Teletherapy in the time of COVID-19

Ali Chartan

Signal Group spoke with Bruce L. Rollman, MD, MPH, Professor of Medicine and the UPMC Endowed Chair of General Internal Medicine and Director of the Center for Behavioral Health, Media, and Technology at the University of Pittsburgh, to discuss the role of teletherapy during the COVID-19 global pandemic and beyond.

Dr. Rollman shared his experiences from the frontlines of care as well as policy changes essential to ensuring access to care for all. This Q&A is adapted from our conversation.
 
SG: Tell us about your organization and what inspires your work?
 
Dr. Rollman: I am a practicing primary care physician and clinical-investigator at the University of Pittsburgh and University of Pittsburgh Medical Center (UPMC). The University and its Schools of the Health Sciences are presently ranked 5th in NIH funding, and UPMC is a $21B integrated global health care delivery and insurance organization. My research focuses on examining the impact of applying the “collaborative care” model to treat depression and anxiety in primary care and other non-psychiatric settings, with a special emphasis on patients with cardiovascular disease. I have been the principal investigator on six AHRQ or NIH-funded clinical trials, most recently the Online Treatment for Mood and Anxiety Disorders Trial that evaluated the impact of a computerized cognitive behavioral therapy (CCBT) program and internet support group, and the Hopeful Heart Trial that tested the effectiveness of “blended” telephone-delivered collaborative care to treat both depression and heart failure.
 
SG: How has your organization had to adjust due to COVID-19?
 
Dr. Rollman: The COVID-19 pandemic has probably accelerated UPMC’s use of ambulatory telehealth services by at least five to seven years. In the summer of 2019, our faculty primary care practice rolled out telehealth visits through the Epic electronic medical record system and secure MyUPMC patient portal. But as of March 1, 2020, just 1% of our patient encounters were telehealth. Yet by March 30, this figure had increased to over 70% of encounters. Pittsburgh moved to the “green” phase of reopening in early June. Presently, about 30-40% of our patient encounters are telehealth, and I think this proportion will stabilize at about 25% or more after the pandemic, as many patients like the convenience.
 
SG: Do you have a telehealth success story?
 
Dr. Rollman: As a primary care internist, much of what I do involves taking a medical history and providing counseling to help patients manage their chronic medical conditions and promote health-related quality of life. Telemedicine provides an opportunity to maintain existing care relationships and even allows me to enter my patients’ homes and see them in vivo, in their natural environment. For example, I recently had a video visit with one of my long-time patients who is partly immunocompromised from her treatment for Crohn’s disease and noticed a sewing machine in her home. When I asked her about it, she proceeded to tell me that she has been sewing cloth masks for her family and neighbors, and it was clear that this has helped her cope with social distancing related to the COVID pandemic.
 
Another patient with diabetes and coronary artery disease was able to show me – on video – the contents of his fridge and pantry. This allowed me to better understand what he was eating and why his diabetes wasn’t under better control so I could provide tailored feedback. These are important interactions when it comes to health, particularly mental health and wellbeing.
 
SG: Do you have any predictions about the future of telehealth or areas primed for key opportunity?
 
Dr. Rollman: Bottom line: We will not go back to our old ways of delivering healthcare. Telehealth is part of our new normal at UPMC. It will consist of a “balanced” mix of traditional face-to-face visits along with video, telephone, asynchronous email and text encounters that facilitate access to care, particularly for patients with whom the doctor has an established relationship and those seeking specialty advice. But telehealth has drawbacks too. For example, our practice’s April-June 2020 quarterly quality report showed declines in our rates of providing guideline-recommended preventive care and disease management (e.g., rates of mammograms, pap smears, colorectal cancer screening, blood tests to measure control of diabetes, etc.). This may be due to fewer face-to-face visits or the reluctance of patients to leave their homes for lab testing, preventive care, and ongoing treatment for mostly asymptomatic chronic disorders such as hypertension, diabetes, high cholesterol, and kidney disease. We will need to develop new strategies to address these issues for our patients. Moreover, because telemedicine reduces barriers to access, some patients may be more inclined to seek medical care for relatively minor ailments that would likely have resolved on their own.
 
SG: Do you see any policy or regulatory challenges that need to be addressed to facilitate/ensure telehealth use for the long term?
 
Dr. Rollman: Yes, first, we need to make universal access to broadband as ubiquitous as access to electricity, indoor plumbing, and clean running water is for all Americans, including the 20% who presently lack home Internet access. This is especially critical for disadvantaged families with school-age children who needed access to instruction when their neighborhood schools are closed, as well as for older Americans whose access to broadband and telemedicine lags behind other segments of the population.
 
Second, patient engagement is key with online care. High-quality trial-derived evidence has demonstrated that merely giving people access to apps, wearables, websites, other Internet-connected home monitoring devices such as scales and blood pressure cuffs with minimal or no human support is ineffective. Therefore, new reimbursement policies are needed to support care managers’ efforts to promote delivery of proven-effective treatments including computerized cognitive behavioral therapy for depression and home self-monitoring of hypertension and diabetes.
 
Third, we need to create fair and reasonable reimbursement mechanisms to support telemedicine and population health following the pandemic. CMS and many other insurers relaxed their payment policies for telehealth during the pandemic, but these policies could easily revert back to the old way of only paying for face-to-face care once the crisis ends. Perhaps a mix of risk-adjusted capitation with pay-for-performance and pay-for-patient-outcomes may make more sense and accelerate the transition of our health care system from simply paying for the volume of face-to-face care and other services to paying for value.
 
Lastly, we need to apply simple yet proven-effective and inexpensive behavioral economic strategies including nudges, choice architecture, automated hovering, framing, and other techniques to promote the adoption of telemedicine, population health, and evidence-based care. We live in exciting times!
 
About Dr. Bruce L. Rollman, MD, MPH
 
Dr. Rollman is a board-certified specialist in internal medicine and has published over 100 scientific papers, including first-authored papers in the New England Journal of Medicine and the Journal of the American Medical Association, and has four U.S. patents. He is also the recent past president of the American Psychosomatic Society, whose goals are to advance the scientific study of biological, psychological, behavioral and social factors in health and disease. In 2015, Dr. Rollman launched the Center for Behavioral Health and Smart Technology to mentor and support the careers of talented junior investigators.

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