Recognizing that patients prioritize convenient and inexpensive care, Duffy and Lee recently asked whether in-person visits should become the second, third, or even last option for meeting patient needs. Previous work has specifically described the potential for using telemedicine in disasters and public health emergencies. No telemedicine program can be created overnight, but U.S. health systems that have already implemented telemedical innovations can leverage them for the response to Covid-19.
A central strategy for health care surge control is “forward triage” — the sorting of patients before they arrive in the emergency department (ED). Direct-to-consumer (or on-demand) telemedicine, a 21st-century approach to forward triage that allows patients to be efficiently screened, is both patient-centered and conducive to self-quarantine, and it protects patients, clinicians, and the community from exposure. It can allow physicians and patients to communicate 24/7, using smartphones or webcam-enabled computers. Respiratory symptoms — which may be early signs of Covid-19 — are among the conditions most commonly evaluated with this approach. Health care providers can easily obtain detailed travel and exposure histories. Automated screening algorithms can be built into the intake process, and local epidemiologic information can be used to standardize screening and practice patterns across providers.
More than 50 U.S. health systems already have such programs. Jefferson Health, Mount Sinai, Kaiser Permanente, Cleveland Clinic, and Providence, for example, all leverage telehealth technology to allow clinicians to see patients who are at home. Systems lacking such programs can outsource similar services to physicians and support staff provided by Teladoc Health or American Well. At present, the major barrier to large-scale telemedical screening for SARS-CoV-2, the novel coronavirus causing Covid-19, is coordination of testing. As the availability of testing sites expands, local systems that can test appropriate patients while minimizing exposure — using dedicated office space, tents, or in-car testing — will need to be developed and integrated into telemedicine workflows.
Rather than expect all outpatient practices to keep up with rapidly evolving recommendations regarding Covid-19, health systems have developed automated logic flows (bots) that refer moderate-to-high-risk patients to nurse triage lines but are also permitting patients to schedule video visits with established or on-demand providers, to avoid travel to in-person care sites. Jefferson Health’s telemedical systems have been successfully deployed to evaluate and treat patients without referring them to in-person care. When testing is needed, this approach requires centralized coordination with practice personnel as well as federal and local testing agencies. It is critical that practices not routinely refer patients to EDs, urgent care centers, or offices, which risks exposure of other patients and health care providers.
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