Your Virtual Gynecology Visit: A brief history, plus do’s and don’ts
By Dr. Aldene Zeno
Virtual doctor visits go by many names, including “telehealth” and “telemedicine” or “telemed.” These include video and telephone visits, and the concept is not new: Physicians have used it for decades to provide guidance to colleagues across the globe, even in cross-continental surgeries. The Kaiser Permanente health system has also used telemed for decades — I remember when video visits were rolled out during my residency at a Kaiser almost 10 years ago.
Telehealth was not widely used until recently. For a long time, both patients and healthcare providers have wanted to offer more remote services, however there was one major roadblock: reimbursement. Most physicians are not paid like lawyers by the hour. There’s a big amalgamation of pay structures, and these days the payments are typically filtered through large health systems before reaching the healthcare providers. Most of these payments are actually reimbursements from insurance companies, and the value for services is often dictated by the government through the Centers for Medicare and Medicaid (CMS). When CMS sets the monetary value for a given service, other insurers often follow suit. The 2018 national budget included an expansion for telehealth services, which was set to take affect in 2020.
The COVID pandemic made a huge impact on the way all healthcare is delivered. March 17, 2020, the CMS made major, but temporary changes to telehealth laws. Among these changes, it allowed for reimbursement of telehealth visits, and some states reimburse these visits the same as in-person (termed “payment parity”). However, only 22 states have laws on the books regarding payment parity or other reimbursement for telehealth. With such nationwide variation, there is concern that the temporary CMS provisions regarding telehealth are at risk. The Post-COVID-19 Telehealth Bill did not make it through Congress last year, however it was reintroduced last month and will hopefully make telehealth here to stay.
In my experience, telehealth has been a great option for the right patient. I hope that our government will do the right thing and continue to support virtual visits. Most of my patients are referred from central and southern California, and without telemedicine many would travel several hours to see me in-person. A lot of urogynecology care can be provided remotely, so I’m happy to offer this service. However, telemedicine does have its limits, and some medical problems are just not appropriate to address on video or over the phone. Here are some tips for those of you who have virtual healthcare visits in your future:
- Make sure telehealth is the right platform for addressing your problem
Many healthcare encounters involve counseling (i.e. just talking), where the healthcare provider is checking in on a patient, or a patient can communicate an update on her condition. Even my new patients can establish their care with me by telling me about their condition, and I can give some initial advice based on general best practices.
One of the CMS provisions in 2020 was to allow for patients to receive insurance coverage for a visit with a provider they had not seen before. However, any patient that is new to me will eventually need an in-person evaluation. Additionally, even if you’ve seen your doctor before, any new symptoms will likely require your doctor to perform some sort of physical exam, which brings me to my next point…
2. Please don’t drop trow by video chat
This is not as obvious as it sounds — yes, I’ve had to discourage a well-meaning patient from seeing if I could take a look at something on her vulva on-screen. It’s just not ideal in a clinical setting to check lady-bits by video, and physicians rely on things besides appearance to make diagnoses. Very few vulvo-vaginal symptoms in women’s health can have targeted treatment without prior in-person evaluation. A few situations that can be treated without seeing or testing someone include treating sexual partners of individuals with sexually transmitted infections, and treating some women over the phone for urinary tract infections or vaginal yeast.
Hopefully, this will also ease concerns patients may have about doing a virtual visit for women’s health. There is a lot we can accomplish in a conversation. Anything more private can be addressed in the office.
3. Protect your privacy — both in your physical space and in cyberspace
Women’s health concerns often involve sensitive subjects. It’s important that you feel as comfortable as possible during your virtual doctor visit, so I advise patients to be in a quiet, private room during their appointment.
Additionally, it’s important to make sure your device is secured. Prior to 2020, telehealth visits had to originate in certain settings or by certain privacy-protected devices in accordance with HIPAA laws. CMS liberalized these rules, making it possible for people to use cell phones for video visits as long as the visit is on a platform with end-to-end encryption and meets other specifications, so even Apple FaceTime or Google Hangouts qualify. We all know that devices using WiFi can be vulnerable to outside threats, so please make sure your device has up to date cyber-security. Ideally, you would use a secure WiFi network as well as opposed to a public one.
4. Sensitive topics may be better discussed in person
I recently had a patient who’d had multiple telehealth visits with other doctors, and she’d mentioned to them a sensitive mental health issue. However, because she lived with family and wanted to maintain her privacy, she did not feel comfortable detailing her recent issues until she happened to see me in person for a separate matter. Thankfully I was able to have her seen by my clinic’s licensed clinical social worker that same day. My patient was so thankful to just have people to talk to.
For a woman dealing with domestic abuse, or patients who otherwise have delicate subjects to discuss, even a private room at home may not feel safe. In these situations, it’s important for us as healthcare providers to recognize when someone needs in-person help. For patients, it’s important to know that even in a pandemic you have a right to in-person assistance when a virtual visit are not adequate.
Women experiencing abuse are not the only demographic that may suffer from telehealth. Virtual visits may potentially exacerbate health inequities among people of color and older people, according to a study done in New York City. Some of this may have to do with access to internet or the devices needed to do telehealth, so while those inequalities are addressed it’s important for patients to also have access to traditional healthcare visits.
