Yale sets the stage for mainstream telemedicine

As telemedicine transitioned from optional to essential in the spring of 2020, Yale School of Medicine became an early leader in the field. Telemedicine was already an appealing option due to transportation costs and delays; illness or injury; and the risk of new infections. A number of Yale clinicians had offered remote visits for several years. Even so, telemedicine was not the default system of care until the pandemic struck. Yale Medicine (YM) and the Yale New Haven Health System (YNHHS) coordinated a rapid response, and the number of video visits increased dramatically. Where there might have been 34 on any given day pre-COVID-19, that number has since risen to 1,500, according to Pamela Hoffman, MD, medical director of Telehealth Services for YM and YNHHS.

Although ultrasounds and surgeries cannot be performed remotely, the range of appointments that can is extensive. So much medical care is cognitive, and telemedicine can provide access to a variety of specialists who can ask questions and observe physical manifestations. Patients can also check their own vital signs if they own the correct devices. “Certain specialties are particularly suited to telehealth, especially those whose consultations are strongly based on diagnostic tests and less so on the physical examination,” said Aldo Peixoto, MD, professor of medicine (nephrology) and clinical chief of the section of nephrology.

Departments defined by physical procedures can also use virtual appointments. “I anticipate that we will continue to use telemedicine in our preoperative screening process post-COVID,” said Jill Zafar, MD, director of presurgical evaluation at Yale New Haven Hospital. In the Department of Surgery at YSM, some 25% of clinic visits are being conducted remotely; ENT surgeons have implemented a novel destination program to conduct cochlear implant testing via telehealth.

COVID-19 also influenced how clinical trials are conducted. “With many aspects of human subject research on hold for several months, our ability to conduct research visits remotely has been essential,” said Allen Hsiao, MD, chief medical information officer, YSM and YNHH. “Even as restrictions are lifted, we are mindful of social distancing and convenience for our trial participants and will continue with remote options.”

Last year, Yale upgraded and streamlined its electronic health record system under the direction of Lisa Stump, MS, senior vice president and chief information officer at YNHHS, adding e-consent for clinical trial participation. “We could not have known then how instrumental these upgrades would become to the Yale Center for Clinical Investigation (YCCI) and our researchers,” said Hsiao. “Without it, we would not have been able to manage this transition as well as we did.” YCCI provides a robust infrastructure of resources for clinical and translational investigators.

“To participate in telemedicine at Yale, patients download the MyChart app and log in to connect with a provider for a scheduled appointment. The platform is completely compliant with HIPAA,” said Hoffman. If necessary, a telephone consult is a second option.

Elsewhere at YSM, the medical student curriculum was also upended by COVID-19. When training moved online and clinical rotations were suspended, students were eager to engage in other ways. Several new electives arose, including two on telehealth.

Health equity is a significant challenge that has yet to be fully resolved. “During the pandemic, the potential of telehealth emerged to increase healthcare availability at a time of significant limited access. But it also revealed a digital divide that created access barriers for many marginalized patients—such as those who cannot connect at all; can only connect by telephone; can only connect within narrow time-frames; have limited English proficiency; and so many others,” said Marcella Nunez-Smith, MD, MHS ’06, Associate Dean of Health Equity Research and founding director of the Equity Research and Innovation Center (ERIC). “However, we have an opportunity to seize this policy moment and address connectivity as a critical health determinant and align incentives so all patients benefit from telehealth innovations.”

In an effort to understand these issues, the ERIC team has convened researchers across YSM, under the direction of Karen Wang, MD, MHS ’12 and Carol Oladele, PhD, to examine barriers and opportunities in telehealth and digital equity.

Telemedicine refers to medical appointments made via video or phone. Telehealth describes the broader use of virtual technologies in health care.