Dialing Into Telemedicine: Virtual Care For Our Most Vulnerable Communities

Taken from the podcast episode “Episode 55 – Healthcare From Home! Using Telehealth to Care For Our Most Vulnerable With Dr. Sam Lin” from Charting Queer Health. Listen here!

Early in my career as a healthcare provider I took a dive into telehealth, looking at women’s health, sexual health, and marginalized populations. I quickly realized the potential that telemedicine has, specifically for medical abortion, believe it or not. I was an early adopter of that in 2001, almost 17 years before the pandemic. Now, we live in a time where we are focused on trying to do as much as possible, virtually. As we know, after the pandemic, everything is different. What does good medicine look like through a screen? How does telemedicine help us advance health care?  

Like I said, I was an early adopter of technology that looked at ways of doing medicine virtually. Before that, I always thought telemedicine was telephone. That’s what I thought the origin was; that you got on the phone, and you were supposed to call someone. Telemedicine. That’s actually not far off. It was coined by this guy, Thomas Byrd in 1970, and if you take two Greek words, telos and medikos, which means “healing” and “at a distance”, respectively. So quite literally, telemedicine is just that; healing at a distance. It’s been around as long as technology has been around. During World War I, you used a telegraph to inform about casualties or the needs of medical supplies. When the telephone was first invented, they were looking at ways to send heart tones through telephone wires and have physicians at one location be able to diagnose patients in another. They applied the same science to kids with croup or cough. So, we’ve always looked at ways to integrate technology and healthcare. It’s had a long history that most folks don’t realize. The pandemic heightened this need, but technology has always existed. It just became oh so obvious that it’s not going anywhere now.  

Telemedicine allows us some unique loopholes legally, as well. There was a ship in international waterways that was sending mail order birth control to folks in a nearby country because technically the ship existed outside the lines of what was legal for that country. That was maybe a decade or so ago. Now, when you start getting into services like that, things like Hormone Replacement Therapy (HRT) comes to mind as well. This is a service for folks that are transgender or non-binary, and here at Howard Brown Health, serving transgender, non-binary, and gender-non-conforming people is a cornerstone of the organization. So naturally we’re looking at how to expand these services, virtually. Having that kind of protection of a digital service, especially as states across the country attempt to limit access to them, could be life changing for a lot of people. 

It is important that we frame telehealth within these current hot-button healthcare issues, whether it’s reproductive health care, or whether it’s gender affirming health care. Prior to the pandemic, there was really no insurance buy-in. We had internet, we had zoom, we had all these things before 2020, but we didn’t have the infrastructure or the reimbursement from important players, like the insurance industry. It wasn’t mass utilized at that point because people didn’t know how they were going to pay for it or what the value was. Until the pandemic. A lot of programs had to pivot overnight, as we all did with life. The question became, “How do we keep going? How do we sustain healthcare and contact with our patients through other means?” Now I think in this post-pandemic climate, we’re looking at laying the foundation in a meaningful and thoughtful way. Telemedicine is not a fad. It’s here to stay. It’s a part of the soul of healthcare now, for good. 

When people think about telehealth, they might be thinking about quick, low grade treatments for things. It’s a project of ours here at Howard Brown Health to involve more primary care with telemedicine. We can use telehealth for really anything that where don’t need a physical exam. The things you cannot use telehealth for are services where you need to have something on your body examined. But if you had joint pain or if you had some kind of sciatica pain, there are things that I could walk you through, via telehealth, like stretches and exercises. Seeing someone in their living space is really helpful and quite important diagnostically, but I can’t put my hands on your body physically. It’s not going to replace the physical exam; one thing’s not going to overwhelm or replace the other. However, the capacity for us to do remote monitoring for chronic diseases is huge. Especially for conditions like blood sugar control in diabetics, where you could just get a constant update that’s sent to your provider so they can track how your blood sugars are moving, or how your heart rate is if you have congestive heart failure, or monitoring for antiretroviral medications to make sure that like your HIV levels are in range. The possibilities are exciting. 

In terms of the scope of services, for Howard Brown specifically, we’re doing a program for Hormone Replacement Therapy with initiating treatment, follow-ups, and more, all virtually. We can even do HIV care. We could do contraceptive counseling. We can do STI screening, where someone could come and talk about their symptoms. We can do the intake and then give you medications based on your symptoms and based on your clinical presentation. That also applies to PrEP, which is huge in limiting the spread of HIV.  There are so many things that you can see virtually first, and then we can either route you to a specialist, or if it’s necessary, we’ll see you in person. We can save you that visit. We can take care of it right in that moment.   

There is no federal agency or regulatory body for telehealth specifically. With the introduction of the Public Health Emergency Act during the pandemic, a lot of the regulations on what is considered acceptable or appropriate for seeing patients were suspended. Especially in terms of prescribing controlled substances. However, the Public Health Emergency Act officially expired May 11. 2023. The good news is, the DEA has issued an extension of permissions to continuing electronic prescribing of controlled substances, including testosterone. The extension is set through December 31, 2024. This means that we can absolutely provide PrEP follow up visits, STI concerns, referrals, medication refills, and HIV follow up through telemedicine as well. I am pushing for expansion to our hormone therapy program, although it is still all just within the borders of Illinois for now. 

Another example laws surrounding telemedicine was the concern around the Ryan Haight Act of 2008, which was employed because of nefarious websites where folks were able to get opioids online and there were unfortunately deaths that were a consequence of that. So, the FDA went, “How are we going to regulate these drugs? We really want to make sure you have an in-person visit with the provider that can authorize these medications. That’s going to be really important.” So that was implemented because of that crisis. So now the DEA is looking at ways that we can all move forward in a more thoughtful, constructive way in regards to controlled substances. It’s a hard stop; you’re going to have to see someone in person if you’re going to be prescribed opioids or any schedule two or three drugs. We’re just kind of preparing for it right now. But here at Howard Brown Health, we have other concerns too. Testosterone is a schedule 3 drug. It’s a life-changing medication for hormone replacement therapy for patients seeking gender affirming care. That drug is essential and vital for that community. These restrictions are problematic given the in-person requirement; a lot of gender-non-conforming patients do not feel comfortable visiting a doctor in person. It may not be physically safe to do so. I am committed to looking at ways that we can move forward thoughtfully to ensure that the services aren’t disrupted for these patients.  

In addition to allowing a provider to see a patient in their living space, I think there’s some benefits to seeing someone in their home when they are unable to communicate or cannot advocate for themselves. To have family members nearby that can help facilitate for elderly parents or someone who may have communication or neurological deficits, people that are able to fill in the picture for the clinician? That’s helpful.  

My other heart project is I look at digital equity and digital inclusion. Those are the cornerstones of the telemedicine program I’m trying to build here at Howard Brown Health. Digital equity is everyone having access to technological services and these digital resources. Sometimes I’m operating out of the south side of Chicago, where we have certain spots that are spotty for internet connectivity. I can’t rewire that, but I can try to help folks, whether that’s a remote van service where we can bring iPads to you and you can connect with the clinician, or something else. It’s a project that we’re thinking about; helping folks connect to their clinicians.  

The digital inclusion part is how well you can participate in this technological experience. What is your health literacy, what’s your technological literacy? How well can you capitalize on this experience with your healthcare? Howard Brown Health has a suite of Aging Services programs designed to help our elders live their best life in all areas. I want everyone to feel capable and competent online, so everyone can get the most out of their healthcare.  

Unfortunately, a lot of metrics for success or drivers of profit in a lot of healthcare organizations is how many patients you can see. Telehealth could be considered advantageous where that’s concerned; you don’t have to wait for a patient to make their way down the hallway into the clinic room. You can just click start and they’re there. On the other hand, there’s no substitute for spending your time with your doctor; building that relationship and trust is crucial. So does telehealth help us hit our bottom lines, at the cost of patient experience? 

Well, it depends on what the patient’s expectations are. If a patient wants to still be seen in person, in-person clinics are always going to exist. It is a question of what makes them feel confident and well taken care of, because even if they have like the best telehealth visit ever and it’s super long, as long as they don’t feel like it’s the same kind of experience, then it’s going to mar that memory for them, even if they get great care. Folks that feel comfortable with technology, that are interested in technology, or that want to engage in that will, I think that’ll always exist.  

Our patient satisfaction is high with telehealth; they haven’t felt a deficit on that. Giving patients options for their care is what it’s all about. That’s what we’re moving towards; how many ways can we touch base with our community? What kind of modalities can we use? Can we do it in person? Can we do it through the telephone? I’m even thinking about asynchronous care, where you and a doctor are almost sending direct messages back and forth, whenever it works for you.  Overall, I think there’s a balance, trying to move thoughtfully and be considerate of what makes good medicine, while knowing what patients are expecting and what the healthcare delivery system is pushing towards.  

I will argue that telehealth is not a perfect solution for meeting productivity metrics. You often have to do a lot of tech troubleshooting with patients. They log in, they have connectivity issues, they don’t know how to open the Zoom link, the sounds off, they’ve muted themselves. You have to spend a lot of time troubleshooting. Besides, in our system patients are still required to meet with a medical assistant first and collect a little bit of data, like their vitals. We still have what we call a “rooming process” where a patient is in a virtual room. They’re not in a physical space, but they’re still meeting with multiple people and progressing through the steps of their appointment. It still takes a little bit of time.  

Doctors had to learn a lot of soft skills in the pandemic. I think clinicians got thrown into it and we had to figure out on the fly how to continue working. You have to find creative ways to obtain information from folks when you can’t touch them. How do you engage with a patient physical exam when I can’t put my hands on you or listen to your heart? What are the questions can I ask specifically? What can you show me? What limitations am I thinking about? What would the next bit of information that I would need to make sure you’re getting care? You have to think as a clinician in a different way than you would in person because you have different data points. It’s a different skill set to do telemedicine. You may have to dismiss some preconceived notions of a patient; you may have to learn when to factor in a patient’s video background into their diagnosis. Is this video stream making them sound nasal? Is the phone shaking because their hands are shaking or because of the connection? All the questions I never thought I would have to ask.  

As for the future of telemedicine, I have some big pipe dreams. My focus point, specifically for Howard Brown Health, is looking at gender-expansive care and expanding services for that kind of care in multiple capacities, especially when it comes to medical aesthetics – making sure you look the way you want to. Let’s just say, for example, hormone therapy. A patient may have an interest in that. They would fill out a medical history and intake form that we would create for them. They would give us documentation, their insurance coverage, some things like that. They would basically enroll themselves. We would have to do some verification on our back end, but they would submit a request based off their profile. A provider at a different point would review the information and would then send lab requests for that patient to be screened. If it was for HRT, we check their baseline hormone levels. If everything comes back good, we then write them a prescription for medicine without ever actually seeing the patient. That’s an example of an asynchronous medical journey. It is great for very specific health issues that can be managed in these very specific ways. It allows the patient to engage on their time without the stress of scheduling an appointment and managing a calendar.  

A lot of times my patients are in the car or going through a drive-through, getting food on their lunch break. Or even in bed; I have all kinds of stories. Asynchronous care would be a way that if, at three in the morning, someone was like, “You know what? I have this really weird itchy infection and I’m kind of worried that I have an STI!” They could send a message, describe their symptoms, create a profile, and someone will get back to them within a few hours to follow-up. The same process can be applied to PrEP. With specific areas of health conditions, I think this would open a whole world.  

There are already organizations that are operating in that way, so I can’t wait for Howard Brown Health to get on board, too.  Not to mention the constant innovation that is happening with our tech; who knows how the biometric data that your phone and watch and earbuds take from you may factor into healthcare in the future. 

The last thing I thought was interesting is the way that we think about healthcare. We, as a society, like to think of healthcare as an isolated individual experience. HIPAA exists for a reason, after all. But it’s intriguing to think of health as a part of a community; really embedded in a patient’s life — not just their medical symptoms — but their identity and their community. Telehealth physically brings a healthcare experience into somebody’s home, which I think is a powerful concept. If you’re a patient thinking about your overall health, it might be easy to compartmentalize that. “I think about my health when I am at the doctor’s office.” With telemedicine, if you’re going about your day, working from home, and then you quick jump on a call, suddenly you’re addressing that health concern in a space that you’re in all the time. It grounds the conversation, your treatment, and how you perceive yourself in a much different way. Telehealth is more intimate because you’re coming into a patient’s world rather than the reverse. There’s also a sense of ownership.  I think there’s some interesting psychology in that. 

That’s the take home; expanding all facets of healthcare delivery to fit a patient’s needs, whatever they may be. If you’re someone who wants your food brought to your door, your dog walked for you, and your doctor on your phone screen, great. See you soon. If you want the experience of heading into a clinic and seeing your care team in person, great. See you soon. I have two little kids and it’s a pain in the butt to try to get both my children anywhere, so telehealth appointments really benefit my life in that way.  

Overall, I want to remind you that Howard Brown affirms who you are. That means in all spaces, we see you and we hold space for you and for your care. I speak specifically for my TNB community; there’s a lot of benefit in the physical safety that Howard Brown Health provides. We want to give everyone the opportunity to seek care in a safe space, whatever that feels like to you.  

It’s my mission to create a solid foundation and to lay a groundwork that is sustainable and thoughtful and meaningful for the future of telehealth, because it’s not going anywhere. It will try to do the greatest good for folks. That’s the goal.