The doctor will see you now through telehealth devices

In their 69 years of marriage, Jean and Frank Mutz have been sustained by love, faith and music.

But when the COVID-19 pandemic struck, isolating them in their Avalon apartment, the couple, who used to perform as a musical duo in nightclubs all around the Pittsburgh area as Jean & Frank, found that they might need a hand getting to see their doctors.

They know they are in the age group — they’re both 89 — that neither they nor their doctors wanted going to the doctors’ offices at Genesis Medical Associates in Pine.

The solution turned out to be a telehealth visit — but for people like the Mutzes, setting up a Zoom meeting or a FaceTime call is not an option. Instead, their doctors arranged for a computer tablet to be brought to them.

“Right now we have some of the most vulnerable patients who need to see a doctor and who don’t want to leave their homes, and we don’t want them to leave their homes, either, if they don’t have to,” said Dr. Mark Woodburn, one of the Mutzes’ doctors. “We wanted to figure out a way to get to see them.”

They tried phone conversations. But that did not always provide enough information, including being able to view Mrs. Mutz’s swollen left leg recently.

“You can’t describe everything over the phone,” Mrs. Mutz said.

A telehealth video visit via a smartphone or computer is something Genesis and every health care organization in the country are doing during the pandemic in such unprecedented volume that experts say is likely to change the industry for all time. It was made possible only because in March both private and government insurance began paying for telehealth visits like they would an office visit, and the government relaxed some regulations, something they had been reluctant to do before the pandemic.

“This [pandemic] is an existential shock to the economy and an existential shock to our system,” said Doug Smith, formerly a leader of Cleveland Clinic’s telehealth efforts and now a managing partner at Wavestone, a global health care technology consulting firm. “It really poured fuel on a slowly emerging set of capabilities and adoption” of telehealth.

Dr. Jesse Ehrenfeld, chair of the American Medical Association board of trustees and a researcher who looks at how information technology can improve patient safety, outcomes and health equity, said that the AMA has heard reports of 1,000fold increases in telehealth visits by some doctors’ practices and health systems around the country, with some practices going from just a few doctors using telehealth to nearly all of them.

“The technology had been gaining momentum in recent years, but the pandemic has pushed physicians’ offices to expand in ways they would not have this quickly,” he said.

But not everyone has a smartphone, or a computer, or can properly make them work if they do, to hold a telehealth visit where the doctor can see the patient visually. While the majority in this small group — the numbers affected vary widely depending on where the practice is located — are elderly struggling with technology, some are younger and financially can’t afford a smartphone or computer.

Different health care operations have resolved this problem in different ways. Preferred Primary Care Physicians in Uniontown decided to ask patients to drive to their parking lot where a staffer in a gown and mask handed them a disinfected computer tablet to do a telehealth visit in the parking lot as a way to prevent exposing them or the physicians and their staff to each other.

“The worst part was that a lot of the patients in the category [of not having a smartphone or computer] were older and people with chronic illnesses. We needed to see them,” said Dr. Rich Cook, a physician at PPCP. “We never thought we’d be in this situation. But the patients love it.”

What started with just a few cases using the drive-up has grown to 25% to 30% of their daily cases at PPCP’s Uniontown office, Dr. Cook said, with about 20 drive-up visits every day. It’s a method they have expanded to most of PPCP’s other 25 locations that have a parking lot that will make it possible.

Through a grant from Highmark Foundation, Allegheny Health Network gave Allegheny County some tablets so that homeless people living in a temporary hotel for people infected with or at-risk of COVID-19 infection could connect with their doctors.

“It’s never the same as being physically present, which is one of the backbones of street medicine [for the homeless] where physical presence matters for a lot of people who have trust issues,” said Dr. James Miller, AHN’s street medicine team lead. “But it’s the closest thing we can get right now to a physical visit.”

To date, AHN has held about a half-dozen telehealth visits with residents of the hotel, known as Safe Haven Hotel — not to be confused with the Safe Haven shelter — and residents have benefited from the technology, said Cynthia Shields, assistant deputy director of the county’s Department of Human Services’ office of community services.

“So far it seems to be working well,” said Ms. Shields. “We have seen folks stabilize their chronic conditions, including diabetes, that were problems for them for years, using the visits on the tablets. It has been a blessing.”

At Genesis, Dr. Woodburn said he was brainstorming in early April about the problem he and his colleagues were having with a subset of their patients they couldn’t see in a telehealth visit. He ran through a few scenarios, including making in-home visits himself to those who could not do a telehealth visit with their own phone or computer.

“But I thought, ‘What if I could get them some sort of device?’ We could ship it to them and have them mail it back. But then I thought, ‘That’s going to be a technical nightmare if they don’t know how to operate them,’” he recalled. “Then I thought, ‘What if I brought them something directly?’”

And that became the idea that brought one of Dr. Woodburn’s staff members, Natasha Ngandwe, a medical assistant, in full scrubs, gloves and a mask to the Mutzes’ apartment building on a recent sunny day, with a disinfected computer tablet, ready for the Mrs. Mutz to have her telehealth visit.

“We don’t have a computer, so this really helps us,” Mrs. Mutz said as Ms. Ngandwe, who now has the added title of program coordinator for Genesis’ MobileMed program, prepared the tablet for her conversation with Dr. Daniel Grob.

They were going to talk about her swollen leg, and an itching problem that might have been related to some new medication she was taking — something telehealth also is a big aid to because doctors can doublecheck what they’re told a patient is taking by getting to see the actual pill bottle and prescription label.

It was the second telehealth visit they’ve had in two weeks, so Dr. Grob, dressed in doctor’s scrubs, could tell from what he was seeing on the phone that Mrs. Mutz’s leg was still swollen.

“That’s not bad. It seems a little better than it was last time when it was splotchy and redder,” he told Mrs. Mutz. “But both your legs look like they need to be elevated during the day. Are you getting them elevated?

“Not every day,” Mrs. Mutz confessed.

After they went over her medication and made a plan to visit again when needed, Mrs. Mutz thanked him and said: “I like you, doctor.”

“Thank you, Jean,” Dr. Grob said. “At some point I’d like to see your smiling face up close and personal. But right now we’re trying to keep you healthy and safe.”

And with that 20-minute visit complete, Ms. Ngandwe was off, disinfecting the tablet before she headed to the next appointment of at least four that day, some of which required her assistance, some for which she just dropped off a tablet.

Genesis started doing about four or five such telehealth-aided visits a day in early April, and saw that number more than double later in the month.

Of course, visiting via telehealth can provide more information than a simple phone call, but it can’t get a doctor those vital figures that are the staple of an office visit: blood pressure, weight, oxygen levels.

But Dr. Grob and others say that could soon change, too, with more in-home devices that make it easy for patients to pass on that information without any expertise through what are called Remote Patient Monitoring devices, or RPM. Some of them are worn and monitor a person’s body and send information in regularly, others are triggered by a patient.

“We’re still exploring” RPM devices, Dr. Grob said. “But they would give us, if we continue to do this, even more access and quicker follow-up with patients.”

The big question for all the practices doing this is whether these efforts will be able to continue, and if insurance will continue to pay for the visits when there is not an international pandemic keeping most of us home.

“This has started a larger conversation in the homeless systems about telehealth and the hope that we can make this available in the shelters in perpetuity,” Ms. Shield said.

Dr. Cook, from PPCP, said he hopes that’s true for his patients, too.

“I definitely think first and foremost that there’s a lot of visits we can do just as effectively with an e-visit, not all visits, but many of them,” he said. “It’s definitely going to play a role going forward.”

Dr. Ehrenfeld agreed. “There will be a recognition that this is an important way to deliver care, particularly for vulnerable communities,” he said.