Telemedicine the new normal for docs, patients in pandemic

DOVER — Dover Family Physicians hadn’t done much in the way of telemedicine, but when COVID-19 hit, that changed — and quickly.

“We had to re-evaluate how we did everything for the safety of our patients and our staff,” said Joseph Rubacky, a doctor at the practice.

Within just a few days — and with relaxed telemedicine constraints given the crisis — the practice began teaching its staff and patients how to come in for an appointment via Zoom.

“We definitely hit the ground running with it. We had to redesign the workflow,” said Leann Legg, practice administrator.

“I’m the most digitally impaired of all the doctors, probably everybody in the practice, and I was very pleasantly surprised at how well it went and also how reassuring it was to the patients,” Dr. Rubacky said. “If you remember when all this hit, the amount of anxiety in the community, and sheer terror present was overwhelming to a lot of people and there was tremendous anxiety by our patients about, A: can they see us, and B: how can they see us safely? So this gave them a good option and it’s worked out amazingly well.”

The practice went from no telemedicine presence to more than 1,500 appointments via Zoom. Since it began in mid-March, 50% of the appointments have been conducted virtually, Dr. Rubacky said. That percentage has increased in recent weeks, with about 70% of appointments being conducted through Zoom.

COVID-19 has changed the landscape for operations across the state. Because of the goal of limiting contact, Gov. John Carney relaxed restraints to expand access to telemedicine in a modification to the original state of emergency declared in March.

The modification allows for patients to begin telemedicine services without needing to be present in-person prior to the virtual appointment and Delaware residents don’t have to be present in the state when the services are provided. The modification also loosened HIPAA privacy standards so telehealth can be conducted through platforms like FaceTime and Skype.

Beebe Medical Group had already been laying the foundation for starting a telemedicine program, but when COVID-19’s impact was felt throughout the state, the plan rolled out faster than anticipated, said Bobby Gulab, senior vice president and chief medical officer.

“What we also realized pretty quickly is we can do a lot of good care through telemedicine,” he said. “Most of the things in the visits that we were able to perform in the office, we’re able to perform through telemedicine as well.”

The practice has seen more than 3,500 telemedicine visits, Dr. Gulab said.

He noted that the practice was quick to implement telemedicine because one of the top concerns was if patients are scared, and aren’t leaving their homes, unmonitored chronic medical conditions may worsen, causing patients to end up in the emergency room for care.

“By having this type of platform we’re still able to provide care, interact with patients, have regular visits and still care for their chronic conditions, and we’re there to help them to make sure they don’t worsen and to stay on top of things with them and partner with them so they don’t end up in the emergency room,” he said.

Practices remain open for in-person appointments that may require a more hands-on approach, but telemedicine offers a way for patients to receive their checkup from home.

Regular follow-up visits and annual wellness visits can easily transition to telemedicine, said Dr. Gulab.

Of the appointments conducted through Zoom so far, Dr. Rubacky said that he’s converted one Zoom visit to an in-person visit.
“The majority of them, we’re able to do, I think, a fairly effective job,” he added.

Other practices outside of primary care physicians have also transitioned to telemedicine. In mid-April, SUN Behavioral Health began offering free level-of-care telehealth consultations for individuals struggling with anxiety, depression, mental health or substance use-related issues.

“We really feel like now more than ever, with all the mental health issues and substance use disorders that we’re seeing coming to us, relapses, that we needed to make sure people knew that — even if they’re not comfortable coming into our facility because they’re afraid of exposure — that they can still get a level-of-care assessment done,” said Erin Willis, director of business development.

The consultation at SUN involves a series of questions that helps an individual determine if they need inpatient, partial hospitalization or intensive outpatient care. If they need individualized counseling in their community, SUN can connect them to resources, Ms. Willis said.

“It is important for us to adapt to our environment,” she said. “Obviously the world as we know it has kind of changed, and it’s important for us to figure out what the community needs. One thing that I love about SUN is it stands for ‘Solving Unmet Needs.’ We figured out that people were afraid, and they still need help, and so we decided to launch this to try and help people. And that’s something that I’m proud that our company saw and is willing to do.”

Troy Raber, optometrist at Vision Quest Eye Care Center, said his practice also began using telemedicine primarily due to COVID-19, but it is something he can see continuing.

In the beginning, they were using FaceTime to connect with some patients. It worked well, Dr. Raber said, and prompted them to try a platform that would actually test visual acuity through a web- and phone-based platform. That became a little complicated for some patients, though, and they ended up moving to a web-based platform called Doxy.me.

“We can email them a link, we can text them a link, they can go to our website and click on the link and it basically puts them into a waiting room; we click on them and we see them face-to-face,” he said.

The model has been useful for follow-ups and making sure patients have their medications, he said.

Though the practices are using different platforms, many have video capability so they can connect one-on-one with patients, like they would in a normal setting.

“There’s been studies done on patient satisfaction with office visits, and it’s interesting: patient satisfaction does not truly correlate with the amount of time a physician spends in the room with the patient, but rather it correlates with the amount of time of eye contact,” Dr. Rubacky said. “If you think about that, these virtual visits allow you to do that and maintain that eye contact in that interaction.”

For SUN, Ms. Willis said that visuals are important for therapists and specialists in intake.

“They’re able to dig deeper when you’re looking at somebody and they can pick up on their nonverbal cues,” she said. “So I know that that was a big thing — we can do an assessment over the phone, [but] just it’s more personal, and it’s more relatable when you see somebody.”

Dr. Raber also has experienced telemedicine from the patient’s side, as his son utilizes it for dermatology appointments, and he said it has been a smooth transition.

Others weighed in on Facebook to note that it has its perks, but it isn’t perfect.

“It has been great for medicine refills for my son. So easy and no waiting in an office or driving,” Laurie Wetzel wrote.

While it’s reasonable for getting refills, “based on recent personal experience telemed is not practical for sick appointments,” Nancy Parker said.

Michael Lindquist visited the doctor via telemedicine for what appeared to be an infection and was prescribed antibiotics through the visit.

“So far so good,” he said.

Similarly, Eric Morrison used telemedicine to have his “annual spring sinus infection diagnosed.”

“It was a good experience,” he continued.

Separately, Yvonne Kirksey, who works for the Delaware State News, said that the several telemedicine appointments she has had to prepare for surgery — which has been postponed — have all been very different.

“For me, the first face-to-face appointment I had was awkward but it was really good, because I was more comfortable because I was home,” she said, noting her doctor was a little nervous since it was new for him too.

She said, as someone with a compromised immune system, she was stressed about going to a medical facility given the COVID-19 environment.

“It definitely took away the anxiety and the stress that comes with having to be in a facility like that,” she said. “All that went away so it made the appointment much more pleasant for me. Because I was relaxed I didn’t forget things I wanted to say; I had notes in front of me just to not forget to mention certain things, so I actually liked that aspect of it.”

The doctors noted that it has been a fairly smooth transition for patients, though Ms. Legg did have to train some older patients on using Zoom before they were ready to go for their appointments.

“It’s been a little different for most of our providers; most of us are trained with really face-to-face encounters and really having that hands-on with the patient,” Dr. Gulab of Beebe said. “It was a little different in that sense, but I think we quickly realized that this is technology that people are very accustomed to; it’s out there with FaceTime and video chats and these kinds of things, so not only provider’s end, but the patient’s end, I think people caught up pretty quickly and got pretty comfortable with it.”


Helpful Coronavirus links

Delaware Division of Health Coronavirus Page
CDC: About the Coronavirus Disease 2019
CDC: What to do if You Are Sick
Johns Hopkins Coronavirus Resource Center
AP News Coronavirus Coverage
Reopening Delaware: Resources for Businesses
Delaware Phase 2 guidance

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