Telehealth might be best as a supplement to office visits, not a replacement
With the pandemic, there has been a rise in the use of virtual appointments for patients seeking health care. A new study by Tufts Univeresity researchers, however, suggests that for many older and chronically ill patients, telehealth appointments may be most effective when they augment in-person health-care visits rather than fully replace them.
The findings suggest that while patients 70 and older may well be capable of navigating the technical aspects of virtual doctor visits and are interested in communicating online with health-care professionals, their opinions on the effectiveness of the care they receive varied widely.
The study, which focused on older patients with serious and chronic kidney disease, found that not all patients were satisfied with telehealth. People of color, including patients who identified as Black, Native American, or Hispanic, or required additional accessibility features such as interpreters, were largely dissatisfied with telehealth.
Patients of color disproportionately suffer from chronic kidney disease and may more often contend with challenges associated with at-home care, such as inadequate space for home-dialysis and limited broadband access to support video-telehealth visits, said Keren Ladin, associate professor of occupational therapy and community health, who led the study.
Owing to historical and experienced discrimination, "we found that patients of color were less comfortable with telehealth and had more concerns about the quality of the care and being deprived of care in a telehealth setting than white patients did," said Ladin.
"I wish I could say we are doing it perfectly in person, and that telehealth is the only challenge we're facing," said Keren Ladin. "We're not. We need to work on this both in person and for telehealth." Ladin said she was surprised by these findings, given that the study, which was recently published in JAMA Network Open, was conducted during the height of the COVID-19 pandemic.
"I thought people of color who were at higher risk would prefer to stay out of the health system for longer, but that was not what we found," she said. Black patients also reported that telehealth appointments prevented them from connecting meaningfully with their doctors, contributing to feelings of mistrust.
"It was really striking," said Ladin. "One woman told us, "I need to see the physician's eyes to know that they were understanding me," underscoring that the persistent impacts of structural racism on health-care experiences of patients of color."
The patients did appreciate that telehealth facilitated the ability of care partners such as family members to join them for appointments, something that has been limited during the pandemic. Beyond the comfort of accompanying patients, care partner participation can help improve treatment and adherence and patient education for older patients managing complex, chronic illnesses such as kidney disease, Ladin said.
Concerns from the clinical perspective
For clinicians, the low regard for telehealth appointments was more pronounced. A majority of the physicians interviewed remotely from Boston, Chicago, Portland (Maine), and San Diego equated telehealth with lower-quality care.
They could not, for example, conduct physical examinations and lab tests virtually, nor could they naturally build and maintain a personal rapport with chronic-disease patients. Patients, too, were worried about this.
"We heard loud and clear from clinicians that they felt that the human aspects of their job that they love so much—the communication with patients and those relationships—were fraught and damaged by this flat interaction style," Ladin said. She conceded that although clinicians were generally dissatisfied with telehealth in its current form, most agreed that it did provide critical insight into a patient's home, which was previously unavailable.
"Up until now, the patient's home environment was really a black box," Ladin said, "Whatever the patient said when they came into the office was accepted as truth." During video visits, however, doctors are able to see patient's homes, the exact medications they are taking, and interact directly with care partners. "That was a positive feature of these types of visits—more holistic care."
To address the range of obstacles perceived by both patients and clinicians in the study, the researchers recommend doctors share detailed post-visit summaries with patients and care partners, leave time during virtual visits for patients to absorb difficult news, and inquire specifically after patients' emotions in the absence of nonverbal cues. Structural inequalities require a longer-term but equally important investment beyond simple communication strategies.
"I wish I could say we are doing it perfectly in person, and that telehealth is the only challenge we're facing," said Ladin. "We're not. We need to work on this both in person and for telehealth."
She stressed the importance of increasing the availability of interpreters during virtual visits and a more diverse workforce throughout the medical training pipeline, including nurses and physician assistants.
"The type of community-building and relationship repair that need to happen in health care will go a long way in improving this aspect," said Ladin. "Diversifying the health-care workforce is crucial."
Many telehealth services will stay covered by Medicare through 2023, under current law. After that, the future of remote health care for older Americans remains uncertain. Much of it will depend on whether perceptions among these patients, and in particular those with chronic illness, are positive. For Ladin, the benefits are as clear as the drawbacks.
"At its best, maybe we are getting back to a more patient-centered approach," she said. "But I would be cautious to use it as a replacement device. For older, complex patients, we want to strive for a balance between seeing somebody in person in the clinic most times and then occasionally seeing them onscreen."