Electronic Health Reporter

By Vikram Savkar, vice president and general manager of the medical segment at Wolters Kluwer’s Health Learning, Research and Practice business

During the pandemic, nearly every healthcare provider in the country had to execute a rapid, unplanned switch to telemedicine for the majority of their consults and activities. According to one study from the RAND Corporation, there was a 20-fold increase in the rate of telemedicine utilization after March 2020. For the most part, this transition was executed well and successfully, but only due to heroic levels of creativity and dedication by clinicians in every field.

With few established practices to rely on, it fell to each hospital, each department, each clinician to more or less invent ways to conduct virtual consultations in dermatology, cardiology, oncology, and more. There was much trial and error, but a commitment to rapid learning meant that the community as a whole was able to achieve a reasonable level of healthcare delivery quality to patients via the web.

Now, however, it is clear that telemedicine will be a permanent and sizeable segment of healthcare delivery; some estimate that more than 20% of healthcare from 2021 onward will be virtual. As a result, every aspect of the healthcare ecosystem must move out of an “emergency” mindset when it comes to telehealth and focus on establishing scalable, sustainable processes that ensure that a steady shift to telehealth drives equity, access, and quality. Healthcare providers themselves are actively engaged in this effort, and medical schools also now need to evolve to reflect this new normal.

Medical schools have incorporated some telehealth training into their programs in recent years, but it has tended to be ancillary. Now, it will be critical for telemedicine training to be incorporated more structurally into core curricula. What is being called “webside manner,” for instance, is significantly different to “bedside manner” and needs to be taught explicitly ?— in both a classroom setting and during clerkship rotations, as well as residencies.

Clinicians need to be taught how to establish rapport with patients whom they don’t see face to face, how to assess possible domestic abuse threats when the patient may not be able to speak freely, and how to gather emergency contact information in case there is a critical event during the consult for which the clinician needs to call emergency services. They also must learn how to take advantage of the unique opportunity that telehealth presents to closely observe and document social determinants of health by, for instance, asking patients to show the contents of their refrigerator. And they must be taught how to navigate the “digital divide” and ensure that patients without access to broadband or smartphones aren’t consigned to a lower quality of telehealth care.

Beyond this, a greater challenge will come from developing techniques for diagnosis and treatment in specific disease areas, such as dermatology or cardiology. How should a clinician assess a rash to determine appropriate treatment when the patient is connecting via a low-bandwidth network on a small phone? How should the clinician assess eye movement as part of a neurological exam? There is no obvious and natural way to adapt traditional assessment approaches for these kinds of activities to a virtual setting. The medical community must learn from trial and error as well as research, publish findings in peer reviewed journals, settle on community-wide best practices, and then teach these best practices as a core part of the curriculum in medical school.

Embracing Digital Health Tools

The greatest challenge may lie in the area of what some call “digital therapeutics.” These are the proliferating set of digital tools on the market intended to help healthcare providers track and respond to patient conditions automatically. Great strides have been made in diabetes care, for instance, with a number of successful automated monitors now regularly used by insurers, providers, and individual clinicians to help patients manage their glucose levels more consistently and precisely. There have been similar success stories in areas as wide-ranging as cardiology and neurology. Collectively, these digital tools have the potential to deepen patient-centered care.

But the sheer volume and novelty of these digital health technologies poses a challenge. Which are credible? Which are based on repeatable research and evidence? Which adequately address cybersecurity and privacy issues?

Already we see some wariness in the market as a result, with some of the larger insurers as well as corporations – who had been early adopters of tools that they believe can help minimize chronic illnesses in their staff, and therefore their insurance costs – increasingly becoming hesitant to adopt new tools. Many such early adopters are now pushing for the market to consolidate into a smaller set of more comprehensive and fully vetted technologies.

Clinicians as individuals will find it even more challenging to sift through the range of digital therapeutics now available. Medical schools must increasingly develop courses to help students develop an understanding of how to make appropriate and cautious use of digital tools in their healthcare strategies. This does not mean that clinicians must become technology experts; but they must understand the risks and know whom to turn to, or which resources to consult, to make informed decisions about risks and rewards.

Sizing the Future of Telehealth

Whether these new approaches to telemedicine training will be a meaningful but small part of medical training moving forward or will become foundational to educating future clinicians remains to be seen, and will depend in large part on how much of healthcare delivery itself moves to a virtual mode.

If telehealth expands to eventually represent 40% or 50% of healthcare delivery, for instance, I would expect there will be specific rotations and even perhaps residencies in telemedicine, or that healthcare providers themselves will build training departments to research and promote telehealth best practices to their clinicians.

Cost is likely to remain the core conversation in the broader healthcare ecosystem. But it seems likely that the rise of telehealth will elevate the dialogue around modes of access to a very prominent level in the years to come. This will in turn drive a significant shift in the future shape of medical education and training.