Telemedicine is here to stay

PHOTO: PHYSICAL DISTANCING: Dr. Ellen L. Singer holds a physically safe meeting with her fourth-year medical students and assistant. Dr. Singer designed and leads NW Permanente COVID-19 Homefront, which launched on April 13, 2020, 12 days after it was proposed. The team includes 10 students and about 10 Northwest Permanente retirees who outreach to ambulatory patients with the COVID-19 illness and follow each patient until “end of illness.”  Many patients told me, "I felt so alone and scared."



With COVID-19 monopolizing the news, daily lives and medical field, many people are afraid to visit a doctor or hospital for fear of being exposed to the virus.
That fear has its own dangers: unvaccinated children, untreated illness or injury, unfilled prescriptions, and increased death from stroke or heart attacks in people sitting at home with symptoms to name a few.
None of those are necessary. 
“People don’t realize what resources are out there,” says Dr. Mark Zeitzer, medical director of acute-care services for Zoom+Care, a chain of clinics in Oregon and Washington.
Telehealth, also called telemedicine or virtual health, offers contact-free care for many conditions and can authorize prescription refills, which can be delivered to your door. A virtual consult can also direct patients to a clinic or emergency room when in-person treatment is required. Hospitals and clinics have safety procedures in place to keep patients and health-care workers safe. Pediatricians have implemented procedures to keep infants and young children coming in for vaccinations separate from ill patients.
“Don’t ignore symptoms; seek care,” says Dr. Zeitzer. He adds doctors nationally are concerned by the drop in emergency room visits, especially due to heart attacks and strokes. “Clearly people are sitting at home with symptoms, which can create worse outcomes.”
“Medicine has changed – we have had our 9-1-1, or our 9/11 moment,” he says. He noted that after 9/11 air travel returned, but now “you never get on a plane without being screened.” Similarly, he says, “After COVID, going to a doctor’s office will be very different. You’ll probably see people wearing masks in medical facilities.”
He noted, however, that telehealth can be complicated. "Operating across state lines" requires a license in both states and complying with regulations in both states.
Interviews with five doctors in our community demonstrate they agree telehealth is here to stay.
“The new face of American health care will necessarily include telemedicine as part of the delivery model,” says Dr. Ellen Singer, who has been active in several of NW Permanente virtual care programs including a new e-visit tool developed last year. In-person care will also change: “I have already purchased a bluetooth-enabled ‘hands free by me’ stethoscope to examine patients who are behind a glass door or who are at least 6 feet away.”
Following are insights and experiences in this new reality from those local doctors.
Zoom+Care: Medical director of acute care services
Member of Neveh Shalom and Kesser Israel

Dr. Zeitzer helped Zoom+Care launch its emergency medicine clinics called SuperClinics, which provide care for serious but non-life-threatening issues. Last year he took the lead on the clinics Chat Care, Zoom’s “defining virtual service.”
Because of the coronavirus, we accelerated video care, too; we got it running in Seattle and Portland over the past couple weeks.
Chat Care is a powerful resource to examine rashes or moles with high-definition images, to refill prescriptions and to assess other conditions. Video visits can be done for orthopedic, pediatric, primary care, urgent care and other specialty needs. 
Often patients still need an in-person visit, but we can take care of probably more than half of those things we normally see patients for at Zoom+Care. People appreciate the ability to stay away from medical facilities.
A lot of facilities are doing virtual care. I encourage people to reach out.
If you are instructed to go to a clinic, you can still be very safe: make sure you are wearing a mask and don’t bring a bunch of people with you to the facility.

NW Permanente, PC, Interstate Medical Offices: Director of graduate and undergraduate medical education
Member Congregation Neveh Shalom and MJCC

 Dr. Singer developed the NW Permanente COVID-19 Homefront program (see photo).  Callers connect with patients, review how they are feeling and coping, teach them about easy ways to assess their breathing, collect information on risks/stresses and provide coping strategies for the next few days. 
My medical group pivoted to full virtual care on 3/16/2020. At that time, it was clear that there was imminent risk to patients and to our care teams. We were very concerned about preserving available PPE for our hospital and ER teams and for high-risk clinical situations.
Phone and video visits are really great for discussing options and alternatives with patients. These visits work well for discussing blood pressure and statin medications, treatment of osteoporosis and assessing risk for fracture, management of depression and mood disorders, and initial evaluation of gastrointestinal concerns. 
My mother lives at Rose Schnitzer Manor, and she has used a video visit (with my help) to address a new skin concern and to discuss her goals of care related to her heart disease. Taking her to a medical visit requires about 3 hours of my day for a 1-hour appointment. So it is great to use an i-Pad in her apartment and talk to her doctor by video or phone rather than driving her to and from a medical office!

Providence Medical Group
Specializing in family medicine; semi-retired; currently part of Providence Virtual COVID Response Team
Rose Schnitzer Manor volunteer

I work at this time as part of the Providence Virtual COVID Response Team,, communicating with patients by phone or online (Zoom), performing COVID-related triage. That is I obtain a history from the caller/patient and then direct them to the most appropriate resource or course of action – isolate at home for the less sick or at risk, or to drive-through testing, tent evaluation or emergency room. I then enter the appropriate action into the computer.
This system was devised by the Providence Administration. 
Telemedicine (as I prefer to call it) absolutely protects both patients and medical providers (like me) by limiting need to be seen in person. The advice I am giving is limited in scope but very helpful in preventing unnecessary in-person visits. 
Regarding telemedicine post pandemic: Telemedicine does offer the possibility of working from home, and I feel very sure that, regardless of what may happen with COVID19, telemedicine is here to stay. 
As we have seen recently, medicine continues to change dramatically, and this crisis has greatly accelerated that process. Exchange of medical information now happens on an accelerated time frame. Medicine has become all about this information management. Telemedicine is a part of that transformation. 
The old world is not coming back.  
Because of this, I am a strong supporter of a single-payer, health-care system with unified information gathering.

Pediatric Associates of the Northwest
Member of Congregation Beth Israel

Telehealth is an alternative to in-person visits (for many conditions), providing the care they need and reducing the exposure to others that could be ill.  
We have been offering telehealth visits for the last couple of years, but few families were familiar with it and it was not highly utilized. Now that people have used the technology, they will continue to find it more convenient and will utilize it more often.
Telehealth has been ideal for behavioral problems. We are able to observe children in their more natural habitat and see them at their most comfortable. Most parents’ concerns are able to be addressed on a video visit, but once in a while we still need to have the patient come in to the office after the virtual visit (to look in the ears, check for strep, etc.).
Regarding telemedicine post pandemic: It is more convenient to open an app than it is to drive to the doctor’s office. Not everything can be resolved that way, but if it can, why not? 
We need to use this as a learning opportunity to bring care to people where they are at instead of the old-fashioned model of expecting everyone to come to us. I hope we can build on the telehealth experience and do more with technology in the months and years to come.  

Naturopath in private practice
General medicine, special focus in menopause and fertility
Member Congregation Kesser Israel; attends Ahavath Achim, Chabad and Beit Yosef

We have switched our practice to telehealth to comply with the social distancing guidelines outlined by Governor Brown. We are clear with patients that for things that require a physical exam, this approach is not appropriate, and we are postponing these types of non-urgent exams. Most of my practice is chronic health issues, mental health and hormonal complaints, so thankfully we are able to glean a lot of information from imaging, lab tests and the patient interview. 
I honestly did not do much of it (telehealth pre-pandemic), because in some ways it is a compromise. There is no way to completely replace an in-person physical exam. 
One of the major issues we are dealing with right now is anxiety; this is followed closely by depression and insomnia. I am also doing great addressing digestive issues, menopausal complaints, fatigue and many other common complaints.
Regarding telemedicine post pandemic: I think it is high time we started making medicine more accessible. There are many places that struggle to have good health care in this country. I have had patients drive to see me from the coast, southern Oregon, California and other rural parts of Oregon just because they could not get the care they wanted where they live. 
This could be a great tool to increase the state of health care in this country. I do think we should be careful to see patients in person one to three times a year or demand that they have a PCP (primary care physician) for a yearly physical.


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