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Telehealth and the Asynchronous Revolution
By Robert Graboyes
Thanks in part to changes prompted by COVID-19, healthcare is experiencing an asynchronous revolution. With asynchronous care, where appropriate, patient and provider interact through a sequential exchange (as with a back-and-forth series of text messages with attached photos) rather than interactively (as with an in-person office visit or a video consult). Arizona, Colorado and other states are recognizing this change in law and regulation. In a real sense, these changes echo the transition from 20th-century to 21st-century healthcare.
An exchange of emails or texts is often better than a phone call. No busy signals. No straight-into voicemail. No telephone tag. You can send your thoughts in the middle of the night or on the weekend or while you’re on an airplane. When you receive a question, instead of blurting out the first thing that comes to mind, you can think seriously about your answer—perhaps doing some research before responding.
In the wake of the COVID-19 panic, we’re discovering that the same realities hold in healthcare. Over the past year, patients have become accustomed to visiting doctors and other providers through their laptops, tablets and smartphones. (In summer 2020, doctors were said to be conducting 50 to 175 times the number of virtual visits as they had done pre-pandemic.) But patients and providers are also discovering that the best care can come from providers separated not only by space, but by time. Patients and providers send queries, observations and data to one another via email, text, webform input or remote telemetry. Either party can send information at any time, both have the opportunity to think about what they’re sending, and there’s a written record of the correspondence.
This realization is wending its way through America’s legislatures. Since February, I’ve submitted testimony to three state legislatures (Arizona, Colorado, and Maine) on bills codifying the role of asynchronous telehealth. On May 5, Arizona Gov. Doug Ducey signed HB 2454, which allows patients and providers to establish a patient-provider relationship via asynchronous interactions. It also allows providers to prescribe or dispense prescription drugs and medical devices via these technologies. On May 19, Colorado Gov. Jared Polis signed HB 21-1190 expanding the definition of telemedicine to include “information, electronic, and communication technologies, remote monitoring technologies, and store-and-forward transfers." At this writing, Maine is still deliberating on a number of bills that would strengthen the role of asynchronous telehealth.
The idea of “visiting” your doctor electronically and asynchronously can seem jarring. But that will change over time. We’re all so accustomed to emails and text messages that it’s hard to remember what a radical departure they were from prior communication. In 1993, I was working at the Federal Reserve Bank of Richmond. One day, there was fear that a truck might have brought a lethal virus into the loading dock and introduced the pathogen into the bank’s ventilation system—threatening thousands of employees. Victor Brugh, the bank’s resident physician, resolved the matter in a few hours, through an exchange of emails with the Centers for Disease Control.
At the time, email was a brand-new concept, and after the crisis passed, Brugh told me of his thrill with the new technology. A quick volley of emails led to a realization that the risk was a false alarm. Not long before, he said, the crisis would have required an endless game of telephone tag and sharing of incomplete information over many hours, if not days. (A fuller account of the crisis is here.)
Increasingly, medical care involves such nonsimultaneous exchanges of information. The new laws in Arizona and Colorado make it possible to compensate providers for these exchanges, rather than locking them into increasingly outdated and counterproductive insurance and billing requirements. Going forward, however, the federal government, states and insurers will have to grapple with the specifics of how we reimburse providers for new and better ways of doing things. A good example of what I’m talking about comes from a personal anecdote I included in my Colorado testimony:
“During a temporary health crisis of my own, the doctor and I had two videoconferences of around 15 minutes apiece. My insurance reimbursed her for that time. However, she spent several multiples of that amount of time corresponding with me via secure text message—not to mention administrative work related to my case—and received no compensation for all that time that she spent helping me.” As my doctor told me afterward, “I have to learn two mutually exclusive ways to understand my patients’ conditions—one to help them and one to get paid.”
Our healthcare system is highly regulated and often can be convoluted. As provider-patient-machine communications evolve, public policymakers and insurers will grapple for years with how best to adjust and compensate healthcare providers for such communications. The goal will be to ensure that our doctors and other caregivers are fairly rewarded for the time and effort they spend helping patients get well, whether that’s meeting in an examination room, or speaking through a computer screen, or tapping out a message on a cellphone. And that can be easier said than done.