For thousands of years, healthcare has revolved around centralized relationships between patients and their healers. In their suffering (the Latin root of patient is “one who suffers”), patients must show patience waiting for the healers. However, the COVID-19 pandemic has launched healthcare into something of an existential crisis. Questions abound on both sides of the rail. Patients worry: Will I be able to find care if I get the virus? Can I afford it? Will I be alone in this? As a healer, I’m at increased risk for contracting the virus. I wonder: Am I endangering my family? Am I placing my other patients at greater risk of infection? There are also long-term consequences and questions: Will our hospitals continue to be safe places during this COVID outbreak, and during the next pandemic to follow? Like tuberculosis sanatoriums in times past, people are now considering extended isolation strategies and COVID hospitals. How we build relationships between patients and healers needs to be reconsidered.
The current pandemic has renewed public interest in telemedicine. It makes sense. While designed to improve access to care, distance is an obvious byproduct. And distance between patients, healers, and families means fewer infections. For most people, telemedicine means seeing a provider with a laptop or mobile device and skipping a visit to the hospital or a clinic. But there is another opportunity, more urgent now than ever, to use telemedicine in the hospital. Whether separated by 800 miles or 8 floors, telemedicine is an opportunity to bring us together, to look one another in the eye and discuss next steps during this time of great need.
During COVID, the benefits of in-hospital telemedicine are obvious. Each time we enter a patient’s room, the provider has to put on personal protective equipment. Gloves, gowns, and masks are now in short supply, and at times, providers have to go without. With new restrictions on visitation policies, families are disconnected from their hospitalized loved ones. Specialists—already in short supply—have to be everywhere at once. Beaming in via telehealth is the next best thing to being there in person.
However, what happens after COVID? Years ago, I looked at data from my own hospital, a national center of excellence for neurological care. In the span of a single year, we treated roughly 1000 patients, about 3 per day, transferred to us from other hospitals by ambulance or helicopter that were then discharged within 48 hours. We can’t do anything in 48 hours—so that means that these patients were thought to have more serious issues by the outside provider than they actually had on arrival. These transfers reflect uncertainty and fear from less-experienced community physicians. When in doubt, transfer. From a physician’s perspective, this is the safe move. But 2 hospitalizations and a medevac can push many Americans into bankruptcy. Unfortunately, a phone call is often not enough to reassure outside providers, patients, and families that the transfer is not medically necessary. We need to bond, to look in their eyes, and tell them it will be okay—and if the patient takes a turn for the worse, we’ll be there for them.
Once in the hospital, a patient’s journey often feels like the game Mouse Trap—a disconnected series of steps, with different doctors showing up at all hours. Patients, let alone families, often have no idea who is taking care of them. Now imagine replacing pagers and cell phones with video monitors everywhere. Family located thousands of miles away could participate and be brought up to speed on the next steps for their loved one. The physician is down in the ED or clinic? No problem—they can be in the room in as long as it takes to place a phone call. This is not only better care, it’s cost-effective care. A while back, Visique, now part of Philips Healthcare, started providing a second set of staff members to look over the shoulders of doctors and nurses at their facilities. Although the cost of these deployments was high (up to a million dollars per room), hospital systems found savings in both the cost and quality of care. Banner Health, one of the leaders in this space, has over 500 patients throughout the US being “watched over” from their command center here in Phoenix. Notably, even a 1-hour decrease in the average length of stay per patient translates into millions of dollars of savings for hospitals. There are many other opportunities—experts supporting in-house staff, specialty care and senior nurses from home supporting new graduates, chaplain services, translation services—the list of applications is long.
Considering all these benefits, why have hospitals been slow to adopt in-house telehealth? Historical barriers have included both technical and financial issues. First, delivering video in aging buildings and hospitals has posed a challenge. There are thick walls, poor WiFi, and privacy concerns. Typically a cart (think of it as a TV on wheels) is deployed. But this is expensive and forces people (nurses, doctors, patients, and families) to change their behavior and gather around the cart at an appointed time. Ideally, technology should support humans—not the other way around! Most video infrastructure (that’s the software piece of the solution) is sold like a cell phone contract; that is, on a per-minute or per-person charge. This makes enrolling everyone in the hospital and 24/7 patient monitoring expensive. However, these challenges are not insurmountable. How we charge for something can be negotiated. I’ve met a lot of smart engineers. With help, I am now spending considerable time building these solutions at scale.
It is worth a pause to mention this type of care should be thought of as a supplement, not a replacement, for in-person care. Like the EMR, used the wrong way telehealth could become a distraction from care, that sacred human-to-human relationship. Ideally, every service imaginable would be available a few feet away. This is just not the case. In-house telehealth is not an oxymoron. When used appropriately, it can save lives and improve the way we care for one another.