Implications for Public Health
The success of MU Health Care’s rapid adjustment and response to the COVID-19 pandemic lies in its dedicated workforce, strong collaborative learning network, expertise in rural health, and robust telehealth infrastructure. One comment made by leadership on the COVID-19 response team was the unwavering willingness of nurses and other health care workers to go where they were needed. This especially epitomized the dedication and professionalism of nurses and health care professionals. Innumerable stories in the media abound of nurses filling in gaps created by new policies, such as restriction on visitors to hospitalized patients and being that hospitalized patient’s touchstone. As the COVID-19 first wave passes, the health care workforce, including nurses, can continue using telehealth successfully, and its use has been extended to departments and specialties that had never implemented telehealth before the pandemic. One of our gynecologic oncologists began using telemedicine after COVID-19 policies were enacted. He remarked that he plans on continuing telemedicine encounters for enhanced patient-centered care and that telemedicine provided more comprehensive family engagement. All family members participated in a telemedicine visit, asked questions, heard his responses, and understood the treatment plan and prognosis. Our oncologist felt the telemedicine encounter allowed the extended family to actively participate in the patient’s cancer journey. Without COVID-19’s disruption of the status quo of health care, it is unlikely that this example of re-envisioning the practice of health care would have occurred.
The pattern of delivering health care continues to adapt to medical, economic, and cultural changes. Before the middle of the twentieth century, few hospitals existed, and the health system enterprise, including health insurance, was nonexistent.[22] Doctors traveled to their sick patients’ homes, provided limited treatment options, and were paid a modest out-of-pocket fee. Pivotal advances in scientific medical knowledge dramatically changed the landscape of medicine. The evolution from health care providers as generalists who provided all care for their patients to health care providers who refer their patients to specialists is complicated, but most consider that the tipping point in this change began in the post-World War II era.[23] Currently, approximately 30% of younger patients (≤64 y) are referred to specialty care, and among older patients (≥65 y), referral to specialists average 2 per person per year.[24] In the initial response to the COVID-19 pandemic, limited referrals for specialty care as well as appointment cancellations by health care providers for established patients and patients opting to not seek routine care were the norm, leaving a group of patients temporarily adrift (Figure). Similarly, just as technology, such as the invention of the telephone and automobiles, shaped health care by reversing the traveler — the patient coming to see the physician rather than physician going to the patient — disruptive technology in the COVID-19 era with focused attention to addressing disparities faced by some can reshape health care, especially for rural patients and patients with multiple comorbidities.
The Institute for Healthcare Improvement’s new quadruple aim to optimize health system performance includes improving population health, lowering costs, and improving patient experience.[25] The fourth aim is often cited as finding joy in work or elevating health equity.[25] These aims may be achieved through a more robust inclusion of telehealth. However, a critical factor for success requires thoughtful supportive interventions to ameliorate reported disparities in telehealth adoption. In the COVID-19 era, informal conversations with health care providers about telemedicine, from primary care to oncology to endocrinology, suggest mixed reactions to virtual visits through telemedicine. Some providers have reverted back to the old ways whereas others have embraced this change.
Further exploration could identify factors, including barriers, associated with use of telehealth from both the health care provider’s and the patient’s perspective. As long as the CMS policy change for reimbursement remains, a telemedicine visit can be an option between patient and health care provider, and therefore by default create an environment of patient-centered care.
The pandemic crisis has tapped into America’s strengths — our ability to summon unity and collective confidence when facing a nationwide challenge. For telehealth, many of the restrictions have been lifted, namely HIPAA compliance, licensing restrictions, and reimbursement differences by type of visit, with the hope that these will be permanently lifted. Although telemedicine has been integrated into daily clinical practice in responding to the public health emergency, barriers to telemedicine and issues surrounding associated health disparities should not be neglected. Telehealth alone is not a panacea for better health care, and it behooves researchers, providers, and educators to explore creative solutions for optimal health care for all, particularly among vulnerable populations. Undoubtedly, a concerted effort by government agencies, organizations, and community volunteers will be needed to ensure effective access to improved health care, both for high-technology and low-technology solutions.