Telemedicine in Ukraine Is Showing That High-Tech Isn’t Always Better

(Photo by iStock/Joel Carillet)

The 2022 Russia-Ukraine war has caused significant loss of life and destruction of people’s livelihoods. However, international aid efforts continue, with a focus on restoring health and safety to the region. Urgent action is needed in times of war, and this has presented opportunities to highlight the incredible innovation that can be applied to our modern health-care system and other situations where humanitarian relief is required. Just as World War II greatly boosted industrial productivity, we’re now seeing remarkable advances in telemedicine stemming from the war in Ukraine. While the COVID-19 pandemic prompted a rapid expansion of telemedicine in the United States and other western countries, Ukrainian efforts by necessity have been much more aggressive.

We are all doctors, medical students, and telemedicine professionals involved in the Ukrainian relief efforts, working alongside nurses, volunteers, and engaged citizens. What have we learned so far? The biggest lesson is that with technology, less is more. Companies and regulators run the risk of missing out on the biggest opportunities for raising productivity by requiring high-tech solutions that are both costly and unnecessary.

Serving in the Catastrophe

In 2022, as Russia’s invasion devastated much of Ukraine’s health-care infrastructure, volunteers and scores of new and old humanitarian groups from around the world mobilized resources to help. Telemedicine quickly became an essential channel and continues to evolve as the war continues. One study of 125 Ukrainian medical professionals found that 99 percent of physicians continued their use of telemedicine tools, and more than half of physicians increased telemedicine adoption during the conflict. 

Soon after the start of the war, we helped to mobilize two organizations: Health Tech Without Borders (HTWB) and Telehelp Ukraine. Together, they have completed over 62,000 tele-consults for patients. HTWB recruited 800 volunteers, most of them from outside the United States, with a focus on Ukrainian- and Russian-speaking physicians that could plug-and-play into a Ukrainian-built telemedicine platform called Doctor Online.

While HTWB focused on primary care, Telehelp Ukraine aided patients requiring specialists. The two organizations coordinated their efforts to hand off patients as needed. In collaboration with other providers, HTWB and Telehelp Ukraine offer the entire spectrum of medical care to Ukrainians, from primary care to specialty consults via virtual means.

Of course, many patients in Ukraine still require traditional in-person care, especially those who were wounded in the conflict. Telemedicine has provided a means of screening and initial treatment, allowing the remaining medical centers to focus on those who need direct attention without being overwhelmed.

By contrast, telemedicine use in the United States peaked during the first wave of COVID-19 in April 2020, when 69 percent of physician visits were conducted remotely. Telemedicine use has decreased significantly since. Health organizations have put significant effort into building digital health infrastructure, however they are still learning how to leverage those technologies to address the problem of low access and adoption in underserved communities.

Across the United States, 80 percent of rural areas qualify as federally designated “medical deserts.” This means that approximately 30 million people live at least an hour away from the nearest hospital with trauma services. Furthermore, many people suffer from chronic illnesses or social barriers that prevent them from accessing health care through physician offices and hospitals. Telemedicine could be an effective solution to reducing their suffering. For instance, telemedicine could allow someone with anxiety to receive mental health therapy from the comfort of their home, while a patient who noticed a suspicious lump on their skin could have a virtual consultation to help determine how serious it is. However, there are key barriers to telemedicine adoption such as lower education levels, digital literacy skills, or access to broadband connectivity that must be addressed in order to ensure equitable access to health care. To further improve adoption, it is important to propose user-friendly and low-tech options for those who are less tech-savvy even if more advanced technology is available.

(Photo by Anna Tartynskyh)

Low-Tech Works Fine

Like many other fields, the world of telemedicine has embraced a kind of technological determinism: if a technology exists that promises a better experience, then we must engineer it into our current offering. But the Ukrainian experience suggests otherwise. Of those 62,000 telemedicine visits completed by HTWB and Telehelp Ukraine, 98 percent involved only text between the physician and patient within a secure telehealth platform. No live video or even audio required, and no call for the sophisticated biometric devices now in development.

Texting has the obvious advantage of needing less connectivity, especially in a war zone. It has also become a generationally ingrained practice worldwide, while many people can struggle with video calls. But texting also allows a more productive use of the scarce resource: the time of clinicians. They can respond asynchronously, when it is most convenient, as can patients. With texting, telemedicine can handle a great many more patients than if it relied on synchronous technology.

American providers are beginning to catch on. CirrusMD is a “text-first” virtual primary care platform, where patients begin each visit by sending a text to a physician. They can send images or host video calls and receive referrals to specialists. Asynchronous messaging allows for greater back-and-forth between a busy clinician and the patient.

Studies suggest that texting is an effective form of health care—including for reducing unnecessary emergency department (ED) visits. A study of 700 children with appendectomies found a text message intervention to answer questions reduced post-op ED visits by over half. Avoidable ED visits lead to increased wait times for all patients in the ED and can lead to worse health outcomes for patients who would be better taken care of in a different care setting. Additionally, the ED is estimated to cost 12 times as much as a primary care office visit, leading to private insurers paying a potential $32 billion per year—raising overall health-care costs.

Texting, as a preventive digital health tool, can also easily fit within the US health-care system's insurance and payment models. When UCSF Health was overwhelmed with questions early in the pandemic, it successfully began reimbursing physicians for their time responding to these messages, and then billing insurance for messages requiring medical expertise. Providers make the determination if a message is billed to insurance, and the hospital system bills insurance based on insurance type (i.e. private, Medicare, or state Medicaid).

One barrier faced by text-based telehealth are provisions in medical boards for “Good Faith Examinations.” These laws extend back to the 1800s when medical boards were first created and set rules requiring a physician to perform a medical history and physical exam prior to prescribing for a patient. While these may be necessary to establish care, digital text methods to follow up with a patient should be created so that in-person physical exams are not always required, especially in situations where the chief complaint is psychiatric or simpler, like medications refills.

Regulators, however, are going in the opposite direction. Telephone calls are still the primary form of telemedicine in the United States. According to a survey by the American Medical Association, two-thirds of physicians conduct audio-only telemedicine visits. Yet Medicare and Medicaid, after allowing audio-only telemedicine for the first three years of the pandemic, are now moving back to reimbursement for video-based visits, except for specific types of visits. CMS (The Centers for Medicare and Medicaid Services) sets reimbursement rates for health-care services in the annual physician fee schedule, with private insurers generally following the lead of CMS policies. During the COVID-19 public health emergency (PHE), emergency rules included higher rates for telehealth reimbursement, however these rules have not been legislated and are set to end soon. Not only would this reversal jeopardize care to patients who struggle using technology or lack reliable internet connections, it would also limit the productivity and capacity of telemedicine.

Patients Need Navigators

While telemedicine promises to solve many of the problems of our broken health-care system, it does create a new one. Health care will always be complex, and telemedicine adds a technological barrier, especially amongst populations unaccustomed to using technology such as the elderly. Telehelp Ukraine realized this problem early. Besides building up translator resources, it sought out volunteers to serve as health-care navigators. They help patients sign-on to the platform and remind them of appointments. They also collect the various information forms ahead of the appointment to send to providers; then after the appointment they adapt the clinical notes into language the patients would understand and arrange follow-up appointments as needed. They also generally advocate for patients and give feedback to the platform.

Regardless of setting, it is complicated to navigate health care. Having someone who understands the system and speaks on the patient’s behalf adds immense value to the experience. High-touch care has already been shown to improve outcomes and reduce costs in conventional care settings, as in this study of 17,000 seniors where researchers compared health care utilization and hospitalizations for patients in two different care models, one high-touch and one not. These non-clinician navigators need minimal healthcare expertise but can greatly improve the productivity of clinical resources.

Realizing the Promise of Telemedicine

In addition to the problem of geographic access, the US faces a looming shortage of health-care expertise. The American Medical Association estimates that by 2034 there will be a shortage of between 17,800 and 48,000 primary care physicians. Telemedicine has the potential to overcome this shortage by greatly increasing the number of patients able to be seen by a provider, but only if we adapt our policies to make it welcome.     

 

Some of these changes are already well understood, including the need for reimbursement parity between telemedicine and non-telemedicine visits with a clinician. Besides reimbursing for non-video visits, reimbursement should extend to health-care navigators, who likewise make scarce clinical resources more productive while boosting outcomes. Further, if patients can self-report their level of digital health literacy, the amount of support provided can be personalized. We need to reform the medical licensing system to allow clinicians to treat across the country, regardless of state or system borders. A full embrace of electronic medical records will also help to improve communication and reduce errors. Lastly, we need to invest in broadband infrastructure in programs such as President Biden’s “Affordable Connectivity Program" as well as extension programs in the private and nonprofit sector to make sure resources reach those most in need. The Affordable Connectivity Program is a benefits program providing $30 per month for internet service and up to $100 for the purchase of a laptop, desktop computer, or tablet for eligible families. Similarly, in the nonprofit sector, Link Health has recognized broadband connectivity as a barrier to health-care access, and is working with health-care systems to connect patients in waiting rooms to sign up for the Affordable Connectivity Program. There still exists much room to innovate for offerings in telehealth, from addressing disparities in digital health access to creating new services for chronic conditions to developing more at-home diagnostic and therapeutic options.

Telemedicine is a crucial component of health care and will continue to shape its future. To ensure a well-rounded and future-proof health-care system, we must approach it as a puzzle and integrate all elements, including traditional health-care delivery, telemedicine, remote monitoring, interoperable data, electronic health records, point-of-care diagnostics, community support, and connected portable devices. Adoption of these components should also be incentivized, not only for patients but also for health-care professionals.

The Russia-Ukraine war has resulted in a humanitarian crisis, and the efforts of clinicians outside the region have only provided some relief. Let us capitalize on these experiences and apply the lessons learned to better the health-care system in the United States and other countries, transforming the way we deliver humanitarian aid for more efficient outcomes, serving more with less.

Read more stories by Jarone Lee, Wasan Kumar, Marianna Petrea-Imenokhoeva, Hicham Naim & Shuhan He.