Health care professionals, like their counterparts in other industries, are feeling their way into the future, unsure of just what the post-pandemic landscape will look like. Many Arkansas providers seem to agree on one thing, however: When it comes to telemedicine, the pandemic has pushed the health care industry ahead by leaps and bounds.
Craig Wilson, director of health policy for the nonprofit think tank Arkansas Center for Health Improvement (ACHI), thinks more happened this spring regarding telemedicine than took place in the previous two decades.
“The pandemic accelerated the use and improvement of related technology by at least five years,” he said. “We’re five years ahead of where we were. Currently, we’re using it in a reactionary way, just to be able to do some of the routine things we need to do. I still think there needs to be a strategic approach to how we use it in the future.”
For the present, COVID-19 has forced providers and patients alike to get comfortable in a hurry with videoconferencing, Dr. Curtis Lowery told Arkansas Money & Politics. Lowery is the founder and medical director of the Center for Distance Health at the University of Arkansas for Medical Sciences in Little Rock; in 2019, he was named director of the UAMS Institute for Digital Health & Innovation.
Such an abrupt introduction isn’t ideal, he notes. Plus, there’s the issue of provider reimbursements for virtual visits lagging behind payments for in-person visits. There remains some ironing out to do. But here we are. Doctors couldn’t stop seeing patients during the coronavirus, after all. The shock to the system was necessary.
“With the pandemic, we literally jumped three to five years into the future with appointment digital health,” Lowery said. “This is not the best way to learn about using videoconferencing. It is very unlikely, due to the rising number of COVID-19 cases in America, that we will limit the use of videoconferencing in the delivery of health care.”
Indeed, as the saying goes, the future is now. Zack Hill, CEO of Little Rock’s digital creative agency Few, believes health care consumers will be receptive to more virtual experiences, especially if those experiences are good ones.
“Just like with any new technology, most of the fear is based in doing something different and less about learning something new,” Hill said. “The patients that are resistant, young or old, are more resistant to change because they aren’t exactly sure what to expect out of the experience. This is where the experience will really start to matter. It will have to be very easy to engage in telemedicine through intuitive interfaces, making it clear how the process works. When people feel guided, they become more comfortable with the change, and then they start to see the benefit.”
Lowery and his UAMS colleagues had been working to slowly introduce telemedicine to Arkansas and raise patients’ comfort levels for decades. Those efforts were turned up a notch with the launching of the Institute for Digital Health & Innovation. The pandemic, well, cranked things up to 11.
A perinatologist (maternal-fetal medicine) by trade, Lowery believes Arkansas actually is ahead of the game in some respects. And that’s thanks in part to something he helped introduce — ANGELS (Antenatal and Neonatal Guidelines Education Learning System), a statewide, high-risk pregnancy management program.
“For more than 25 years, telemedicine has been evolving at UAMS,” he said. “Through the ANGELS program, we learned a great deal about the management of patients remotely. We further developed Arkansas SAVES, a stroke treatment program, as well as other programs running off the ANGELS platform. In addition, we are developing a directed consumer solution built around cellphone technology. This advanced to creating a platform which could more easily be adapted to universal care delivery.”
Bo Ryall, president of the Arkansas Hospital Association, said telemedicine had been advancing incrementally in the state before the virus hit, “in pace with technology, training and patient trust.” Once the virus hit, federal and state officials responded immediately with key adjustments that have paved the way for substantial and rapid growth in virtual care.
“All hospitals have looked for ways to increase not only telemedicine but also the total care of the patient through telehealth, spurred on by the imperative to keep all patients and health care workers as safe and as healthy as possible,” Ryall said. “The pandemic has also shifted the perspectives of patients who previously felt that care must be provided in person. Many Arkansans have now experienced for themselves virtual care for chronic care management, post-discharge management, medication education, specialty consults and behavioral health counseling.
“This time period has allowed for patients and providers alike to become more comfortable with providing and receiving services that are not conducted face-to-face. The benefit to rural providers and hospitals, in particular, will be seen in some alleviation of the pressures of workforce shortages and in the extension of specialized medical expertise to all areas of the state.”
Telemedicine is expected to benefit rural communities especially, connecting them with resources previously hard to reach in person. El Dorado, seat of Union County, isn’t a small town by Arkansas standards. It was home to about 18,000 residents as of 2019. But it anchors a large swath of lower, very rural Arkansas, and many communities in its orbit rely on El Dorado for important things like health care services.
Many of those services are provided by the 166-bed Medical Center of South Arkansas, which was already utilizing telemedicine to connect patients in both hospital and clinic settings with partner specialists in larger markets such as Little Rock. CEO Scott Street said the ability to connect in such a way is critical to rural markets such as El Dorado. For those patients seeking specialty care, telemedicine provides an alternative to driving all the way into Little Rock.
And, of course, it provides an end-run around the virus.
“Telemedicine is bridging the gap between people, physicians and health systems, enabling everyone, especially symptomatic patients, to stay at home and communicate with physicians through virtual means, helping to reduce the spread of the virus and get people the care they need,” he said.
The state’s osteopathic medical schools are focused on helping place doctors in rural areas where they’re needed. Telemedicine helps bridge the divide between providers and rural residents who’d otherwise be forced to drive long distances. Dr. Shane Speights, D.O., campus dean of the New York Institute of Technology College of Osteopathic Medicine (NYIT) at Arkansas State University in Jonesboro, said his school’s mission is focused on training doctors to serve medically underserved areas of Arkansas and the Delta.
“For doctors who practice in rural areas, telemedicine can reduce many of the burdens — including time, travel and cost — their patients incur when they need to visit a specialist,” he said. “That makes NYITCOM’s commitment to telemedicine all the more important as it trains future physicians.”
Lowery expects telemedicine to be a boon not only for rural providers and patients but for the industry as a whole.
“Patients may be able to remain at home or in their local doctor’s offices and get care rapidly,” he said. “There will be no need to drive long distances, and almost all follow-up visits can be conducted by videoconference. Besides these rural patients, any patients who live in underserved areas will benefit from these new technologies. Systems of care will be developed utilizing other non-MD providers to manage chronically ill patients to keep them healthy rather than treating them when they decompensate. We can aggressively begin to treat brittle diabetics and unstable congestive heart failure patients in their home environments rather than admitting them to the hospital for stabilization. This will save money and improve outcomes.”
Dr. Ezinne Nwude (pronounced WOO-day), chief of staff at MCSA, thinks telemedicine represents a necessary step in the evolution of health care.
“Since the pandemic, we have implemented telemedicine in our outpatient primary care clinics and increased telemedicine in the inpatient setting. Our outpatient clinic physicians now can see patients from the comfort of their home through a mobile device, tablet or computer,” she said. “We have also added interventional cardiology, pulmonology and neurology telemedicine services in an inpatient setting to increase patient access to these services and provide more resources for our physicians.”
While the need was immediate for increased use of telemedicine because of the virus, its adoption is another story. Street noted the obvious challenges faced by older generations not as familiar with new technology. But health care is about as personal as human interaction gets; won’t there always be patients uncomfortable with remote interactions?
“One of the limitations with inpatient telemedicine is getting patients used to not having a doctor in person and to receiving care over a screen,” Street said. “During telemedicine consults, the physician spends the same amount of time with a patient to access them and develop treatment options. The necessity of social distancing during the pandemic has made virtual face-to-face calls more acceptable to both clinicians and consumers.”
Street hopes increased use of telemedicine will result in more patients seeking treatment in a timely manner. The pandemic actually has kept non-viral patients away from hospitals and doctors’ offices for fear of overloading the system.
“We are seeing a delay in people seeking health care for both emergency and routine health care needs,” Street said. “Tragically, people with serious emergencies, including heart attacks, stroke and infection are waiting too long for medical care. The same goes for chronic conditions and even routine health care needs. Annual wellness visits and screenings are now more important than ever to keep people in tiptop shape to fight COVID and catch any illness and disease before it progresses.”
In rural states like Arkansas, one of the main obstacles to widespread telemedicine adoption is the lack of access to broadband services.
“Rural communities tend to have the most trouble when it comes to accessing the internet, impeding their access to telemedicine services like remote patient monitoring, patient consulting and even appointment reminders,” Street said. “Some rural Americans can’t afford broadband access, which can easily cost over $100 a month.”
Gov. Asa Hutchinson last year launched the Arkansas State Broadband Plan to expand access to high-speed internet across the state. He intends to expand high-speed broadband access to all Arkansas communities of 500 or more residents by 2022.
This past December, the U.S. Department of Agriculture (USDA) made an additional $550 million available for broadband infrastructure grants through its ReConnect program. The program was launched in 2018 with $600 million to expand broadband infrastructure and services in rural America. The goal is to build modern infrastructures in areas with insufficient internet service, “insufficient” defined as connection speeds of less than 10 megabits per second (Mbps) for downloads and 1 Mbps for uploads.
For Lowery, expanding access to high-speed internet service is about much more than health care.
“Broadband is an important economic-level leveling program for rural areas,” he said. “Broadband not only allows for health care but also education and economic development. The importance of education has been made apparent as we closed schools to protect our children and adults from the COVID virus. Rural communities have been penalized since they are often lacking broadband. The federal government has recognized the need to expand broadband to rural communities for more than 10 years. As a result of the virus, billions of dollars are being spent to help internet service providers and rural governments deliver broadband to underserved areas.
“This massive expansion has been compared to providing electricity to rural areas, a process which started in the early 1900s and was mostly completed in the 1960s and ’70s. Lack of broadband in today’s world significantly puts an individual at a disadvantage in so many ways — health care is just part of this. I am glad that we are now focused on a national approach, which will improve broadband delivery to these rural communities.”
While many rural Americans don’t have broadband in their homes, most have a smartphone with some sort of internet access.
“The key for health care providers is making sure the platform they use isn’t particularly taxing on a cellular data network,” Hill said.
In January, the USDA awarded grants totaling $7.1 million to create or improve connectivity in Baxter and Marion counties with 548 households being connected to the internet for the first time.
Nwude said the pandemic has exposed to government officials the importance of access to health care, no matter where one lives.
Wilson agrees that telemedicine will “stimulate the push” for better access to broadband in rural areas. However, “Just like health care, you can provide availability of broadband, but there’s still a question of affordability and quality,” he said.
Lowery said as telemedicine becomes more commonplace, the industry will need to develop appropriate-use cases and scenarios to protect patient confidentiality.
“This is just the beginning of a long journey, which is going to result in a new hybrid for health care delivery, which is a blend between in-person visits and videoconferencing between patients and health care providers,” he said.
Wilson said the next step is to take telemedicine from a side concept to a “natural and integral” part of health care delivery.
“We’re very young in the telemedicine space,” he said. “It’s just been in the last five years that legislation established what telemedicine was. We’ve edged into it, and the pandemic has blown the doors off of it. We have to be mindful of safety and effectiveness. There are some things that you just can’t do. You can’t give vaccinations or perform certain types of screenings. But there are so many benefits. In pediatrics, the physician can really look into the home environment. That’s a real benefit.”
As of July 8, MCSA had performed more than 2,200 COVID-19 tests. And Union County, the state’s largest geographically speaking, has held steady in preventing the spread of the virus.
COVID-19 has pushed organizations to become innovative, Street said.
“Instead of focusing on the uncertainty of the future, we need to accelerate the positive transformations we have already undergone and focus on creating a new normal for our patients,” he said. “Hospitals have seen the importance of improving supply chain measures, including having more vendors, resources and a more diverse supply chain. We have always kept a large cache of ample emergency supplies and have increased our resources to prepare for a surge of patients.
“All hospitals participate in disaster preparedness drills and preparation, but COVID-19 has validated the importance of being prepared in any type of situation, including a global pandemic.”
Ryall believes the recent emphasis on telemedicine will spur the industry to new innovation, providing that providers start getting reimbursed at the same levels for virtual appointments. Many Medicare providers, for example, are reporting that virtual care reimbursements are about 80 percent of what they’d be for regular visits, according to the industry website MedPage Today.
“During the pandemic, we have seen patients reluctant to travel who nonetheless continue to have chronic illnesses that require care,” Ryall said. “By utilizing remote patient monitoring for chronic care management, efficient post-operative follow-up and better medication adherence, patients will see positive care outcomes, and hospitals will see lower readmission rates. All the improvements we are seeing in telemedicine and telehealth, however, will experience declines if payments for virtual care are not adjusted to levels equal to payment for services delivered in person.”