Investigating virtual modalities
Some policymakers worried that inappropriate use of virtual care was leading to an increase in ED use. “Findings of this study refute this hypothesis,” the authors write. Increases in ED use seemed to coincide with decreases in COVID-19 cases, not with increases in virtual primary care visits.
Furthermore, at the population level, patients who were cared for by physicians who provided a high percentage of virtual care did not have a higher rate of ED visits, compared with those cared for by physicians who provided the lowest levels of virtual care.
During the pandemic, the switch to virtual care worked well for some of Dr. Kiran’s patients. It was more convenient, because they didn’t have to take time off work, travel to and from the clinic, find and pay for parking, or wait in the clinic before the appointment, she said.
But for others, “virtual care really didn’t work well,” she said. “This was particularly true for people who didn’t have a regular working phone, who didn’t have a private space to take calls, who weren’t fluent in English, and who were hard of hearing or had severe mental illness that resulted in paranoid thoughts.”
Clinicians also may have had different comfort levels and preferences regarding virtual visits, Dr. Kiran hypothesized. Some found it convenient and efficient, whereas others may have found it cumbersome and inefficient. “I personally find it harder to build relationships with patients when I use virtual care,” she said. “I experience more joy in work with in-person visits, but other clinicians may feel differently.”
Dr. Kiran and her colleagues are conducting a public engagement initiative called OurCare to understand public perspectives on the future of primary care. “As part of that work, we want to understand what virtual modalities are most important to the public and how the public thinks these should be integrated into primary care.”
Virtual care can support access, patient-centered care, and equity in primary care, Dr. Kiran added. “Ideally, it should be integrated into an existing relationship with a family physician and be a complement to in-person visits.”
The right dose?
In an accompanying editorial, Jesse M. Pines, MD, chief of clinical innovation at U.S. Acute Care Solutions, Canton, Ohio, writes, “There is no convincing mechanism consistent with the data for the observed outcome of lower ED use at higher telehealth use.”
Additional research is needed, he notes, to answer the “Goldilocks question” – that is, what amount of telehealth optimizes its benefits while minimizing potential problems?
“The right dose of telehealth needs to balance (1) concerns by payers and policymakers that it will increase cost and cause unintended consequences (for example, misdiagnosis or duplicative care) and (2) the desire of its proponents who want to allow clinicians to use it as they see fit, with few restrictions,” writes Dr. Pines.
“Future research would ideally use more robust research design,” he suggested. “For example, randomized trials could test different doses of telehealth, or mixed-methods studies could help elucidate how telehealth may be changing clinical management or care-seeking behavior.”