Telemedicine Before, During, and After COVID-19

Robert Graboyes interviews Doctor On Demand’s Ian Tong, MD

By Robert Graboyes

The COVID-19 crisis is like no other in American history. As was the case in 1918, there’s a raging pandemic. And like the situation in October 1929, stock markets have plummeted. There also is widespread fear for loved ones’ safety, which the country experienced most significantly in December, 1941 and for three-and-a-half years after. But 2020’s social distancing imperative—the massive shutdown of street-level commerce and disruption of family and social life—has few if any precedents in the United States. The great silver lining thus far has been the lifeline afforded by modern transportation and communications. Truck caravans still restock grocery shelves; clerks take personal risks to load shelves; and an armada of cars and trucks carry food, medicine, and other goods to Americans in quarantine. All of this, plus the ability to stay in close touch with family, friends, and co-workers, is thanks to an internet that wouldn’t have existed had this crisis occurred a generation ago.

Dr. Ian Tong, chief medical officer of Doctor On Demand

One of the great life preservers the digital age offers is telemedicine. The other day, I corresponded with Ian Tong, chief medical officer of Doctor On Demand (DOD), a San Francisco-based company providing telemedicine services across America. He’s an adjunct clinical assistant professor at Stanford University Medical School, where he taught hands-on medical examination for seven years. Before that, he was Stanford Internal Medicine chief resident and was also founder and medical director of the Health Resource Initiative for Veterans Everywhere (THRIVE).

Ian earned his medical degree from the University of Chicago Pritzker School of Medicine. His undergraduate degree, from the University of California at Berkeley, was in English. I’d be remiss if I didn’t add that Ian has been a friend of and resource for the Mercatus Center for five or six years.

The following transcript has been lightly edited for clarity.

Tong: Hi Bob, it is good to talk with you again.

Graboyes: Ian, to lay the groundwork for our COVID-19 discussion, tell us a little about Doctor on Demand’s pre-COVID history and niche. In the past, you’ve told me some dramatic stories about lifesaving experiences. I’m hoping you might have a new story or two to tell.

Tong: Sure. Doctor On Demand launched in 2014. We have completed almost 2.5 million visits and recently became the first telemedicine practice to receive designation as a virtual primary care practice. This means we can treat the whole patient, perform screening and preventive health assessments, coordinate vaccines, offer specialty referrals, while, most importantly, patients develop relationships with and see the same physician. Just weeks ago, a parent informed us of an amazing family experience; his graphic LinkedIn post stated that DOD saved his daughter’s life from a severe bone infection that was missed in the emergency room.

Mercatus senior research fellow Robert Graboyes

Graboyes: Now, let’s move forward to the COVID-19 present. I’ll share two stories. First, I saw that some states, anticipating severe stress on the medical workforce, are trying to lure retired providers back into the fray by offering fast-track re-licensing; but many of them are in at-risk categories and not anxious to interact with patients. Second, a physician friend is working endless shifts because so many doctors and nurses have already self-quarantined, leaving her hospital grossly understaffed. My wife (whom you met a few years ago) asked me whether telemedicine links could persuade both groups to join the fray—working from the safety of home to lighten the burden of those on the front lines. Any thoughts?

Tong: COVID-19 has forced many of us to change how we work, and doctors are waking up to the many benefits of working remotely, including safety. Using telemedicine, retirees and quarantined doctors can work without taking unnecessary risks from exposure. Plus, they also can remove the physical demands of working on their feet all day. Telemedicine is extending the career of the senior physician. It is really a matter of working smarter. In our case, visits are half the length of in-office visits, and yet patients and doctors feel the relationship is enhanced. In our third-party employee engagement survey (Great Places to Work Survey) last year, our doctors scored 99 percent.

Graboyes: In particular, state and federal officials are suddenly open to the idea of doctors licensed in one state treating patients in other states. Has this already impacted the telemedicine world?

Tong: Yes, removing these regulations has enabled better patient access to care, no question. It has also significantly lowered the barrier to entry for doctors which is enabling those who would have never attempted to go digital due to the significant financial cost of buying numerous state licenses.

Graboyes: Have people in areas hard-hit by COVID increased their use of telemedicine since the outbreak began? If so, are they using telemed to address COVID issues or addressing things other than COVID?

Tong: It’s not just COVID-related or just areas that are hard hit. We are seeing patients in markets we never penetrated, including age and gender demographics like seniors and men, who were previously slow to adopt.

Graboyes: I spoke with one 70+ retiree and asked what it would take to bring him and other retirees back into the fight during the COVID emergency—assuming that they could work from home via telemed links. He named some likely conditions: remuneration, immunity from malpractice litigation, relaxed HIPAA requirements, limited electronic medical record responsibilities. At the state and federal levels, there’s already talk or action or both on several of these issues. Can you shed any light?

Tong: The federal government has acted quickly to lower the barriers to entry with removal of HIPAA and state licensure. Malpractice risk is very low, and working with an existing virtual practice removes the concerns and administrative overhead around medical billing.

Graboyes: The abovementioned 70+ retiree said he couldn’t imagine what would be involved in establishing a telemedicine capability from his home. Thinking of you, I said, “I don’t know either, but I’ll bet a friend of mine could answer your question.” So, what would it require to set him up, and how long would that take? And for a bit of conjecture, if state governments came to you or one of your competitors and said, “We have a 1,000 doctors ready to pitch in,” how long would it take to get all of them up and running?

Tong: You really just need a strong internet connection, a laptop computer with a camera, and great webside manner. Doctor On Demand requires about ten hours of training, which can be done in a group session. With that, I imagine most practices could onboard 1,000 physicians within a few short weeks.

Graboyes: As you know, I’ve been a big fan of telemedicine for a long time—and have even used DOD’s services on one occasion. I suspect (or at least hope) that after COVID-19 passes from the scene, America and the rest of the world will view telemedicine much more favorably. I suspect that heretofore, telemedicine will be a far more important part of healthcare than it has been up till now. Do you agree?

Tong: Absolutely, I don’t think there is any going back, now that we have seen the critical role telemedicine has had with this global crisis. Behavioral health is the most obvious change. I don’t think mental health will ever need to be done in an office if you can get it over video.