As wide swaths of the southeastern US work to recover from the recent spate of hurricanes, they won’t be reliant on local health care providers alone. Since Hurricane Harvey began threatening the Houston area in late August, telemedicine vendors and healthcare providers alike have opened up their lines to receive emergency calls and support relief efforts free of charge.

This isn’t the first time that telemedicine providers have pitched in during a disaster, but it’s clear that the technology is now enjoying a much warmer reception. For Hurricane Irma, Nemours Children’s Health System told MobiHealthNews that downloads of its CareConnect telemedicine app increased 554 percent between September 8th and September 12th, while Florida Hospital told the Orlando Sentinel that its eCare service received 2,700 new users between September 8th and September 10th. In addition, Nemours noted that its social media posts describing the free services spread among followers like wildfire, and quickly became the system’s most widely shared posts.

“We decided once a state of emergency was called in the state of Florida that we could really provide the care and access that might be needed to parents across the state, and also to southern Georgia,” Carey Officer, administrator of telehealth at Nemours, told MobiHealthNews. “There were a lot of doctor’s offices that were closing due to the storm, and so parents were scrambling. Kids get sick when they want to get sick — they don’t wait for a storm to pass when they do. I think it brought a lot of relief to parents as they were [encountering] certain situations where they couldn’t leave their house.”

Teladoc — who along with American Well, Click-A-Clinic, Cure Companion, Doctor on Demand, MDLive, the Rowe Network, Vidyo, and other telemedicine vendors opened up their services during the disasters — saw a similar increase in use. Over the course of Harvey and Irma, its emergency line served more than a thousand people, Anne Stowell, Teladoc’s vice president of member experience, told MobiHealthNews. While the volume of callers was undoubtedly driven by the severity of the storms, Stowell she felt that these numbers could also represent a turning point for the maturing telemedicine industry.

“Telemedicine is reaching a critical mass of people being aware of what it is, and how it can help,” Stowell said. “It’s been a lot easier to help people understand how that fits into their life when they are displaced and need care. Five years ago it was much less of a known quantity. I think now that people know what it is, and when we make it available, it’s something people are inclined to trust and use, just because there’s a wider public awareness.”

Learning to prepare

Medical literature has long viewed telemedicine as an an opportunity to expand and support care during disasters — in fact, disaster medicine experts have been singing the praises of telecommunications as far back as 1995. However, understanding how best to leverage the developing technology and meet its growing demand has been a continuous learning experience.

“It’s an extremely important service in times of disaster,” Officer said. “We’re looking at it very closely to find ways that we can be proactive [in the event of] another storm, and learn from these lessons.”

Officer said that one of her organization’s major takeaways from its Harvey and Irma relief program was the value of raising awareness through various media channels prior to the event. Whether through social media or mainstream news, Officer and Stowell both stressed the need to connect with potential patients, and the impact doing so had on call volume.

“We have kind of an engagement engine running here at Teladoc,” Stowell said. “We’re working to get our members aware and registered using our service. With this, it’s really easy for us to switch that engine over to making people in Texas, or in Florida, or in Louisiana aware of the hotline itself. … There’s been much more uptake as well as much more chatter for the Harvey and the Irma relief efforts, and I think that has to do with our ability to push that message out in an effective way.”

Meet this demand and the numerous challenges of a natural disaster also requires extensive planning. Stowell said that her company’s experience providing service during prior emergencies led Teladoc to develop a multi-phase internal emergency preparation and response plan. In the weeks before, a team will gauge the expected severity of an event and, if it’s deemed to be a significantly pressing emergency, begin reaching out to partners and sending out awareness messages to the public. Then, once the storm hits, Stowell said, their teams will have their infrastructure prepared for the influx of callers.

“Because we have such a robust technology infrastructure, we were able to turn that on within a day and our network was able to support the volume of the thousand-plus people who were coming to us well above our normal volume,” Stowell said. “We couldn’t do this — turn it on quickly and do it well — without the groundwork.”

Disaster preparedness plans are not unusual for telemedicine vendors. MDLive told MobiHealthNews last month that it also had a pre-drafted plan ready prior to Hurricane Harvey. However, it still pays to be flexible, Officer said, as their service had to quickly increase the number of providers on-call to meet the growing demand.

Telemedicine can benefit larger relief efforts

Beyond securing their own infrastructure, telemedicine services must also coordinate with relief organizations, local and federal government, and other emergency responders. As a system of pediatricians, Officer said that much of Nemours’ role during the storm involved supporting shelters or other healthcare providers on the ground who may not be fully equipped to provide the appropriate specialty care.

“Talking to the leaders of the special needs shelters, they didn’t even think about having an iPad,” Officer said. “Having the opportunity to have an app ready to go, and ensuring that there are lines of communication that can handle that type of video conferencing — that would be tremendous, and that really solves a lot of the equation when you start to think about having the right expertise at the right place. That’s a part of the conversation today, and I think that has to become a very important piece of how we prepare for disaster moving forward.”

Teladoc, on the other hand, has a standing partnership with the American Red Cross that allows the company to assist shelter staff and those who have evacuated but may not have a working mobile device. The arrangement, Stowell explained, is an example of how telemedicine can be integrated into organized relief efforts.

“Our partnership with the Red Cross is a really good model for that, and I think it’s extendable to any other relief agency, or governmental agency, or support infrastructure [after] an event like Harvey or Irma,” she said. “We have worked to make sure that they have the information they need in shelters, so when people evacuate and stay in a Red Cross shelter, the Red Cross staff there has information about the available Teladoc services and hotline, and then they are able to deploy it in the shelter.”

Dedi Gilad, cofounder and CEO of telemedicine vendor TytoCare, also sees larger-scale collaborations between telemedicine providers and relief efforts as the future of disaster relief. He argued that while telemedicine companies are “being nice” by distributing services to disaster evacuees, the relatively low number of government-backed emergency telemedicine programs is a missed opportunity that needs to be amended.

“[We] really should do it in a more organized way, and be better ready to support these kinds of situations,” he told MobiHealthNews. “I’m not part of any governmental or state board, but if I were I’d say it is relatively simple and low-cost to get ready with this kind of tool. We basically only need communication, and maybe some very basic tools.”

Such preparations may be sparse now, but telemedicine’s growing adoption during these emergencies could improve its chances of being noticed. In an story published on FierceHealthcare.com following Harvey, Nathaniel Lacktman, a partner and chair of the telemedicine industry tream at Foley & Lardner LLP, said he expects public and government officials to appreciate telemedicine’s support during emergencies, and suspected that many “forward-looking hospitals” may look to integrate telehealth into their disaster preparations. For Officer, though, the case has already been very clearly made.

“What we saw during Hurricane Irma is confirmation that telehealth can also be a very important channel for connecting families with providers when traditional means of accessing care are blocked,” Officer said. “Reviews from families who used Nemours CareConnect during the storm were very positive and our providers felt they were truly able to help. I expect this will be an important solution as our country responds to future disasters."

Overcoming telemedicine's shortcomings

Telemedicine does have its shortcomings when it comes to providing disaster relief, however. Perhaps the most stark limitation is the inability to treat life-threatening injuries or other critical conditions that require hands-on attention.

“The first challenge is really what we can help with and what can’t we help with,” Stowell said. “Someone has a broken leg in Houston — telehealth definitely can’t help that.”

Still, the technology can provide indirect help to these patients by reducing the number of patients flooding emergency departments with low-priority issues, Gilad explained. And in many cases, the capacity to provide prompt, personalized triage alone will provide the best outcomes for those weathering the storm.

“When someone is very physically hurt, even a good quality camera to be able to look at a cut, or a bruise, or any issue that requires attention [is useful],” Gilad said. “The diagnostic side is important just to tell you if this is serious and you have to run to the hospital, or if just putting on some bandages and getting some rest [is enough].”

Officer agreed that, for many, telemedicine’s primary role may simply be diagnostic. However, she stressed that this benefit cannot be understated when people are displaced and in need of more information.

“There was a lot of great triage because parents have a lot of questions,” she said. “You know, you’re hearing across the state ‘Stay in, stay in, don’t go out, it’s too dangerous.’ So, you have a lot of nervous people, a lot of families that were moving across the state thinking they were escaping the storm and then having to move again, so not necessarily in their normal communities.”

Another issue comes with infrastructure and connectivity. Winds and water can frequently knock out power, telephone, and internet services, meaning that many of those taking shelter in boarded-up homes are effectively cut off from the outside world. Further, those who do leave their houses to seek care or shelter may not have a mobile device with them, or might lose their source of communication after the first few days of traveling.

For these particular storms, Officer said that she was surprised at how many people maintained connectivity despite any service outages. Regardless, she admitted that Nemours and other telemedicine providers need to challenge themselves to find a good way for the technology to overcome these roadblocks. Conversely, Stowell said that in Teladoc’s experience with these storms and those prior, well-equipped relief shelters with a sturdy connection have served as the best means for expanding access. Gilad took this approach one step further, and argued that more should be done to make access ubiquitous outside of major shelters.

“You can deploy this kind of low-cost solution in schools, in malls, and other shelters,” he said. “You can have a few rooms with very good service tools and communications where people can come in. You can put it in many, many areas … and maybe as part of the more governmental or state-wide strategy you can define locations that have high-quality networking.”

Additional logistical issues arise as other services in disaster-struck communities, such as local pharmacies, begin to close their doors. Officer said this is a key concern that comes with storms, and ensuring that patients who need antibiotics or specialized treatments for chronic diseases can find an open distributor is a top priority for telehealth services. The issue is only exasperated by evacuees seeking shelter in unfamiliar communities, Stowell noted, leading her company to tap outside resources when helping patients.

“The ways that we solve that is working with third parties who publish lists of pharmacies that are still open and making sure that that is available on social media and available through our provider networks,” Stowell explained. “So, if someone is providing care to someone in the moment, they can also help advise where to go.”

Telemedicine fills gaps in disaster care

Despite these challenges, the recent relief efforts have been a showcase of telemedicine’s specific strengths, including its capacity to provide continuous support in the days and weeks following a disaster. Dr. Deborah Mulligan, chief medical affairs officer for MDLive, explained last month that virtual physicians are capable of diagnosing the various infections that come from upended sewage systems, for example, and using video consultation can examine bites marks from feral animals. Her company — along with Teladoc, Doctor on Demand, and others — also provides behavioral and mental health treatment, which normally might be pushed to the wayside when local providers have their hands full with physical conditions.

“Roughly 20 percent of the population suffers from a mental health diagnosis at some point in their life,” Mulligan said in an earlier interview with MobiHealthNews. “A hurricane of this gravity may exacerbate pre-existing conditions, as well as increase stress levels, anxiety and depression in those affected.”

The back-to-back storms have also better demonstrated the benefits of a decentralized physician network. Whether it’s due to a wide-sweeping power outage or an emergency evacuation, local doctors frequently find themselves unable to handle patients, Stowell and Officer explained. In these situations, providers who are unaffected, or are easily able to resume their services after a blackout, are an invaluable advantage.

“We have our providers in multiple states and locations,” Officer said. “Once we lost power, it was wonderful to have consistent service from our clinicians who were in a different state. So the fact that we do have physicians sitting in multiple states was a wonderful advantage — that we could bring the same level of pediatric care, the same protocols, the same quality of care to our patients and families, not relying on all of our physicians being in Florida in a storm.”

While Florida and other states have allowed out-of-state practitioners to lend their services through telemedicine for some time, Texans recovering from Harvey would have been left in the cold if not for a new Texas telemedicine law that went into effect earlier this year. The law, signed on May 27, made Texas the last state to abolish the requirement that patient-physician relationships be established with an in-person visit before telemedicine can be used.

Even during an emergency, though, complications remain when coordinating cross-state care. According to the American Telemedicine Association’s resource page for disaster relief, “most states” have existing statutes for out-of-state providers that waive the need for additional licensure. As of Sept. 29, Florida, Georgia, North Carolina, Puerto Rico, South Carolina, and Texas have all declared States of Emergency and are still seeking outside assistance (although the ATA still suggests that providers contact state licensing boards to ensure appropriate practice in the affected area).

That being said, many of these restrictions would primarily apply to professionals interested in volunteering their services through telemedicine without specific licensure. Teladoc, Nemours, and the long list of other established providers who have opened up their services will have a collection of cross-state practitioners ready for action. It’s just another part of the planning and groundwork whose importance Stowell says becomes more clear to telemedicine providers with every disaster.

“The lesson learned, at least for me, is that preparation pays off,” she said. “Making sure you have a plan, and making sure that you have the technology infrastructure, and the people, and the processes, and the awareness mechanisms in place to be able to help people quickly in the right way is really critical.”

Or, in fewer words:

“Prepare for the worst, and you’ll be a little better when the worst comes.”