What Role Will Telemedicine Play in Health Care After COVID-19?
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What Role Will Telemedicine Play in Health Care After COVID-19?
We talked with Dr. Jonathan Wright about the diagnostic and economic challenges that need to be overcome before patients can fully take advantage of the benefits of telemedicine.
Learn more about Dr. Wright’s practice and research, or connect with him on Twitter:
- Dr. Wright, University of Washington, Dept of Urology
- UW Medicine, Dr. Jonathan Wright
- Seattle Cancer Care Alliance, Dr. Jonathan Wright
The patient had to be in a healthcare facility, and you had to be, as a doctor, in a healthcare facility, for this to occur. So it just wasn't a very good system for it. Although most people said, I mean, "If we could just get this to work and do it from home, it'd make a lot more sense."
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My guest today is Dr. Jonathan Wright, a surgeon at the University of Washington Medical Center and associate professor as well. We'll discuss how Dr. Wright is adapting to the current environment in a profession that has historically relied on face-to-face interactions and answer the question, can doctors really work from home?
Dr. Jonathan Wright:
Oh, hi, I'm Jonathan Wright. I'm an oncologist at the University of Washington. I'm a surgeon and also a researcher as well.
Paul Estes:
Well, thank you so much for joining me today. I think one of the things that was really interesting when we ran into each other is how ideas like telemedicine, and just the health industry overall, is starting to evolve and specifically you being a surgeon. But before we get into how your practice is starting to change, I want to get an idea of what led you to oncology in the first place.
Dr. Jonathan Wright:
I always wanted to be a doctor as a kid growing up. I actually thought I will end up being a family practice doc back in the rural community that I grew up in. But then, when I got into medical school, I realized that I enjoyed operating to kind of fix whatever the patient was facing. But I really enjoyed that relationship with patients too, seeing them in the office and getting to know them and their families.
So oncology really offered me that opportunity. Specifically, in urologic oncology, because I knew the screening, the diagnosis, treatment, and the long-term follow-up for patients. So I get to work with them through their entire experience around their disease. So, it really is a perfect opportunity for me to do the things I enjoy, which is taking care of patients, operating, and being a part of their lives, too.
Paul Estes:
Now let's go back six months. Six months ago, when you were practicing with patients, were you doing any sort of telemedicine or Zoom video calls or any of that consulting?
Dr. Jonathan Wright:
Yeah, essentially none. I had one of my partners who was trying to do a research project to help those in rural communities, since we bring patients in from five states, to save them the couple thousand dollars to travel. So we were doing it once every couple of months, it was very, very rare that we were doing it. But I had a ton of in-person meetings—many of my days starting at 6:30 with in-person meetings at work. So very little telemedicine, telework whatsoever six months ago, and boy, did that change.
Paul Estes:
When you were doing that project six months ago, before we get to how things changed when you were doing that project six months ago, did it feel radical? Like, were there a bunch of doctors saying, "Hey, we can't do that. This face-to-face connection is critical." Like what stopped medicine or the health industry from going to your point, reaching out, and using technology to people in rural situations or saving people that may want to spend the money on the actual care instead of travel and some other things, what was the resistance?
Dr. Jonathan Wright:
Yeah, I think that ... So for this project, I think when it was put in front of us, it was like, well, "This is a no-brainer. Why haven't we been doing this?" But as far as why we weren't doing it more broadly, there were a lot of barriers to that. First and foremost, is the whole HIPAA, which is patient confidentiality. You had to have a platform that would be HIPAA-compliant. So you'd be forcing physicians and groups to go out and buy those types of things, they didn't have that. Insurances weren't paying the same parity for in-person versus visits that were being done in-person. Medicare was only covering primarily for those that live in underserved areas.
At the time you had to, and this has gotten better even just before COVID, but the patient had to be in a healthcare facility, and you had to be as a doctor in a healthcare facility, for this to occur. So it just wasn't a very good system for it. Although most people said, "I mean if we could just get this to work and do it from home, it'd make a lot more sense."
Paul Estes:
Take me to the current situation where coming to the hospital, if you have some of the diseases that you diagnose and treat, it may not be possible, especially with people that are older or have other conditions, how did it change? And what has the process of change been like not only for the doctors in the hospital but for the patients? Take me through that journey.
Dr. Jonathan Wright:
Yeah. Because we literally almost stopped seeing patients overnight. Patients cannot come into the clinic unless they have very certain conditions, and we're doing a lot of just telephone stuff because the infrastructure, the hardware was not in most centers to be able to do it. So there was a huge ramp-up to get departments and hospitals and clinics having the hardware. Then, we had to get the training.
Now, you could say, "What do you mean you have to do training?" But everything is so regulated. All the doctors had to go and do training to do this, and that slowed things up too, and then I had to get approved to do it. But once we were able to get it up and go, then it really was like the light switch. We're just, "Okay, we're calling patients at home and we use Zoom and we're zooming with everybody."
Paul Estes:
I want to talk about how this change has impacted you personally. Instead of getting in your car every day and driving to the office, you're sitting at home with your family. I mean, I, like yourself, have everybody at home with me and we're trying to do school and some other things, how has the experience impacted you, both positively or negatively?
Dr. Jonathan Wright:
First, for just overall, then for me, myself, is that in my group, some of us do cancer and some of us do non-cancer. So the non-cancer people were having a lot more at-home time. My actual practice of coming into the office has not changed dramatically because cancer still needed to be treated. So I've still been coming in almost every day to the office. I will say that the bookend parts of the days have become shorter. I love being able to do my 6:30 meeting via Zoom, then me having to drive in and be there in person, it saves me a half-hour on both sides of the day, too.
But as far as how it's impacted me because I am at home more, not dramatically, but you just realize what's important really in your life sometimes, and you realize that work can still go on. Our health is so crucial and our families are so important to us, and just watching my family trapped in the house, how important that personal interaction is. I noticed in our community, and I know you see it all too, is that there are so many more people out walking with their spouses, with their kids, and everyone waits, everyone stops and talks and social distances. I think, at least thus far, I think I see a lot of positives in our social awareness and care for each other as human beings. It certainly makes me remember what's really important in life, and that's our health, our family, and our friends.
Paul Estes:
One of the things that I was reflecting on the other day, it was actually a sunny day here in Seattle. To your point, I saw a ton of people walking, and it brought me back to when I was a kid. In many ways, that's how it used to be. People sat in their front yards and went walking and they'd stop and chat. So it's really interesting to reflect on being in a neighborhood and seeing people out constantly walking. I see people that are friends that are walking six feet apart, but down the street together. Let's talk about the adoption of the technology. You said light switch. Was it a, "Hey, this just feels natural," or did it feel strange the first couple of calls that you were doing?
Dr. Jonathan Wright:
Yeah, I guess. I guess I did oversimplify it a bit, because of it ... I mean the light switch was, we had to start doing it. But then there was the panic. I think almost every one of the doctors, myself included, you're nervous, you're doing something new, and you're going to expose yourself that you don't know what the heck you're doing. We certainly had problems with us on our side, getting it appropriately, there were problems with the patients on the other side. So it was a nerve-racking situation, I think just because it's the great unknown. We had the usual problems that we've all experienced now with it, you can get the video to work but you can't get the audio or vice versa, or you have a crappy connection. So you can't hear or see the patient very well. Those were the challenges, that certainly early on, for how to do it.
Paul Estes:
So I come from a family of doctors, all of my uncles in Louisiana are family practitioners ... there's a heart surgeon and other doctors. The one thing that I would say about all of them, they're amazing doctors, they have amazing bedside manner and care about their patients. As it relates to technology, I would say that you're just maybe a little bit behind in just the adoption of technology and feeling comfortable with it. As you look across your contemporaries, do you find that they are technologically savvy or that they have a lot of work to do to just get used to employing technology like Zoom into the way they work?
Dr. Jonathan Wright:
I think you can imagine that there is a pretty good range. When we first went a few years ago to electronic medical records, it was rough for some people, and certainly led some people to just retire. I think that telemedicine has challenged people to, again, its change is hard. Doing anything new, especially when you're used to knowing all that you do and doing it well, and to be humbled again, can be challenging for some people. Now, certainly for the younger people that we have, it's much easier for them to adopt it. I think I'm lucky, in that, in a university setting where we're all about trying to find new things and trying new ways to approach it. But even within that, change is hard.
Paul Estes:
Yeah. I have a sign on my desk that President Obama kept on his desk, that says, "Hard things are hard." I think sometimes, we forget that, especially right now, that we're all having to do things that are different and things that are hard, but that in the long run, I think will bring lasting change and resiliency to a lot of professions and a lot of professionals.
Dr. Jonathan Wright:
Yeah. I agree completely.
Paul Estes:
What has been the patient response as everybody's been forced to start working this way, how are they responding? Is it, "Hey, I miss that face-to-face, or this is much more convenient?
Dr. Jonathan Wright:
I think the vast majority of patients that we have worked with greatly appreciate it and prefer it. For a lot of people, especially if you're working, I take care of a lot of older patients that are retired, but for a working patient, you can just carve out 15 minutes to hop on your computer and do your visit. You don't have to drive into the doctor's office, you don't have to pay for parking and then wait in line to get in, or wait in the exam room. Then the doctor's running late and all those kinds of things. It's just, "Hey, I just do my quick appointment and get it done and move on."
The other thing that has been wonderful is that, you know obviously, you can have more than one person on a telemedicine call, on a Zoom call, or a Team's call. So the patients' families, no matter where they are in the country, can join on the call as well. For someone that does cancer, and we're talking about different treatment options, it’s so fantastic to be able to see the patient and then their three children in different spots on the call to participate. Then, we don't have the “lost in translation” when the patient passes it on to their family, and everyone can as a group be more on board and help that person with the decision process.
Paul Estes:
I interviewed a first-grade teacher who had just moved to do parent-teacher conferences via Zoom. He said the same thing, that it was amazing that he was now able to get both parents on the call. Where before, one parent would show up, and I know at least in my house we take turns of going because it's hard to get the schedules, but now, and even when there are parents separated, he could get both of them on the call and have a conversation about their child. That was pretty powerful in the work that he was doing, it's interesting to see the commonality.
How do you take vital signs? At least, when I go to the doctor, the thing I enjoy is one, the magazines. So with telemedicine, I would need to get a magazine subscription because I'd get to be exposed to a bunch of stuff that I normally don't read, but it's the vital signs, right? The first thing that happens is you weigh me, you take my blood pressure, and do those basic things. How do you handle that today? And how do you envision that going forward if telemedicine really does increase?
Dr. Jonathan Wright:
Yeah, it's a big issue because you can't get vitals unless they are somehow able to take it at home. They could count their pulse or you could get their respirations, but you're not going to get their blood pressure at present. That is a challenge, and the lack of a physical exam also is a problem. Now, certainly you can do some exams through just [inaudible 00:13:46] by looking at them. I've had patients pull up their shirts to show me where their surgical scars are so I can help plan for their operation. But if you don't have a really high-quality camera, you can see how, if you're looking at a skin lesion or something, you might have a challenge with that.
So I think for the long term, the return patients, where you already have an established relationship with them, you're following up on how the symptoms are doing. How's our new treatment going for you? That kind of thing, where the vitals probably aren't as critical. But the challenge is certainly if you're managing someone with blood pressure, or for a brand new patient where you want to have a sense ... because you're just seeing their face and you may completely miss that they have significant obesity or significant, lower extremity swelling that you don't normally see.
So that is going to have to be something to work through long term. But again, letting patients get in the door first quicker for a first visit, for a first consultation, and then deciding who needs to come in for an in-person or the follow-up and just avoiding those things. But there's no doubt not having vitals, not having all the parts of the exam is a drawback, but I think we can get around that for most of our conditions right now.
Paul Estes:
Yeah, I can imagine me, as you were talking, I was thinking, "Wow, just for the cost of parking, a couple of times I can buy my own blood pressure cuff and like some other things that I should have around the house and check my vitals." One of the things you've mentioned that I've been thinking a lot and it wasn't apparent to me at the beginning of this crisis was the financial impacts of in-person versus remote, right? The idea that I go to a facility, and if I need to have my blood drawn or like a number of different services that are offered are all part of a financial model of a healthcare facility. When I go remote, those services are not as readily available. How do you square the business of health care and the services that are offered that bring in revenue for the hospital versus patients that are saying, "Hey, I generally like this better, I live in a rural area"? How do you start to square that? And what is the economic impact of that long term?
Dr. Jonathan Wright:
It is something that we have to think about. Medicine is business too. It costs a lot to keep the lights on and to do what we do. So we can not acknowledge that, which is why many states—and Washington State is one of them that we just recently approved—pay parity for in-person versus telemedicine. That got passed earlier this year because if you're not getting as much money to see the patient in-person versus telemedicine, that is a disincentive to see telemedicine patients.
The other thing, as you mentioned, just the extra downstream labs and CAT scans, et cetera, that they may or may not be coming to get. Although, I think if we can work around that and they're still going to have to go in and get their labs and CAT scans and chest x-rays as well, but hospitals have what's called a facility fee, which is an additional charge on patients and their insurance and Medicare, Medicaid, to essentially pay for the whole infrastructure of the hospital. A private clinic doesn't have that.
Their reimbursement may be a little bit higher for the provider to account for that. But a doc in a hospital setting has both a professional fee and a facility fee. There is no facility fee with telemedicine visits. So the hospitals are disincentivized to have us do telemedicine because they lose that revenue. Now, during this acute COVID crisis, this has been brought up a lot. They are allowing a facility fee to be captured now, this just came through a couple of weeks ago for patients we're doing telemedicine for. But there's clearly going to have to be a reevaluation of this whole concept of the facility fee moving forward. So economics definitely plays a part in it, pay parity and other aspects are crucial.
Paul Estes:
Yeah, it's interesting when you’re at even big tech companies, right? I mean, Microsoft is building a multibillion-dollar campus, and of course, Apple has the spaceship, and all of those are facilities that, when you do a full burden cost of an employee or added on, right? To have this person sit in this office generally costs about that much. So all organizations, not only healthcare, are incented to ensure full utilization of that capital expenditure. So I think it's a really interesting thing that's being played out in medicine.
One of the things that you do besides seeing patients is clinical trials and working with other doctors. I know that from my experience in working on location, those fly-by conversations and that collaboration are important. I can only assume that in your field, it's not only important, it's essential. So we talked about the patient side, but when you think about the trials and the conversations and you collaborating with other doctors, as you try to solve these complex issues, how does that happen remotely? Are you concerned with that aspect of your work?
Dr. Jonathan Wright:
I really appreciate you bringing that up because it's been nearly devastating to the research enterprises right now. First, from a standpoint of clinical trials, where trying new treatments, new medications, most of those have been completely put on hold during COVID. There are a few rare exceptions, but over 90% of our clinical trials have been closed to a curl during this time. So we are not finding those next treatments for patients. Obviously, there are COVID-specific trials, which are incredible that are happening, but the run of the mill cancer therapy or a new therapy for rheumatoid arthritis has been on hold. So that has been rough.
You take also that most of these we have funded through federal grants, and the grant's for five years, for example. Now we have to negotiate with the federal government to give us an extension of the money or potentially more money because a lot of the funds are going to support salaries, those are still being paid, and we're going to eat into the total budget for our clinical trial.
The other aspect is that the, what we call bench work, where you're sitting around in your chemistry lab, essentially doing pipettes and little mice studies, et cetera, all the buildup to clinical trials has almost completely stopped, whereas normally the lab might have 10, 20 people in there. They're letting one person in a lab at a time at the Fred Hutchinson Cancer Research Center, for example. That has just completely stalled all of that research. We're starting to kind of get a little bit more of our people back in those spots, but it's going to be hard to come out of this for some time with what has had an impact on research.
Paul Estes:
I imagine that not everyone is saying, "Hey, this telemedicine thing is really helpful to patients, I'm leaning in, I'm learning." I'm imagining that there are still some naysayers or people that are like, "I just can't wait to get back to the way it was." What are you hearing from people that are saying that? Or doctors, or anybody in ... Not only the doctors but the other health professionals, what are their objections to using telemedicine after the fog of COVID clears?
Dr. Jonathan Wright:
Yeah, I think people have pretty well embraced that it's going to have a role, it's just depending on how much in their practice they can do it with. Those that really require a physical exam need to get back to seeing their patients in-person. There are certain fields where it's crucial. You can't really assess the problem without touching the patient and examining them. A lot of these exams are sensitive exams where there's no way you could accomplish them over a screen.
Then, the other aspect is there's an assessment of performance status, how healthy, strong the patient is, how robust they are. I'm trying to think of good ways to describe it where it's just kind of your gestalt, or can this person tolerate this treatment? It is just difficult sitting and looking only at their face through a television screen, or computer screen, to really get that. So I think those are the things where it is, we want to go to see how well they'd use it, how well they can move, see their whole body. But I think there haven't been ... I have not encountered really any massive naysayers other than those that say, "I can't see everybody this way. I can see it being part of my practice, but I need the in-person."
Paul Estes:
So we talked about patients of yours that may have a computer or may have internet access and access to the ability to do Zoom. But there's a large population in the United States that is underserved by the internet and may not have the technology. In your practice, how are you navigating that population.
Dr. Jonathan Wright:
It's a real problem because there are a large number of individuals out there who don't have access to the internet or a computer screen to do this with. So we have had to, in those situations, use telephone visits. We've talked about some of the limitations of telemedicine. Well, if you're just talking on the phone to somebody, it's a tremendous loss there, and you know from your own meetings when you do them face to face, there's a lot more interaction and a lot more engagement. Part of the doctor-patient relationship is building that trust, and that happens much easier through face to face, even via the computer. So we've had to just do telephones for them.
That has had a big impact too financially because a telephone visit, you get reimbursed $11 for a 10-minute phone call versus 10 times that for an in-person or telemedicine. You take a hospital that serves an underserved population, they're already having problems financially because the patients have poor insurances that don't pay very well or no insurance. Then, you put on top of that, they can't do telemedicine, so they're doing telephones, so you're even getting less reimbursement for it, and you worsen an existing problem.
Now, thankfully, in the last couple of weeks, two or three weeks, there is some addressing of this that if a patient is unable to do telemedicine with video, we can collect on a telephone equivalent to a visual as well. But again, if the patient doesn't have insurance, that's not going to help them either. So it's limiting the access and it's limiting what we can do. Real problem.
Paul Estes:
The conversation around inequality that the current situation has brought up and whether that is access to opportunity and jobs or access to medicine, it's something that is being highlighted very acutely, and really interesting to hear your perspective.
Dr. Jonathan Wright:
Absolutely.
Paul Estes:
Jonathan, thank you so much for taking the time to share your thoughts and your experience. I think one of the things I've always been curious about as I've started to experience telemedicine as a patient myself is, what are the benefits and what are the challenges? And I think you did an amazing job of articulating those. I wish you the best.
Dr. Jonathan Wright:
I really enjoyed doing this. I appreciate you taking the time to do it.
Paul Estes:
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