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“Almost overnight, the COVID-19 pandemic has completely disrupted how we deliver primary care to patients. Before the pandemic, telehealth seemed to be a way to deliver urgent care for acute issues to a select group of tech-savvy patients. Now, at least in my practice, the majority of primary care (acute care, chronic disease management, and preventive care) is being delivered through “telehealth,” meaning that we conduct visits virtually via video or telephone. While, of course, this is currently safer, many patients also seem to value the improved convenience and accessibility of these visits compared to traditional office-based care. However, as we continue to move forward providing virtual care to patients during the pandemic and beyond, we need to recognize our current deficiencies in providing this type of care and acknowledge that providing the full scope of quality telehealth will require more than just a video connection with a patient.”
Cara Litvin is an internal medicine physician.
She shares her story and discusses her KevinMD article, “Envisioning the delivery of true primary care telehealth.”
This episode is sponsored by The Nuance Dragon Ambient eXperience (DAX). The Nuance DAX solution makes it possible to forget the tech-toggling and reduces documentation burdens no matter how or where care is being provided.
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Cara Litvin. She is an internal medicine physician, and she wrote the KevinMD article “Envisioning the delivery of true primary care telehealth.” Cara, welcome to the show.
Cara Litvin: Thank you.
Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?
Cara Litvin: Sure. I’m a general internist by training, but in addition to taking care of patients, my long-term career interest has always been to identify how to improve the delivery of primary care by health IT. This interest actually began almost 20 years ago now, when I was a medical student and I did a summer research project, which involved traveling across the country to meet with doctors who were, at that point, early EHR adopters. This was well before meaningful use, and it became clear to me then that if EHRs were implemented and used properly, they could be this incredible tool to help us improve the care we provide to patients. I think that still holds true today.
Up until a few years ago, I was primarily an academic health services researcher. I conducted studies funded by the NIH and the Agency for Healthcare Research and Quality, which focused on learning how to better measure quality using EHR data, and then studying how practices could improve their care by reorganizing their delivery system around EHR tools like clinical decision support.
But a few years ago, it seemed to me that a lot of the innovation in the health IT world was actually happening outside of academia. So I’m still an academic faculty member, but my long-term research mentor and now colleague, Dr. Steve Ornstein, and I also formed a small startup focused on developing HIT solutions to improve the delivery of evidence-based health care. Our first application is a platform called BP Correct. It’s a remote monitoring platform that consists of a patient app and a clinician portal, and the app guides patients through a scientific approach to monitoring their blood pressure at home.
It seems simple, but it’s one of the most common clinical problems I encounter as a primary care physician: I have no idea what a patient’s blood pressure is. Office blood pressure is often inaccurate for a number of different reasons, but you have to spend a lot of time educating patients how to take blood pressure correctly at home and do it on the appropriate schedule. An app can do all of this easily and then aggregate the results for the doctor, so it’s a clear problem that technology can easily solve.
We had actually started working to develop this platform before the pandemic started. But then, as I started taking care of patients virtually, I realized how telehealth platforms, like my platform but like many other telehealth platforms, could actually be so valuable in the COVID era and then beyond. That’s what led me to write this article.
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Kevin Pho: Great. So let’s talk about that article, “Envisioning the delivery of true primary care telehealth.” Now, for those who haven’t read your article, can you walk my audience through it and the story of why you decided to write it?
Cara Litvin: Yeah, sure. When writing this article, I drew from my experience as a primary care physician taking care of patients during the telehealth era, but also from my experiences as a health services researcher and as a developer of a telehealth platform.
If you think about it, before the pandemic began, at least in the primary care world, telehealth was really a niche thing. We heard about it for really acute care, so tech-savvy patients who needed urgent care but didn’t want to go to the doctor’s office. For example, a patient would have UTI symptoms, they’d fill out a questionnaire, do a brief video visit, get their antibiotic, and be on their way. That’s simple and straightforward, but we hadn’t really started exploring how to deliver typical primary care, like management of chronic diseases, through telehealth.
So when the lockdown began, all of a sudden, over really just a couple of weeks, COVID forced us to start delivering the majority of our primary care virtually. At least at my institution, we started doing video visits or phone call visits for almost all patients. It’s quite laudable that our clinic leaders were able to recreate these workflows so quickly, but we’ve also essentially just replicated our same model of care, meaning this 20-minute provider-patient interaction, and done it virtually. I think that’s fine for a crisis, for right now, but I also think it’s the opportune time to say, “Wait a minute, we don’t have to do things the way we’ve always done them. This is a perfect opportunity to think outside the box. Let’s reimagine how we can deliver health care going forward. We have all this technology now; let’s use it.”
So I think even after a few months of conducting virtual visits, we’ve learned what really works well and also identified the barriers. In this article, I described what I envisioned the future of primary care could entail if we really utilize technology and implement what I consider true telehealth, which is beyond just the video connection with the patient. Drawing from my health services background, I make the point that we actually have years of extensive research that’s told us what the evidence-based strategies are for delivering high-quality care. We just have to figure out how to apply them to a new delivery model. So in the article, I outlined some of the ideas that I have, using the chronic care model as my blueprint.
Kevin Pho: Sure. So tell me, over the last few months, what has worked well with telehealth, and what has not worked well?
Cara Litvin: Right. I think the most important thing that’s worked with telehealth is the convenience for patients. A lot of my patients love it. I’ve done video visits with patients while they’re on a work break or while they’re taking care of a grandchild, and they don’t have to drive to the doctor’s office, they don’t have to find parking, which is an issue at our institution, and they can be on their way. You can also just do follow-up really quickly. So if you have an uncontrolled diabetic patient, instead of saying, “Oh, come back in three months,” we say, “Well, we’ll check in through a quick video visit in another week.” So I think it increases access, improves patient satisfaction, and improves patient convenience.
Kevin Pho: A lot of practices, like mine, like yours, had to implement telehealth systems within days, and there’s been a lot of innovation and there’s been a lot of learning points. What do you see as some of the lasting innovations from the last six months?
Cara Litvin: I think telehealth will persist going forward. I think we have to have private and public payers agree to continue it, but I think they eventually will, because I think we’ve seen that we can’t go back, like we can’t go back for a lot of different things besides health care. I think it’s important, though, to think about other ways to innovate, and I think that’s what I talk about in my article.
So if you think about the things that we don’t have, the problems that we have with telehealth are our lack of access to data. You can look at a patient and do a quick video exam, but you’re missing vital signs, and that’s where my platform comes in, to be able to get data, vitals like blood pressure, remotely. But you’re also missing physical exam components. There are things like small telehealth kits, and I envision a future where every home would have a small telehealth kit with a little otoscope, a digital stethoscope, a blood pressure monitor, and a thermometer. So, for example, if a patient had ear pain, they could put the probe in their ear and take a picture, and then that picture would be sent remotely to the doctor.
I think there also would be AI to help us interpret data, like sounds from a digital stethoscope and other vital sign data. Not just blood pressure monitoring and not just glucose monitoring, but even thinking more outside the box: We have all of this data now from our watches, our physical activity, our heart rate variability, but we need clinical information systems to aggregate that information and help interpret it for physicians.
Kevin Pho: Now, who is doing most of the innovation when it comes to telehealth? Are there any big companies? Are they mostly startups?
Cara Litvin: There are some big companies. I think there’s big and small, and everybody is kind of exploring what the future will look like in this space. There are lots of other companies that are doing remote monitoring and chronic care management and trying to do that virtually.
Kevin Pho: So we’re talking to Cara Litvin. She is an internal medicine physician, and she wrote the KevinMD article “Envisioning the delivery of true primary care telehealth.” Now, let’s go forward 12 months. Let’s look into your crystal ball. Where do you see telehealth in September?
Cara Litvin: I think we’ll see continued video visits, a lot like what we’re doing now, and hopefully some expansion of things like remote monitoring. I think it’ll take a little bit longer to see all of the things that I outline in my article, like home telehealth kits, but hopefully over time we’ll be able to aggregate more and more information and data and also change the way we take care of patients. So involving not just the provider, but involving the clinical staff and helping us review this data, expanding the way we take care of patients beyond just a 20-minute office visit.
Kevin Pho: And in your opinion, do you see Medicare and the other insurance payers continuing to pay for televisits?
Cara Litvin: I think so. I think it may take some time, but I think everybody’s realized that there are some benefits. I think the payers will want to make sure that we do it in the right way, with the right documentation, but I don’t see us going back to purely in-office patient visits.
Kevin Pho: And my final question, Cara: What is your take-home message that you want to share with the KevinMD audience?
Cara Litvin: So even though I’ve been an EHR proponent all of my academic career, I don’t think we’ve ever utilized EHRs to their full potential, and I think maybe this time we’ll get it right with telehealth. The notion that primary health care has to happen all within a 20-minute session in a doctor’s office is actually kind of ridiculous and archaic. We have this enormous technology now that enables us to truly reinvent how we provide care to patients. I think in some ways, one of the positive unintended consequences of the pandemic is that it’s been this perfect sort of catapult forward to force us to change how we deliver care. Hopefully, if we get it right, we’ll eventually provide true telehealth in a way that actually improves the quality of care that we deliver to patients.
Kevin Pho: Cara, thank you so much for sharing your time and insight, and thanks again for being on the show.
Cara Litvin: Sure. Thanks for having me, Kevin.
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