1.
When there is a need, there is a way to
change policies – To quote Christopher Roth, Vice-Chair of Radiology at
Duke, who said during one of the many excellent SIIM webinars, “this pandemic
was as dramatic and life changing as the implementation of a new EMR, but with
the difference that instead of taking 2-3 years, it had to be done in less than
a month. Therefore there was no time for committee meetings, no time for
training and planning, but instead practitioners had to learn and make changes
as-you-go.”
New uses for modalities were invented, for example, instead of bringing a COVID
patient to a radiology department to perform an exam, with the result that a cleanup
crew has to take half an hour to clean and disinfect it again for the next
patient, it might be better to take a chest X-ray with a portable unit at the
bed-side in the ICU or ER or patient room. Federal guidelines for reimbursement
of non-standard procedures, which under normal circumstances would not be
reimbursed were quickly changed and adapted.
2.
POCUS use has sky-rocketed – The
emergence of hand-held ultrasound (Point Of Care Ultrasound, or POCUS) over the
last 2 years could not have come at a better time. These systems are relatively
affordable as the cost ranges between $2k and $6k, and as they connect to
either a standard phone or dedicated phone-size screen or tablet, a healthcare
practitioner can carry one in his or her pocket and make an assessment on the
spot.
Uploading the images that a physician wants to keep as part of the electronic
health record has been a challenge that has been addressed by the standards
community in the form of an “Encounter Based Imaging” IHE profile. As a recent
JACR study
showed, its usage did not impact downstream ultrasound volumes which is good
news for those who feared that it would cannibalize the “standard” ultrasound procedures.
3.
Telemedicine has shown a massive increase
– Telemedicine takes place in three modes: 1) Synchronous where a patient is
talking real-time to a healthcare practitioner, 2) A-synchronous where the
communication takes place in the form of texts, emails, uploaded documents,
etc., and 3) Telemonitoring or Virtual
Observation.
Telemonitoring does not only include monitoring a patient at home but also
monitoring inpatients such as in the ICU. The less a practitioner has to
interact physically with an infected patient, the lower the risk of spreading
the infection and the lower the need for PPE usage.
Estimates for telemedicine business range between a 7 to 10 fold increase over
the next 5 years. If you consider an individual practitioner, the increase
could be dramatic from having virtually no telemedicine consults to converting
more than 70% of their practices to remote consults. This increase became the
ultimate test of the scalability of the platforms that are being used. It can
only be expected that when the pandemic wanes there will be a certain
percentage of those applications kept in place.
A positive effect also has been that tele-visits are now chargeable because of
changed regulations, let’s hope that some of these “emergency rules” by CMS
will stay in place as there is no reason for a patient to show up in a doctor’s
office for simple things that can be dealt with remotely.
4.
The cyber security attack surface has been greatly
enlarged – Many non-clinical healthcare workers have been working from
home, clinical workers might be working from home as well, and last but not
least, because of teleconsultations, patients are now also directly connected
to providers. This is especially challenging for smaller providers who might
not have the IT resources to deal with this.
5.
Patients have become users of an organization
technical infrastructure – According to a survey, most
of the telehealth consultations used commercial applications such as Zoom (23%),
Facetime (17%) and Skype (9%) with telehealth platforms (34%) in the minority.
One cannot assume that every patient is familiar with the functionality of
these tools, and some of them are definitely more user-friendly than others.
Who is the patient going to call if they cannot get into the tele consult
application? IT support had to ramp up significantly to support patients as
well as their remote employees.
6.
Telemedicine extended beyond COVID calls
– The same survey
showed that only 14% of visits were related to COVID symptoms. The other 86% of
the calls ranged from urgent care to scheduled visits, behavioral health,
chronic illness management (diabetes, cardiac, others…), and surgical follow
ups. Again, the social distancing requirement showed that a significant
percentage of routine visits can be done equally well remotely.
7.
Artificial Intelligence (AI) has proven not
to be a panacea (yet) – As most AI algorithms are based on deep learning it
requires a significant amount of training data which was certainly in the
beginning not readily available. It is getting better as many institutions make
their data available to researchers. Many AI vendors were “reprogramming” their
algorithms from existing applications, such as pneumonia, for COVID which has
proven not to work as well. In addition, it was and is still not clear what modality
is the best to diagnose COVID, is it a chest X-ray, a CT, an ultrasound or
other modality? The advantage of imaging is that it is almost real time, or at
least has a much faster turn-around time than having to wait for a lab test
result.
8.
Digital pathology is a major laggard –
With tele consults and teleradiology being widely available it is definitely
frustrating to see how it is currently challenging if not impossible to
exchange a digitized pathology slide, especially in the US due to a lack of
regulatory approvals and interoperability. Some countries, notably the
Netherlands already have a nationwide digital pathology exchange set up to for this.
There is no reason why this kind of implementation could not be deployed in the
US, as a matter of fact this is the main topic of an upcoming seminar
on this subject.
9.
How to get access to all of the records is
still very challenging – Just from anecdotal experience, after one of my
good friends had arranged for her scheduled in-person visit to be changed to a
telehealth visit with a major institution for a second opinion, the physician
did not have access to the most recent X-rays. The fact that my friend had the
CD did not really help as there was no upload mechanism for them in the
platform/portal they were using. Having all the information in a timely and
complete manner is even more of a challenge with these telehealth consults.
10.
A major workflow redesign is needed – I
was rather impressed with the new workflow when I had an in-person appointment
with my specialist. I was instructed to text my arrival to the front-desk, upon
which a nurse came to my car with a wireless tablet to confirm my identity,
take my temperature, ask basic questions and when I “passed,” escorted me to
the clinic straight into an exam room using a path that would limit any close
encounters with other patients or practitioners. Similarly, hospitals now have
a special dedicated entrance for suspected COVID cases.
In conclusion, the pandemic has had a major impact on healthcare IT and
accelerated some of the “dormant” applications to a degree that will very
likely stay, most of it for the better. I recall the last visit of my spouse with
the surgeon one week after she was discharged following a minor surgery, upon
which the surgeon took a quick look at her scar and determined in a matter of
seconds that all was OK. There is no reason for that type of visit to be in
person as she could simply take a picture with her phone and email it or during
a synchronous telehealth session point her phone to the incision to show it.
Telehealth is in many cases more efficient and creates less of a burden for patients
and has the potential to lower costs as well, let’s hope that the result of
many of these COVID impacts will remain for the better.
