of a handful of customers. In cities, that same 2018 Pew data shows about two-thirds of residents were connected to home broadband. Thanks to population density, that means about three times as many metropolitan households are disconnected. For them, it’s often less about access to internet and more about the price of that access. Horrigan’s analysis shows that a third of households with annual incomes below $35,000 (which represents about one-third of all households) lacked home broadband (compared to all but 5 percent of homes with annual incomes at or above than $75,000).

And smartphones cannot and will not fill in the gap. Areas with poor broadband often suffer from bad cell phone reception, Ali says. And research indicates that those who depend on smartphones for their internet access—low-income, low-education, and non-white individuals—are also more likely to reach their plan’s data cap and have their phone cut off due to financial hardship. “There’s not just one digital divide: it is low-income, it is minorities, it is newcomers and travel communities,” Ali said. “There’s this assumption that broadband is ubiquitous in the U.S.—an assumption that everyone has it, and that everyone’s speeds are equivalent to city speeds. This is the hubris of the connected.”

Now, we’re seeing all of this play out during a pandemic. A woman in Cleveland—where about one-third of households lack broadband—recently made headlines after her phone service got cut in the middle of a telemedicine visit. Some of the country’s least connected cities are now covid-19 hotspots, including Detroit, where almost 60 percent of households lack broadband, and Miami, where about half do. In the U.S. covid-19 epicenter, New York City, one in four households doesn’t have an at-home broadband subscription. On the opposite coast, in tech mecca San Francisco, one in eight residents don’t have high-speed home internet service. Under those circumstances, telemedicine can’t be considered a perfect solution for providing healthcare during a pandemic. “The coming weeks will lay bare the already-cruel reality of the digital divide,” wrote FCC Commissioner Geoffrey Starks in a March 19 New York Times op-ed, “tens of millions of Americans cannot access or cannot afford the home broadband connections they need.”

The covid-19 pandemic has completely altered Dr. Colleen Krajewski’s day-to-day medical practice.

Krajewski, a gynecologist in Pittsburgh, continues to provide abortion care, which, along with cancer procedures, are among the few surgeries deemed essential during this time. Routine pap smears and breast exams have largely been deferred, for now. Her patients’ needs have fundamentally changed, too. Some women are now choosing to stay home and get a tele-prescription for diaphragms, Krajewski said, in order to avoid coming in for a long-lasting contraceptive insertion. Others have risked in-person visits to get an IUD or implant if their situation is more urgent—as in the case of intimate partner violence in which a patient may now be quarantined with someone they fear is tampering with their oral contraceptives. She used to see up to 20 patients in-person a day; on Friday, she saw four who needed urgent care. The rest she “sees” over the phone or video. “I was worried it was going to be impersonal,” Krajewski said. “I actually find it’s kind of intimate to see someone in their home.”

It’s one of several silver linings clinicians like Krajewski say they’ve discovered during the industry-wide covid-19-induced pivot to telemedicine. “Ideally, we’d press the flesh,” said Dr. Joe Kvedar, Harvard Medical School professor, dermatologist at Massachusetts General Hospital, and incoming president of the American Telemedicine Association. “Now the world’s different. We want everyone to stay at home and take care of them at home.” With video conferencing, physicians can guide someone through using an at-home blood pressure cuff or reconciling prescriptions from multiple specialists. Dermatologists can examine rashes, pediatricians can peep inflamed tonsils, and physical therapists can watch patients exercise. Doctors can help assess potential covid-19 cases by asking patients to take a deep breath and then count how many seconds they can hold it (to test their oxygen saturation), and they’ve identified emergencies like appendicitis, gallbladder infections, ruptured ectopic pregnancies, and spinal cord compressions by asking patients to, literally, jump up and down. It’s also easier to practice good bedside manner—showing a calm face, not interrupting, expressing empathy—over video, compared to over the phone.

But doctors who need to closely observe, palpate or listen to symptoms quickly reach telehealth’s limits. Kressly, for example, says comprehensive pediatric “well exams” that include vaccination and hearing, vision, height, weight, blood pressure checks are practically impossible over the phone or web. And, she adds, “There’s clinical value in looking a kid in the eye and giving them a hug at the end of the visit.” Other specialists report similar difficulties. Addiction counselors may not be able to do regular urine screenings, and oncologists can’t ask patients to run bloodwork or biopsies at home. For psychiatrists, even video conferencing obscures subtle diagnostic cues, like if a patient is making eye contact or maintaining personal hygiene. “We’re practicing with one hand tied behind our back,” said Dr. Gail Basch, director of addiction medicine at Rush University Medical Center.

Plus, many practitioners were blind-sided by the pandemic. “This is a crash course,” said Mei Kwong, executive director of the Center for Connected Health Policy, a non-profit telehealth policy center. In a matter of weeks, thousands of healthcare providers have installed new apps and updated their understanding of changing regulations around inter-state licensure, prescriptive authority, and patient privacy requirements. “Most clinicians had in the back in their mind that there would be times when they couldn’t meet patients in person,” said Dr. Elie Aoun, a Manhattan-based psychiatrist. “But a lot of people hadn’t set themselves up for that, me included.”

Patients have had to adapt, too. Those with internet at home can download an app and adjust their expectations for what a doctor’s appointment looks like. But things are more complicated for households where the only available telehealth device is a landline phone. Just as the American Medical Informatics Association warned the FCC in 2017: “access to broadband is, or soon will become, a social determinant of health.”

Amy Sheon, executive director of Case Western Reserve University School of Medicine’s Urban Health Initiative, has been concerned about digital divide and health disparities for the last decade. The covid-19 pandemic has lifted certain barriers to care, like transportation and childcare, said Sheon, who is also a senior fellow at NDIA. But disconnected individuals not only lose out on live two-way conferencing, but also patient portals where they can get credible health information, message their doctors, request prescription refills, log blood sugar or blood pressure, and review their medical history, previous care recommendations, lab results, and immunizations. “With covid-19, healthcare closed its doors and went online,” Sheon said, and now some people can’t even knock on telehealth’s door.

Matthew Faiman, an internal medicine physician at Cleveland Clinic and medical director of its virtual, on-demand urgent care program, has been waiting about 15 years for this: In a matter of weeks, the various barriers that have prevented a widespread adoption of telemedicine—issues of licensure, IT, coverage, and reimbursement, for example—have begun to fall away.

“I always knew there would be a lightbulb moment, but I’ve been blown away,” Faiman said. “For patients, from a safety standpoint, we had to do this, and do it safely, and quickly, and properly. I just didn’t think it was going to come as a steamroller.”

Take, for example, telephone consultations. Broadly speaking, pre-covid-19, they did not fall within the definition of “telehealth” for many private and public insurance plans, including Medicare and Medicaid. Some plans even stipulated that, in order to bill for telemedicine, a provider needed to record video of both them and their patient as evidence against fraud and abuse. Some mandated the use of specific telemedicine apps, and not FaceTime or Skype, to ensure patient privacy. And even if you received telemedical care, pre-pandemic, not all states allowed insurance plans to bill for telehealth as they would for the corresponding in-person services.

Much of that has changed in a matter of weeks (which, to be clear, is lightning speed for the healthcare industry). Public and private health plans, as well as federal and state health programs, have scrambled to improve billing and reimbursing telemedicine. “The biggest issue we had to overcome was inertia,” said Mark Fendrick, a primary care physician and director of the University of Michigan’s Center for Value-Based Insurance Design. “This crisis moved it from 5 miles an hour to 100 miles an hour.”

As of Tuesday, Washington D.C. and every state but Hawaii had taken actions like expanding Medicaid and easing licensure or patient privacy requirements, according to the Center for Connected Health Policy. The Department of Health and Human Services continues to relax its policies around HIPAA. The March 27 CARES (Coronavirus Aid, Relief, and Economic Security) Act, among other things, allowed non-covid-19 telemedicine services to be covered, pre-deductible, until the end of 2021. And the Centers for Medicare and Medicaid Services has continued to expand its covered telemedicine services—including allowing phone-only consults when they’re the only options available. “(I)n the context of the goal of reducing exposure risks,” CMS recently explained, “we believe there are many circumstances where prolonged, audio-only communication between the practitioner and the patient could be clinically appropriate yet not fully replace a face-to-face visit.” Along the same lines, Medicare has had to create and implement new billing codes—since pre-covid-19, patients had no option for indicating they received care from home.

Private insurers have also changed telemedicine policies in response to covid-19. Aetna, which serves 39 million people, says it’s offering a $0 copay for telemedicine visits until June 4, 2020. Anthem has offered its 79 million customers to waive member cost sharing voor bepaalde bezoeken aan telehealth tot 14 juni. UnitedHealthcare nu stelt leden in staat bekende digitale audiovisuele technologieën (zoals FaceTime, Skype of Zoom) te gebruiken om verbinding te maken met hun eigen artsen, en heeft een 24/7 virtuele mobiele app voor spoedeisende zorg aangeboden voor medisch advies van covid-19 en om aandoeningen zoals seizoensgriep, allergieën en roze ogen te behandelen. Het aantal op telegeneeskunde opgeleide providers in haar eigen zorgverlening netwerk groeide binnen enkele weken van 1.000 naar 5.000, zei Dr. Michael Bess, vice-president van de gezondheidszorgstrategieën van UnitedHealthcare. Hij hoopt dat aantal eind april te verdubbelen tot 10.000 providers. ‘We wilden zeker weten dat mensen toegang hadden’, zei dokter Bess. “We wilden leden niet dwingen om naar bepaalde zorgcentra te gaan waar ze een risico op infectie zouden kunnen lopen.”

Maar zijn we getuige van een fundamentele verschuiving in de gezondheidszorg, of zullen we dit allemaal verdwijnen tegen 2021? Pat Keran, vice-president van product en innovatie bij United Health, zegt dat de verzekeringsmaatschappij zich inzet voor tele-gezondheid en hoopt het beleid permanent uit te breiden waardoor artsen patiënten van thuis naar de toekomst kunnen zien. ‘Het is een essentieel onderdeel van onze strategie’, zei hij. ‘We hopen dat sommige van deze belemmeringen zullen worden opgeheven en dat dit beleid permanent blijft, post-covid-19. Ik denk dat dit deel gaat uitmaken van de nieuwe norm. ‘ (Keran was niet duidelijk specifiek over welk van deze beleidsmaatregelen permanent zou kunnen blijven, behalve dat het artsen toestaat kosten in rekening te brengen voor bezoeken aan telezorg voor patiënten die thuis zijn.)

Anderen zijn cynischer, waaronder Dr. Judd Hollander , specialist in spoedeisende geneeskunde en decaan voor strategische gezondheidsinitiatieven aan het Sidney Kimmel Medical College van Jefferson University in Philadelphia. Verzekeringsvoorzieningen van Covid-19, zei hij, zijn misschien niet zo goed als ze lijken. Zonder uitgebreide tests is het onduidelijk hoe patiënten moeten worden gefactureerd; betalers zeggen dat ze betrekking hebben op covid-19-gerelateerde klachten, zei hij – hoe zit het met patiënten die niet weten of ze positief of negatief zijn, maar worstelen met symptomen zoals koorts en kortademigheid? En omdat veel netwerken een einddatum voor hun beleidswijzigingen in juni of juli hebben vastgesteld, kan eventuele verlichting van verzekeraars van korte duur zijn, zei Hollander, zonder meer permanente toezeggingen om de premietarieven opnieuw aan te passen of de dekking uit te breiden tot niet-covid-19 telecare. “Ik ben sceptisch dat ze alles doen wat ze kunnen”, zei hij. “Ik denk dat ze genoeg doen om te doen alsof ze doen wat ze kunnen.”

Maar Hollander compenseert zijn scepsis dat verzekeraars telegeneeskunde zullen blijven vergoeden met zijn optimisme dat patiënten erom zullen vragen. “Niets zal de herinneringen kunnen wissen van mensen die het hebben geprobeerd en het leuk vinden”, zei hij. ‘Patiënten zullen dit voortstuwen.’ Net zoals artsen aan het uitzoeken zijn hoe ze het massaal kunnen aanbieden, beseffen patiënten dat ‘de dokter zien’ niet langer hoeft te betekenen dat ze een afspraak plannen, betalen voor parkeren, in een wachtkamer zitten en 30 minuten bij een arts doorbrengen. “Mensen verdragen dat allemaal omdat ze denken dat er geen andere keuze is,” zei Dr. Kvedar. ‘Het is een doorbraak. De meeste mensen wisten niet dat ze gebruik konden maken van telegeneeskunde. ”

In de post-covid-19 wereld, Dr. Fendrick zei: “Een van de echt positieve resultaten is dat patiënten de zorg krijgen die ze nodig hebben zonder het huis te verlaten.” Zwangere vrouwen, mensen met mobiliteitsproblemen of mensen met onvoldoende transportmogelijkheden kunnen reizen voor afspraken vermijden, tenzij het absoluut noodzakelijk is. Bloeddrukonderzoeken bij u thuis kunnen mogelijk nauwkeuriger resultaten opleveren, omdat ze meer natuurlijke omstandigheden weergeven. Ondertiteling, tekst-naar-spraak en instantane vertaalhulpmiddelen kunnen de manier veranderen waarop patiënten met gehoor- en gezichtsstoornissen, of mensen met Engels als tweede taal, gezondheidszorg krijgen. Kinderartsen konden regelmatig getuige zijn van hoe kinderen met ADHD zich gedragen in het comfort van een vertrouwde omgeving, en ouders helpen beslissen of een ziek kind naar school moet gaan zonder families te vragen om vijf uur ’s ochtends naar een kliniek te rijden.’ Iedereen moet tijdens een tijd als deze, ‘Kressly, de kinderarts. “Wat we gaan zien, denk ik, is dat we de geest niet helemaal terug in de fles kunnen stoppen.”

Maar zelfs in de meest rooskleurige tele-gezondheidsvisies maken Siefer en andere voorstanders van breedband zich zorgen dat miljoenen patiënten worden buitengesloten. “Zowel lokaal als nationaal proberen we mensen met elkaar in contact te brengen”, zegt Adam Perzynski, universitair hoofddocent geneeskunde en sociologie aan het MetroHealth System en Case Western Reserve University in Cleveland, die onderzoek heeft gedaan naar de impact van de digitale kloof op de gezondheid. “Het blijft een kritieke bedreiging blijven voor sommige gemeenschappen.”

Tijdens recente shutdowns hebben gemeentelijke wifi-providers zoals bibliotheken hebben gestreden om hun openbare hotspots te behouden. Internetproviders zoals AT&T, Verizon, T-Mobile, Sprint en Comcast hebben geëlimineerde datacaps , en sommige hebben aangeboden gratis of goedkope plannen. En realistisch gezien zouden bedrijven kunnen investeren in het plaatsen van meer celtorens om lacunes in de dekking op te vullen, stelde Ali voor . Maar Siefer zei dat ze nog meer progressieve actie wilde zien, zoals een federale breedbandensubsidie ​​of een ontheffing om patiënten in staat te stellen een ziektekostenverzekering te gebruiken om een ​​internetverbinding en een laptop of tablet te betalen (wat volgens haar als essentiële medische apparaten in de leeftijd van telegeneeskunde). Sheon zei dat ze graag zou zien dat meer gezondheidswerkers in de gemeenschap technische ondersteuning bieden aan patiënten met een lager niveau van digitale geletterdheid, en dat meer gezondheidssystemen goedkope smartphones en tablets kopen voor patiënten die ze hebben gescreend en geïdentificeerd als niet verbonden. Zolang er geen permanente fixes zijn aangebracht, dekken covid-19-patches voor de digitale kloof ‘op geen enkele manier iedereen’, zei Siefer. “Dit zijn pleisters.”

Marion Renault is een wetenschapsjournalist geboren in Frankrijk, gefokt in het Midwesten en nu gevestigd in Brooklyn. Haar werk is verschenen in The New York Times, Popular Science en The Atlantic.

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