Telehealth: It’s About Appropriate Use, Not Technology

I’ve been critical of services that are providing largely episodic primary care via telehealth, Telus Health being the most prominent example.

That’s easily construed — particularly in a brief comment on social media — as being critical of providing healthcare via communications technology. I’m writing this to make it clear that the use of technology is about the last thing I’d object to.

It’s about episodic care: when it’s appropriate and when it’s not. Whether that’s delivered in person or using technology as an intermediary.

When it comes to these services, the question is not about technology but appropriate use of technology.

This is the Future. Leave the Technophobes Behind!

The healthcare field has its share of Luddites afraid of new technologies or clinging desperately to the past. I’m not one of them.

I’m a computer scientist by training. My graduate work, subsequent research, and professional career focused on using technology to facilitate communications and remote collaboration. I published probably 15-20 papers in this field. I’ve started companies that created software solving the same problems that people use tools like Zoom for today.

I’m about the last person to say, “oh please, the ’70s were so great, let’s keep fax machines.” Hell, one of my early jobs was as lead developer of some advanced email software.

Here’s the thing. Supporting people to collaborate through technology is tricky. The success (or, more often, the failure) of these systems has far more to do with the context in which they’re used than the technology itself. You need to understand all the subtle details and nuances underlying the social dynamics of how shared work actually happens. Adding technology into the mix is likely to interfere with effective communication, not make it better.

It’s a highly multidisciplinary field. It includes not only technologists but psychologists of many types, sociologists, anthropologists, management and communications experts (and at times even diverged into more obscure areas like existential philosophy). Definitely made the conferences fun.

Video Calls Are Mature, Well-Understood Technology

Technology to do video calls has been around since the 1960s. It’s not new, though the widespread adoption is. Its strengths and limitations have been well studied. We know that video calls are closer to telephone calls than face-to-face interactions in many measures of communication effectiveness. We know they’re better used to maintain existing relationships than to develop new ones, better for some tasks than others. We know the effects that quality parameters like latency have on communication.

I help with my wife’s psychiatry practice (including on the technology front). She
uses tools like Zoom extensively. But she uses them, appreciating the benefits and limitations, in the context of longitudinal, not episodic, healthcare. In other words, appropriately.

The widespread adoption of these technologies is one of the few small benefits of the pandemic. There offer considerable benefits in reducing (some) barriers, travel, environmental impact, and more. They often save time and make (some) things more efficient or even possible in the first place.

I’m hardly suggesting we stop using telehealth or other technologies. But I am urging that we use them in ways that enhance the quality of healthcare, not detract from it.

History of Information Technology in Healthcare

Other than things like diagnostic imaging and medical devices, technology use in healthcare doesn’t have a great track record.

The prototypical example is point-of-care electronic medical records. They’ve turned physicians into data-entry clerks focused too long on their screens rather than the person in the room with them.

They’re big, complex, awkward to use, and disrupt the flow of clinical care. They still create massive problems when they’re implemented. They require massive volumes of information, much of it not needed for clinical purposes. Instead, it allows hospital administrators can generate all kinds of financial and operational statistics that ultimately don’t provide any value for patients or clinicians.

Why? Because the people who source these systems and get the benefits from them (managers, administrators, IT) are not the ones who actually have to use them. The people who use them have to jump through all kinds of hoops, making their work harder and take longer, but they don’t get the benefit.

This mismatch between who does the work and who gets the benefit comes up all the time. It’s not new, and not only in healthcare. One of the classic examples was meeting scheduling systems. Before everyone had a supercomputer in their pocket, and secretaries and typewriters were still a thing, the poster child for “office automation” was shared calendars to arrange meetings. They flopped because the people who got the benefits (managers, who had many meetings) weren’t the ones who had to do the work (the peons who had to keep all their availability up-to-date in their calendar, even if they themselves had very few meetings).

Telehealth Use and Misuse in Longitudinal Care

Let’s focus back on telehealth and its appropriate use. It’s important to separate the medium (audio/video or face-to-face) from the type of care (longitudinal or episodic). They’re two separate things. Your long-term family doctor can provide longitudinal care both face-to-face or via telehealth. You can also receive episodic care face-to-face or via telehealth.

Let’s say you have concerns about abdominal pain, and nobody examines you but just tries to refer you off to a specialist or says, “it’s probably…”. You’re getting lower-quality care than if someone can actually palpate your abdomen. Most of the time, things may work out okay for you, but it’s wasting system resources and has led to situations where serious cancers, etc., have been missed.

The high volume of telephone-only health appointments (more common in independent family practices than the large telehealth platforms) has also raised alarm bells. It’s easy to miss all kinds of things that would be obvious if you saw the person. Even with video calls, it’s not the same. Full embodiment is missing, making it easier to miss or deemphasize some things. It can take more time to get the same quality of info.

If the only option available for healthcare is telehealth, that also presents challenges to access for some people, many already at a disadvantage due to poverty, education, etc. It can worsen inequality.

Telehealth can also have unique advantages over face-to-face. For someone who is physically disabled, telehealth can reduce inequality vs. traveling to appointments or lining up for hours at a walk-in clinic. And I’m sure many doctors have gained new insights into their patients by observing them in their homes or other more naturalistic settings. They can better appreciate their social determinants of health. This information is infinitely more valuable in the context of a long-term relationship between a patient and physician.

Walk-In Clinics, Virtual or Otherwise

The massive corporate telehealth platforms are not replacing full-service family practices offering primarily longitudinal care but bricks-and-mortar walk-in clinics offering primarily episodic care.

I don’t want to dwell on this. The tradeoffs between longitudinal care and episodic care are pretty well understood by now. I just want to emphasize two distinct advantages of longitudinal family practice that can result in improved care.

The first is the value of patient history, implicit (getting to know patients) and explicit (medical records), built up over time. I’m not a doctor, but I’d guess that patient history is easily the most valuable tool they have in many situations.

The second is the incentive doctors have to clean up their own mess. In other words, they’re going to see these patients again, have to deal with them, and deal with the aftermath of the care they provide. That’s a pretty good motivator. Contrast that with a provider who will meet a patient once and never have to see them again. They may provide just as good care, but the motivation to do so is much less. It’s easier to buff and turf them: give them a pill, send them for tests, refer them. Let it be someone else’s problem. They’ll likely not have to see the patient again.

Downsides of Virtual Walk-In Clinics

So, what happens when episodic care is combined with telehealth on a large scale?

On the plus side, it can increase access for some. It can bring down some wait times (one queue to access a larger pool of resources is faster overall than a very large number of queues each accessing a very small pool of resources). Plus, there’s the same advantages around travel, environmental impact, etc. mentioned before.

But there’s a down side. It damages some of the key pillars that delivering good care requires: motivation and incentives, relationships, and sustainability.

The motivation for doctors to clean up their own mess is even lower. In a bricks-and-mortar walk-in clinic, you may have a rotation of 10 doctors servicing the clinic. There’s a reasonably good chance you’ll see that same patient again. And there’s an excellent chance that one of those other 10 doctors will be the one who has to clean up any mess. And that same group of doctors is picking up your mess for all your patients. And you’re picking up their messes. These are doctors who effectively share many patients, communicate with each other, and work together frequently. If it’s not professional pride, the peer pressure to pull your own weight and do a good job is significant.

In the telehealth platform situation, you’ve gone from a small group of doctors you regularly intersect with to several hundred spread out across the province or country. The odds of having to deal with any one of them closely or regularly drop exponentially. So does the peer pressure to do a good job.

In medicine, geography still matters. A family doctor working in a particular area gets to know the resources that are available for their patients. They know who the specialists are and who is best for what types of problems. They see the wait times, the alternative resources and options. They develop relationships with other physicians and organizations that come from sharing several patients over time. Ask any specialist physician, and they’ll be quick to tell you about the family doctors they most (and least) enjoy working with.

In the telehealth platform situation, you have family doctors from one part of the country who are completely unfamiliar with specialists, resources, constraints, and procedures in another location. That’s what leads to all the bad referrals specialists receive from telehealth platforms. You’ve got a doctor in Vancouver referring a patient for care in Victoria with limited knowledge of what’s available. And because they’re not referring to the same set of specialists all the time, there’s less of a relationship and less peer pressure to do a good job with the referral and follow-up care.

Medical care is built on relationships and tacit knowledge, most of which is local. It doesn’t scale. There are ways we could improve this somewhat, which I’ll talk about another time.

Skimming. The people most likely to use telehealth platforms are young, middle-class, and overall healthy, who need help with simple problems. This takes less time and effort than dealing with more complex problems. If they’re paid about the same, whether it’s a simple or complex problem — which is the case now — it’s easier and more profitable.

Full-service family practice is less attractive, which drives more doctors to telehealth platforms, further hollowing out the availability of high-value care. It’s even worse if the telehealth platforms can make things more attractive: less overhead, compensation for no-shows, etc. Again, I’ll have much more to say about this another day.

It’s the Incentives, Stupid

There’s a common theme running through this entire piece. When you have the right incentives in place, quality care follows. When the incentives are wrong, it damages the system and favours bad actors.

Some of this is financial — not just “more money” but more equitable compensation based on the value of care and effort required to provide it (a spin on “equal pay for equal work”). There’s no simple answer like “replace fee for service” that will magically solve these problems, but there are solutions.

But it’s not all financial. Other incentives like fostering relationships, peer pressure, job satisfaction, and ensuring that those who do the work get the benefits.

We can fix these things. Not just by throwing money at it. And there is a critical role for government. Not in trying to compete with current providers. But by working to rebalance the incentives. And where incentives won’t work, supporting all practitioners by providing infrastructure that makes important but difficult jobs easier.

Next time, I’ll talk about strategies to solve these problems.

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