The surging popularity of telemedicine during the COVID-19 pandemic occurred with little analysis of how appropriate or effective these virtual consultations were for patients. Phone and videoconferencing visits were embraced primarily as a means to limit patients' exposure to the virus while maintaining their access to care.
Between March and October 2020, nearly 40% of Medicare patients received a telemedicine consult. By one estimate, telemedicine-defined as interactions between clinicians and patients via text, audio, or video-accounted for 13% of private medical claims in April 2020 compared with 0.15% in April 2019. Another estimate found virtual care peaked at 42% of all ambulatory visits covered by commercial insurers in April 2020.
One year after this pandemic-fueled uptake of virtual care, the February 2 JAMA published several articles addressing the safety, effectiveness, and quality of virtual consults and their future in health care.
Benefits. Virtual care can be more efficient than traditional office visits. Research has shown it to be particularly suitable for mental health consults, prescription refills, and straightforward evaluations. Virtual care may reduce inconveniences for patients such as travel to appointments and time lost from work, and also enable patients to receive needed care sooner, especially those who work irregular hours, have limited mobility, have caregiving responsibilities, or live in remote areas. In addition, virtual care has the potential to improve coordination of care by enabling primary care clinicians and specialists to confer jointly with patients.
Risks. A significant drawback of virtual medicine is that it does not allow for physical examination. It is inadequate for many common clinical situations-diagnosing a child with ear pain, for example-and could potentially undermine preventative screenings. Herzer and Pronovost note a study showing that blood pressure assessments, for example, declined by 37% from April through June 2020 compared to the same period in 2018 and 2019 because of virtual visits. Moreover, patients who opt for virtual visits even when symptoms warrant in-person examination could experience delayed diagnoses or misdiagnoses. Virtual care might also end up costing more as a result of clinicians excessively ordering tests to compensate for the lack of physical examinations.
Finally, to the degree that virtual care becomes a standard treatment modality, it could increase disparities in health care access and quality because of uneven Internet or cell phone service in rural areas and among older or low-income Americans. In a study of California outpatient health centers providing care to 30 million low-income individuals cited by Uscher-Pines and colleagues, 48.5% of patient visits from March to August 2020 were by telephone, compared with 3.4% by video, and 48.1% in person. Audio-only telephone visits suggest a lack of digital literacy or videoconferencing equipment. The absence of visual cues when clinicians and patients talk by phone but cannot see each other might also result in lesser-quality care. Lastly, human connection, which can be so integral to clinician-patient interactions, might be reduced by virtual health care.
The future. Research assessing the quality and accessibility of virtual care is underway, and clinical practice guidelines will likely follow. Among many questions are when and under what conditions should clinicians pivot from virtual to in-person care. Emerging, Internet-based medical technology such as mobile apps and wearable devices will further challenge researchers and clinicians to define best practices for virtual medical care.-Joan Zolot, PA