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An extremely important lesson we have learned from this pandemic is the value of telemedicine. Of course, it comes with challenges, particularly offering equitable access to all of our patients.19 Healthcare professionals need to be taught how to interact with patients via telemedicine so they have a better professional–personal interaction. Of importance, the sustainability of telemedicine will be defined by healthcare reimbursement practices, but we hope that those practices will be extended and remain intact in the long term.
We need to have more patients becoming technology aware so they can use the latest advances in telemedicine.19 Anecdotally, several of my medical colleagues have observed that most of our patients with housing and food insecurity do have a cell phone. This is a good reminder to guard against making assumptions about who may benefit from telemedicine. We need to keep informing all of our patients about the latest options in telehealth. Some patients who have trouble traveling to clinic may actually receive more frequent assessments when leveraging telehealth options.
Cell phones notwithstanding, it makes sense that people with more resources have better access to telemedicine, on average. This analysis of from University of California, San Francisco primary care clinics19 confirms disparities in telemedicine use: White patients showed an increase in visit frequency after telemedicine scale up in 2020, while this was not the case for most other racial/ethnic groups.
The authors suggested strategies to reduce disparities that could be summarized by saying that we need to be proactive about making telemedicine happen, both at the patient level and the healthcare system level.
Here are some details of those strategies for improving telemedicine access proposed by Nouri and colleagues in the University of California, San Francisco study.19 These include creative solutions such as reducing broadband costs and/or making it free for low-income individuals, distributing personal digital devices or laptop computers to individuals who do not have them, and training them on their use as part of their healthcare.
We really need to improve funding for telemedicine services by making reimbursement for telemedicine on par with reimbursement for in-person visits. There should be a national licensure program in which healthcare professionals are licensed across the United States, rather than by individual states, so healthcare professionals can offer telemedicine services seamlessly throughout the country. In many regions, including my practice area, good language interpreters are necessary so there is language concordance with patients.
The Project ECHO (Extension for Community Healthcare Outcomes) model out of the University of New Mexico School of Medicine is an outstanding example of how teleconferencing technology can bring expert consultation to primary care professionals, allowing greater to access to complex care within a patient’s own community.20
This project was started in 2003 by a physician inspired by the death of a patient because of lack of access to timely HCV care.21 It is now reaching 9000 cities and 180 countries with a goal of affecting 1 billion lives by 2025.21 This model was designed for underserved communities but is applicable to expanded populations in the COVID-19 era, as it helps healthcare professionals and patients overcome barriers to care during lockdown periods.
Healthcare professionals and patients alike have missed the face-to-face contact that we enjoyed in prepandemic times. But the pandemic has taught us some valuable lessons in disease management that are worth carrying forward, particularly because we do not know how long this pandemic will last or what may come after this one.
Telehealth reduces the risk of infection and travel burden for patients and relieves overburdened staff and healthcare facilities. Without a doubt, we need to build on the positive opportunities in telemedicine and make it a routine part of healthcare delivery and reimbursement.
For services that can only be delivered in person, we need to pay close attention to streamlining in-person encounters to maximize efficiency while minimizing infectious disease transmission.
What we must NOT do during lockdown periods is lose ground in our efforts to end viral hepatitis and related liver disease. To maintain progress, we need to be innovative about testing until every person knows their ABCCs—that is, their status regarding hepatitis A, B, C, and COVID-19. Whenever people are getting COVID-19 care, vaccination, or testing, they should be educated and linked to care to test and vaccinate for hepatitis A and B and test for hepatitis C. To accomplish this, we should scale up rapid diagnostic testing and point-of-care testing for viral hepatitis. This topic is discussed in further detail in one of the dialogues between hepatologists featured in this program.
We recently learned that the FDA reclassified certain premarket HCV diagnostic tests from Class III to Class II, which is a less burdensome pathway to review; this should stimulate the development of more HCV diagnostic tests, and I believe the same approach needs to be considered for hepatitis B virus diagnostic tests.
Furthermore, using the example of COVID-19 at-home testing with app support as a model, we should work toward developing similar at-home testing with supporting apps for viral hepatitis. If HCV treatment is needed, we know minimal monitoring is very effective at very low cost. Finally, going forward, we should bring technology to bear on the provider side of the healthcare interaction equation as well, as is being done in Project ECHO.