By Daphne Mark
Boston University News Service
BOSTON – Even in 1967, Boston traffic was bad enough to turn Dr. Kenneth Bird’s 3.5 mile commute between jobs into an ordeal that took an hour both ways.
Stopped in a tunnel under the Charles River, he had an epiphany.
According to Bird’s student, Dr. Jay Sanders, the professor of medicine at the Massachusetts General Hospital and medical director at Boston’s Logan Airport, came up with a new way to see patients. Using two-way microwave audio with cameras and monitors, Bird would examine patients at the airport from his hospital station.
No more hated commute.
Fifty years later, remote medicine is ubiquitous, but still novel. Since March, virtual medical care has expanded in the face of COVID-19 restrictions.
Benefits for patients range from increased convenience to affordability, to being more environmentally friendly. Telehealth visits also keep doctors safe and reduce the need for limited personal protective equipment. Hospitals are seeing more patients and more new patients.
Since 2000, Mass. General has experimented with many generations of steadily improving technology, said Dr. Lee Schwamm, director of the Center for TeleHealth at Massachusetts General Hospital.
The pandemic has accelerated telehealth technology and usage, Shwamm said on the phone during his commute home from work.
Schwamm’s interest in remote care was piqued in 1996 when the FDA approved a new clot-dissolving drug for stroke patients. The drug needed to be administered within hours of a stroke, and many hospitals thought it was too risky without a neurologist’s approval. Many patients missed the window of effectiveness, Schwamm said.
“It just felt like an enormous waste of human life that we couldn’t just see the patients directly,” Schwamm said.
Now, Mass. General supports approximately 30 hospitals that rely on virtual neurology consultations, Schwamm said.
Mass. General was pioneering telemedicine long before the COVID-19 pandemic. The hospital used virtual options such as secure messaging, image sharing, issuing questionnaires about side effects or mood changes, and remote blood pressure monitoring. Mass. General received 10,000 telehealth visits in 2019 across a variety of specialties.
Despite those advances, the hospital wasn’t totally prepared for the pandemic. This year, Mass. General telehealth visits surged from just 0.2% of total visits in 2019 to 62% of all visits, said Schwamm.
The hospital had 1.38 million virtual visits in the six months between mid-March and the end of September — more than 200,000 patients a month.
“We were in a very good position because we have been doing this for about seven years, pretty intensively,” Schwamm said. “But nobody was prepared to shift to that degree of scale with a moment’s notice.”
Are vitals vital?
A missing component of virtual appointments is the collection of routine vital signs such as breathing rate, blood pressure and weight.
Dr. James Udelson, chief of cardiology at Tufts Medical Center in Boston, said vitals are only important for some patients.
“If you’re working to control someone’s blood pressure, the entire visit is about that,” he said. “If you just gave me that number, that’s 90% of what I need to know.”
To replace in-office vitals, Udelson said his patients are encouraged to schedule a blood pressure test at a local pharmacy before their appointment or test themselves with an at-home monitor, which costs as little as $20.
When necessary, his team instructs patients on how to take their own vital measurements, Udelson said.
“We teach people, even as we’re talking to them, how to take their pulse and to give us their heart rate,” he said. “Is [telemedicine] really, really accurate? You don’t really know. But is it better than no information? Yes.”
Building connections online
Dr. Paul Hyman, a physician in Maine, worried that telemedicine would reduce doctors’ abilities to relate to patients. In an interview with NPR, he said touch is an important factor in care.
“I think there’s something therapeutic about seeing a physician and having them lay their hands on you,” Hyman said. “A lot of people agree that it’s therapeutic in its own right — and that can be lost without the physical exam.”
Schwamm, however, said that although visits can be different, generally patients feel more comfortable with televisits than their doctors.
“[Doctors] tend to over-value the experience of being in the room with the patient, compared to the patient’s experience,” he said.
Schwamm said that while Mass. General already had high satisfaction ratings for in-person visits, remote visits have scored exceptionally well.
“In some ways, it’s even better, because now [patients] have the provider’s undivided attention– face to face,” he said. “Because [doctors] can look at their computer screen, they can share information, and they’re looking at the patient at the same time.”
Both doctors agreed that telehealth is a good solution for visits involving patients with mobility issues or those who require frequent visits but have small children who can’t be left alone.
“Can you hear me now?”
Patients’ grasp of technology can limit their experience.
Udelson said some patients struggled with Tufts’ virtual care, which could only be accessed through a smartphone app and lost precious time during their 15-minute appointment searching for the unmute button.
“It was pretty challenging, honestly,” Udelson said. “The age of our patients in cardiology are a little bit older on average; not everyone is tech-savvy.”
Different groups respond to telehealth differently. While a November 2020 study in the Journal of the American Medical Informatics Association shows that people of color are slightly more likely to use telehealth than white people, Schwamm said undocumented people felt especially uncomfortable using the app.
“They were worried that Immigration and Naturalization agents could use that information somehow to locate their position, and then come in and arrest them,” he said. “Even in a city like Boston, which has largely been a safe haven, that fear is widespread.”
Increasing access to rural communities
There have been country-wide strides to increase broadband access; somewhere between 20 million and 41 million Americans do not have stable internet, according to a 2020 study by Broadband Now.
Though rural patients were some of the telehealth’s earliest adopters and have benefitted from life-saving and specialty care as rural hospitals vanish, the “digital divide” may impact how many are able to see a doctor.
“It has become painfully clear there are too many people in the United States who lack access to broadband. If this crisis has revealed anything, it is the hard truth that the digital divide is very real and very big,” FCC Commissioner Jessica Rosenworcel wrote in response to the 2020 Broadband Deployment Report.
Udelson said in the past his cardiology team would routinely send doctors to areas outside of Boston to meet with patients at a local practice. With telemedicine, they began using a hybrid model where patients have their vitals recorded in-person at a local practice, then meet with a specialized doctor virtually.
For specialized medicine, like Udelson’s cardiology unit, people traveled from across the country seeking treatment. Now, with telehealth, he said those patients can see specialists without the expense of traveling.
Moving forward
In the past, Dr. Udelson’s cardiology unit was so busy with patients returning for routine post-procedure check-ups that he did not have time for new patients.
“Sometimes our slots get so clogged with these routine follow ups that it’s hard to get new people. New people are like the lifeblood of our practice. And they’re more interesting,” said Udelson.
In the future, he plans to shift routine appointments– which he says accounts for 15% of his work– to telehealth to free up clinic spots for new patients and people who need to be seen in person.
“[Virtual care] is way more doable than everybody thought it was,” Schwamm said. “Patients of all ages have been able to adapt and excel at conducting these visits. We really need to put patients first as we try to think about the best ways to continue.”
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