Contributor: Ian Tong, MD
To learn more about Ian, click here.
For the last nine years, one could say I have been deeply involved in the world of digital health care delivery. In fact, some people might even go so far as to say I am a national expert. However, the point of this article is not to display my “deep knowledge,” but more so to make a humbling admission about my ignorance. I cannot figure out why some of our leaders and lawmakers refuse to see the value of telemedicine? or what I call virtual care?
When I talk about value in healthcare, it is important to provide a little more context. Value is typically defined as the quality of the care and outcomes a patient receives divided by the cost to deliver that care. As an example, if you can lower your patient’s blood pressure just 5 mm Hg (that is the bottom number) you can reduce stroke risk1 by 30-50%. That obviously is a great clinical outcome; however, if you spent millions of dollars to achieve that outcome, then you have not delivered much value. In fact, you may be doing harm, because you have probably taken much needed healthcare resources from some other area that could have benefited tremendously from those dollars.
So, I admit achieving value is not always straightforward, but in the case of telemedicine, it seems very clear our health systems can improve access, quality, and better, more equitable clinical encounters for patients and clinicians. I will come back to the value for clinicians, but to go a little deeper on patient outcomes and experience, let me take you back about 15 years when I was first introduced to telemedicine. At the time, I worked for the federal government in the Department of Veterans Affairs in northern California about 2 miles from Stanford where I was on faculty. I was developing a Veterans outreach program, and I applied for a grant from the Office of Rural Health (ORH) to improve access to care for Veterans living in rural or highly rural settings. Through that experience, I learned 1 in 4 Veterans lived in a rural setting and struggled to get primary and specialty care services. It was clear then, and remains clear today, that telemedicine was one of the highest value tools to provide much needed access and health services to these Veterans.
Some of you have noticed by now I have deliberately been referring to Veterans as a minoritized or underserved group or population that is deserving of equitable healthcare delivery. I started with this framing of Veterans, because they are an easily identifiable population for whom no one would deny access to high-quality care. They are a group, especially the geographically isolated rural Veterans I spoke of, for whom no leader or regulator would deny the value of telemedicine or technology-enabled care. So why are our leaders so hesitant to unlock this valuable healthcare tool for other minoritized parts of our population, like members of the Black community?
As a Black, cis-gender physician with he/him pronouns, I care deeply about improving health outcomes in the Black community, and I want to use all of the tools at my disposal. I believe telemedicine can improve healthcare access to communities living in poverty where Black non-Hispanic African Americans are overrepresented.2 In late 2020, Lori Uscher-Pines, PhD reported in the Journal of Medical Internet Research that over 50% of Included Health’s (formerly Doctor On Demand) telemedicine encounters in the early months of the COVID-19 outbreak served patients from low-income households with less than $20,000 annual income.3 Insights like this point to telemedicine as a potential remedy for combating structurally racist policies of segregation, but access is not enough.
Expanding access to outstanding clinical care is an important value driver of telemedicine, but virtual care platforms offer additional value beyond a simple substitution of virtual for in-person clinical competence. Telemedicine practices can offer patients more opportunity to match themselves with culturally-concordant and competent clinicians. Pre-pandemic, Doctor On Demand boasted an incredibly representative and diverse panel of clinicians. At one point, the practice consisted of over 60% women, over 40% Black, Latinx, Asian, and Indigenous Peoples, and a behavioral health practice with 20% of doctors identifying as members of the LGBTQ+ community. If this type of practice composition hosted in the “cloud” 24/7/365 could be duplicated and scaled, we would have a secret weapon in our national mandate to impact health disparities. Black patients living in rural and urban “primary care deserts” could access clinicians with their shared experience across state lines. These are opportunities for our healthcare delivery organizations to improve not just access, but potentially improve clinical outcomes, as we earn back the trust of Black patients who have understandably disengaged from a healthcare system with a long history of racist thinking, inhumane and unethical research, and medical gaslighting, much of which still very much exists today.
To close, let me circle back to some of the value we see telemedicine offers clinicians. In late 2020, researchers at the Mayo Clinic published the Telehealth Impact Physician Survey Results.4 A clear majority of clinicians reported telehealth improved their job satisfaction, and 75% stated it enabled them to deliver quality care across numerous domains, including behavioral health, chronic disease management, preventive care, and care coordination. This is consistent with our all-virtual care practice where we see average annual retention of 90% and high clinician satisfaction scores [Net Promoter Score (NPS) >90!]. In this period of the “great resignation,” it is critical we enable clinicians with every tool possible so they can find sustainable, rewarding careers.
Whether you or someone you love is a patient or a clinician, we all have something to gain from better engagement of telemedicine. The virtual care experience we have gained during the COVID-19 pandemic has provided us with a rare glimpse into the future value telemedicine will deliver to both patients and clinicians. Let’s hope our leaders join us in embracing and then realizing it fully.
Contact Ian at: [email protected]