To officially diagnose COVID-19, a physical test must be performed. Here’s what telehealth should be able to do:
1: Establish pre-test probability of disease from patient self-reported symptoms.
2: Based on symptoms, communicate to the patient detailed next steps and exactly where to go and what to do.
3: Connect pre-test probability with actual test results.
4: Maintain a relationship with the patient throughout the course of their disease.
Detailed next steps should include:
- Possibly positive = Get tested at a drive through testing center
- Presumed positive= self-quarantine at home or a quarantine center
- Likely positive with mild respiratory symptoms = same as presumed positive
- Likely positive with moderate respiratory symptoms = not ICU but supportive oxygen therapy
- Likely positive with severe respiratory symptoms = ER/ICU
Here’s how telehealth should work in this situation to leverage the full potential of telehealth:
- It should be asynchronous (video is not necessary and leads to bottlenecks due to demand)
- Powered by standardized questions that can be updated based on new recommendations across all telehealth services (this should be in writing, not an oral conversation via video)
- Answers to standardized questions should be correlated with test results (ongoing relationships, not video visit transactions). Continuity of care is vital. If telehealth is transactional between strangers, there’s no way to track progress.
- Patients with symptoms and diagnoses managed in quarantine at home need to feel like they have a consistent team who knows them as their disease progresses. Patients are going to be anxious, scared, and their symptoms will wax and wane. They need relationships and questions answered over time, not transactions.
So what do we need to make this happen?
1: Telehealth needs to support ongoing relationships, not transactions. We need to be able to triage and associate triage advice with positive or negative tests. You do this via continuity of care, not video call centers. The word on the street is there’s a 6 hour wait for insurers’ synchronous video visits. Asynchronous solves this problem.
2: We need to create standardized questionnaires to asynchronously take standardized history of symptoms across all telehealth services. We should all come together and share these standardized questions.
3: Drive through testing centers need to be in all communities everywhere and all telehealth services need access to a list of local centers so this can be communicated to patients in writing, not via an oral conversation.
4: Temporary centers need to be created that can provide oxygen support short of ventilation need to be in all communities. All telehealth services need access to a list of these local centers so this can be communicated to patients in writing, not via an oral conversation.
5: ICUs dedicated to ventilator support specifically for COVID-19 cases need to be established. All telehealth services need access to a list of local ICUs so this can be communicated to patients in writing, not via an oral conversation.
In summary, telehealth services need to be standardized, asynchronous, continuity-based, and connected to local testing centers and the most appropriate treatment centers.
Transactional synchronous telehealth as it exists today is a tiny fraction of its potential. But that’s because it was invented to perpetuate and expand transactions for simple issues like pink eye, not to actually solve real world problems.
Questions I have:
Shouldn’t there be a standardized, open-source list of questions we should be asynchronously asking all patients with symptoms?
Shouldn’t there be a list of crowd-sourced:
- local drive-thru testing centers?
- local supportive treatment centers?
- local ICUs transformed into COVID-19 specific ICUs?