Telemedicine experts discuss their biggest challenges

"I think the biggest challenge is the technical aspect, because there's always a potential that even if you have good connectivity, your patient may not; or even if you both have good connectivity, the platform might be suffering some sort of overload or some sort of error," says urologist Aaron Spitz, MD.

The COVID-19 pandemic has had wide-ranging effects on the practice of medicine. These include cancellations of in-office visits, surgery postponements or cancellations, social distancing in the office, and the explosion of telemedicine. As a result of the pandemic, the federal government has instituted emergency measures that lift restrictions on the use of telemedicine. This Urology Times® webinar, featuring experts in telemedicine, practice management, and coding and reimbursement, examines the impact this public health emergency has had on the practice-related aspects of urology and how urologists can prepare for the future once the emergency declaration is lifted. (To view the webinar in its entirety, see

The panelists were moderator Jonathan Rubenstein, MD, chief compliance officer, Chesapeake Urology Associates, Towson, MD and clinical associate professor, department of surgery, University of Maryland School of Medicine, Baltimore; John Gore, MD, MS, professor of urology, University of Washington, Seattle; Aaron Spitz, MD, a urologist in private practice at Orange County Urology Associates, Laguna Hills, CA and assistant clinical professor of urology at the University of California, Irvine; and Eugene Rhee, MD, regional coordinating chief of urology at Kaiser Permanente Southern California.

In this segment, the panelists discuss their most difficult challenges in implementing telemedicine.

Rubenstein: Let's talk about challenges. Dr. Gore, what do you think is the biggest challenge that you have had with telemedicine?

Gore: Number one is identifying patients we have typically seen as in-person visits where we can still do some telemedicine visits. Number two is the technology on the patient end and the patient comfort with it. That may relate in large part to my patient population, but I also think it's an opportunity. I may have a clinic where I've planned all telemedicine visits, and 30% of them get converted to telephone visits. But when I initiate the visit, one of the things that I always try to tell patients is the time that you and I invest in trying to make the video visit work is time that will pay off with our future telemedicine visits as we continue to do this in the future.

I try to take this opportunity during COVID where my clinic schedule is not as crazy busy as it usually is because we rescheduled a lot of the non-urgent patients. I try to use it as an opportunity to help patients learn how to do the telemedicine on their end, because that's been one of the biggest challenges is technology on the patient side.

Rubenstein: Dr. Spitz, your biggest challenges?

Spitz: I think the biggest challenge is the technical aspect, because there's always a potential that even if you have good connectivity, your patient may not; or even if you both have good connectivity, the platform might be suffering some sort of overload or some sort of error. It's really important to have backup communication systems ready to go. It's also really important to have staff that is preparing the patient for the upcoming encounter.

Have the staff talk to the patient ahead of time to either ensure they understand the platform and our onboarding, or if they don't understand the platform or don't want to use the platform, have provided the staff with a telephone number where they can be reached most easily for a FaceTime, an email, or a Skype, or ultimately a phone number where they can be reached for a phone call. Have that staff provide you that information behind the scenes so that if your audiovisual encounter fails, you can immediately toggle to the next line of communication without delay and without frustration, and both you and the patient understand that those lines of communication are open.

A lot of that is contingent on having your office staff there, either from their home or from a central hub but still working with you with these telemedical patients. Don't make the mistake of thinking because you're doing telemedicine on your own computer, you're on the hook for the whole kit and caboodle. Just as with patients when patient charts were prepped and patients were prepped, this is still going on, on the telemedicine side of things, in our practice, and it keeps that workflow very smooth.

Rubenstein: Dr. Rhee?

Rhee: In terms of scalability, our challenge with this is determining whether the amount of volume that we're doing really translate into efficient care. In other words, does a telephone or video visit translate later to continued telephone video visits, or does it just create more work over time in terms of interest and throughput with face-to-face visits? That's the challenge: to prove whether or not the telemedicine actually increases capacity for those patients that we really need to be seeing versus those that don't necessarily need to be seen face to face.

On a really exciting note is the innovation that is occurring. It is unbelievable the opportunity here to look at everything from devices to genetic tests to markers. Which of these things can replace a face-to-face visit? What are these things that can actually help us along the way? Whether it's used for proctoring or whether it's to teach or to do something with the advanced practice provider, these are the things that we're really interested in doing.

That to me is a positive challenge that I think we are embracing. We're looking at things like bladder cancer markers to really see which of these really do not need surveillance cysto, as an example. We're looking at genetic markers. We have different devices we're looking at. We're looking at an at-home uroflow that's an app. We don't want to bring in the patient, nor does the patient want to come into the clinic, to get a uroflow done. These are just small tidbits, but it gives you a window into the future.