Ryoko Hamaguchi1, Kristen Bormann2, Simon G. Talbot2, and Dennis P. Orgill2
1Harvard Medical School, Boston, MA
2Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA
Telemedicine in the time of COVID-19
The global COVID-19 pandemic has evolved into a natural experiment putting telemedicine to the test on an unprecedented scale, sparking conversations about the implications of tele-health across diverse specialties and international boundaries [1,2]. Taking our institution as an example, our plastic and reconstructive surgery team—previously with little to no telemedicine component across our practice—made a rapid transition to conducting most of our patient encounters virtually, exceeding 70% of all clinic appointments at our peak. As our surgeons traded in the scalpel for virtual pre-operative counseling and post-operative check-ups, we created a practice of consolidating our growing pains through weekly surveys that asked the simple questions: “What are you learning? What is working? What is not?” This exchange of wisdom quickly evolved into a collaborative practice and candid lens into the day-to-day pitfalls and triumphs of virtual medicine, which have been under-discussed in the daily COVID-19 media coverage yet are critically important as we envision a niche for telehealth in a post-COVID-19 “new normal.” At least six key lessons have emerged to the surface through this exercise.
Implementing telemedicine: six lessons learned
Telemedicine boosts access to care… but risks leaving the vulnerable behind
While telemedicine can be a lifeline for elderly patients with limited mobility and rural communities where in-person visits can be cost prohibitive or logistically difficult, these patients are simultaneously threatened by the new virtual connectedness afforded by modern technology. Our elderly patients – some still with flip-phones – struggle to navigate unfamiliar video conferencing platforms, and for those in rural areas, we found that their tenuous satellite internet connection quickly falls prey to rain and wind. The homeless community, whose chronic barriers to care access have only been exacerbated amidst the COVID-19 crisis, also present a vulnerable population at risk of falling through the cracks of this new digital connectedness. While video-based appointments may benefit homeless individuals equipped with smartphones but lacking the means for reliable transportation, the rapid shift to telemedicine threatens to further deepen rifts in care for those without reliable phone or Internet access. Future expansion of telemedicine practices demands mindful and specific discussions of how to best support high-risk populations that simultaneously are threatened by remote care but stand to gain the most from its convenience factor.
Information infrastructure is the foundation
It took a global pandemic to reveal that our hospital’s built-in proprietary telemedicine platform – which had largely been collecting dust until the outbreak – was highly difficult to access by providers from their home computers. Few hospital computers had webcams, frustrating providers as they tried to squeeze in virtual visits between operations. When we abandoned our home-grown virtual visit technology for a commercially available counterpart, this came at the cost of the valuable integration with the patients’ electronic medical record (EMR) – hampering the efficiency of our workflow and underscoring the value of sound hospital information technology (IT) design in large-scale telemedicine transitions. In the span of weeks, however, our IT team was able to rapidly re-integrate the EMR into our new platforms – demonstrating the speed of progress that is possible when fueled by necessity and when pain points are exposed.
Simple tools for simple problems
Our shared experiences also elucidated simple frustrations ripe for simple interventions. We quickly realized that an unacceptable proportion of each visit was lost in coaching patients – many of them less familiar with digital technology – on the most basic steps of logging onto the visit or connecting their audio. To fill this gap, we designed simple, single-page visual guides that could be easily pulled up on a screen or seamlessly shared with a struggling patient. These visual guides noticeably increased patients’ comfort levels with navigating their visit, highlighting the value of a minor fix in making the machine run more smoothly.
Consider clinical fit
Some aspects of our field – and likely many others – are simply not conducive to video-conferencing. For many patients, difficult-to-manage chronic wounds are located where bringing them onto the screen requires an act of contortionism. Grainy video quality makes it difficult to safely discern whether a new wound is something that can be treated at home or calls for urgent surgical attention. In this COVID-19 crisis, where no specialty has the luxury of “opting out” of virtual medicine, lies a rare collective opportunity for each medical specialty to thoughtfully identify the clinical problems where telemedicine has the most positive impact – building the blueprint for intelligently incorporating telehealth into our profession as it emerges from this outbreak.
Physician wellbeing as a tradeoff?
In a modern medical ecosystem where administrative burdens contribute greatly to provider distress, the rapid iterations of new telehealth configurations and concomitant pressure to coach patients through these imperfect technologies will inevitably add to this load . When providers disclosed their email addresses, they struggled to keep up with midnight patient emails that flooded their inboxes, blurring boundaries between personal and work lives. Expanded use of telemedicine calls for enhanced physician support and institutional guidance on how to construct boundaries, manage patient expectations, and prevent telemedicine from devolving into an unhealthy 24-hour on-call obligation.
Shared spaces for innovation
These pearls of telemedicine implementation arose from the simple act of asking our team members each week: “How are you doing? What are you learning?” – and in sharing our collective wisdom with the team, we carved out a collaborative space that facilitated the exchange of ideas among providers and their administrative staff. In any act of health care innovation, such spaces empower us to identify pervasive issues in underlying health systems and targetable pain points for creative solutions.
A new normal: where do we go from here?
In our swift exodus out of the operating rooms and into our virtual clinics, our day-to-day frustrations have shed light on the broader system-wide pitfalls that have long preceded COVID-19 – disparities in healthcare access, gaps in health and technology literacy, pervasive cracks in hospital information infrastructure, and a poor understanding of how to manage physician wellbeing while concurrently providing optimal care. However, when executed with deep appreciation of these pre-existing faults, telemedicine can be harnessed to close these very gaps in a way that improves the quality and efficiency of patient care delivery in the post-COVID-19 era. Active efforts to adapt our hospital IT infrastructures to accommodate telehealth will serve as an unprecedented opportunity to not only expose and eradicate pre-existing inefficiencies but also re-engage providers in critical questions about work-life balance and physician-patient relationships in the context of an increasingly digital health ecosystem. In rethinking hospital architecture and design, in-clinic telemedicine booths could facilitate multi-provider care coordination meetings and enable elderly or complex care patients to combine one face-to-face appointment with multiple virtual visits across specialties – thus mitigating some of the logistical hurdles to care while offering telehealth in a technologically supported environment. Active partnerships with local municipal governments may enable investment in Internet-equipped spaces, tablets and other tools within local homeless shelters, providing access to telemedicine for homeless patients at highest risk of slipping through the cracks of preventative and chronic disease care.
COVID-19 has forced our profession, among so many others, to adopt citizenship in an uncharted world of virtual connectedness. As the country reopens amidst possibilities of subsequent waves of the virus, the American Medical Association recommends that patient encounters that are able to be conducted remotely should be done so . Previously a tool with variable utilization within certain fields, telemedicine will inevitably occupy a new space within our new collective repertoire of care, whether it be for safely screening and triaging patients for in-person appointments to navigating pre- and post-operative counseling in surgical subspecialties such as our own. As we work to forge new ecosystems of care, we must continually engage with the above six learning points and commit to the exchange of experiential wisdom both within and between specialties, shaping telehealth into a tailored tool for safe, efficient and equitable care for all patient populations. Our day-to-day observations and challenges – bolstered by a space to share and reflect on these insights – empower us to improve telemedicine today, inform strategies for healthcare innovation broadly, and craft impactful roles for telemedicine in the “new normal” of tomorrow’s healthcare.
 Hakim AA, Kellish AS, Atabek U, Spitz FR, Hong YK. Implications for the use of telehealth in surgical patients during the COVID-19 pandemic. Am J Surg. Published online April 21, 2020. doi:10.1016/j.amjsurg.2020.04.026
 Ohannessian R, Duong TA, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill. 2020;6(2):e18810. doi:10.2196/18810
 Rao SK, Kimball AB, Lehrhoff SR, et al. The Impact of Administrative Burden on Academic Physicians: Results of a Hospital-Wide Physician Survey. Academic Medicine. 2017;92(2):237–243. doi:10.1097/ACM.0000000000001461
 COVID-19: A physician practice guide to reopening. American Medical Association. Accessed June 24, 2020. https://www.ama-assn.org/delivering-care/public-health/covid-19-physician-practice-guide-reopening