Health professionals answer the call of telemedicine in Oklahoma

Telemedicine use in Oklahoma grew significantly as a result of the COVID 19 pandemic, according to an online survey conducted by the Oklahoma State Medical Association in 2020.

The results of the survey, with 370 physicians responding, indicate that 84% did not use telemedicine prior to the pandemic, but after the crisis began, 72% of the physicians adopted telemedicine into their practice.

Despite substantial increases in telehealth use in 2020, state physicians are reporting declines in the number of patients requesting virtual services in just about all areas except behavioral health.

Before the pandemic, physicians were generally reluctant to embrace virtual care, as most were unfamiliar with it, reimbursement was poor, and many questioned its value.

These Oklahoman health professionals are sharing how these online visits have affected them and their communities, and how they see this trend going forward in Oklahoma.

'Gone is the stress of getting places on time'

Dr. Mary Clarke: President, Oklahoma State Medical Association

When she graduated the OU College of Medicine nearly 30 years ago, Dr. Mary Clarke — a graduate of Oklahoma City's NW Classen High School — couldn't have imagined her medical practice during the pandemic.

Along with thousands of physicians and providers across the state, the family practice physician ended up diagnosing patients using her personal computer at home in Stillwater rather than visiting one-on-one with patients in a medical office or hospital.

In doing so, she was deviating from the time-honored medical practice of seeing patients "face to face" in her clinic — physically palpitating their bodies, looking into their ears, and listening to their hearts with a stethoscope.

Telemedicine? She had heard of it, but wasn't impressed.

"It did have a stigma in the past ... I hate to say 'cheap medicine' but it definitely was not high quality. I'm sorry, but it's not," she said.

Not any more.

Within about a week of the public health emergency declaration in 2020, physicians at Stillwater Medical Center — Clarke's employer — had hooked up their personal and office laptops to connect with patients online.

The decision to go virtual wasn't complicated.

"Don't see patients or pivot to seeing patients," Clarke said in a conference room at the Oklahoma State Medical Association office in Oklahoma City.

Prior to COVID 19, access to telehealth was highly restricted, with only some clinics in rural areas allowed (authorized) to use telehealth, but patients could not access it from their homes. In response to the pandemic, and as people were being encouraged to stay home to protect themselves from COVID, (federal) regulations regarding access to telehealth were waived or relaxed to allow virtual appointments from one's own home or any location. In addition, Medicare would pay physicians the same rate for telehealth services as they do for in-person visits.

The waivers were extended for at least five more months when President Joe Biden signed into law the omnibus spending package on March 15.

"When we were able to do that (get paid), it makes it easier. We have to be paid," she said.

But even with current parity in reimbursement, there are obstacles.

Physicians say significant problems with internet reliability and broadband availability will compromise telemedicine's future, and the problems aren't limited to those living in rural areas.

Clarke estimates about 20% of her patients have "very spotty" cell coverage or no broadband at all where they live, and that's probably, she says, only 15 miles outside of the Stillwater city limits. The smaller towns even further out might even be worse, with only 50% of patients having digital access.

"There's no (reliable) access. We usually can't get a hold of them for days if we need to talk to them about something or about their labs. They tend to be people of color, they tend to be people less affluent, so now we're tiering health care," she said.

"We're trying to increase access to everybody, right? We want health care for everybody. We can do that, but we have to have (internet) service in place."

Is there a downside to telemedicine?

Not all of her patients are suitable candidates for virtual appointments, she said.

As a family practice physician she does a lot of gynecology, and about 50% of her practice is preventive medicine and care, none of which she can do online.

"And people who are unstable, those are not easy to do ... surgery, it's never going to work. Obviously, you have to have your hands on those patents."

Clarke surmises that the cost of Medicare might rise, as more and more people use it for telemedicine. Which is not necessarily bad if it increases access and brings more patients into the system, especially from rural or underserved areas.

When you increase access to something, patients are going to use it more than they did before, so the cost has to be somewhat higher than what it was, to pay for it, she says.

"In the past, if people felt they couldn't get out of the driveway because of ice and snow, in the past, they would cancel the appointment and not go, or they'll just skip it or 'no show' (presumably saving the insurer some money)."

But now, on bad weather days — or if transportation or work issues — patients are more likely to opt for virtual, and Medicare, or the private insurer, will then have to pay for it, when in the past — the appointment wouldn't have happened, she said.

During the pandemic, Clarke worked most of the time from home on her computer. Her spouse, Stephen Clarke, is a professor of nutrition at OSU and the incoming associate dean of the College of Education and Human Services Administration.

As both of them do a great deal of academic research in their off time, they were fortunate to have a more sophisticated home office already set up. Both of them worked from home during most of the pandemic.

"Everyone was a little nervous about it but business was pretty good. When we were sitting at home or in our office, trying to take care of as many people as we could, the internet showed us that we can," Mary Clarke said.

During the pandemic, Mary Clarke saw about 50 virtual patients a week — all of whom were established in her practice.

Today, along with her partners, she still offers virtual appointments, but fewer than five a week go online with her.

There were other benefits associated with virtual care.

The state medical association saved money during the pandemic when a national conference in D.C. was held virtually.

Delegates from Oklahoma had planned on attending, but instead of using the funds for air travel, food, and hotels, a "substantial" amount, according to Jennifer Dennis-Smith, communications manager for the Oklahoma State Medical Association, was shifted to public service campaigns in the state, like Vax for Good and Got Mask, to promote COVID vaccinations and mask advocacy.

Funds were also used to upgrade equipment and electronic systems for virtual meetings at the medical association's headquarters.

Using virtual communication also made Clarke's one year tenure as state president easier.

From home, she could use video conference or Zoom to conduct business.

"Gone is the stress of getting places on time," she said.

But as others question why virtual visits have declined, Clarke says she knows why.

"We love being in person ... we want to be personable. We want to network, we want to say hello to people. When patients walk into a room, they want to see their doctor sitting there," she said.

She wants to see them, too, but she's realistic.

"I don't see business or medicine going back to what it was before COVID, as far as technology. We've figured it out. It's too easy to do," she said, while heading out the door for a two hour drive back to Stillwater.

'You can't do telehealth without internet access'

Dr. Lydia Nightingale, M.D.: Chief medical officer at Variety Care

Oklahoma City’s Dr. Lydia Nightingale, chief medical officer for Variety Care, is proud that during the worst days of the pandemic, none of the 18 Variety clinics in central and western Oklahoma for which she is responsible closed their doors to patients.

And within days of the 2020 public health emergency declaration, Wi-Fi access was quickly extended into clinic parking lots, available to patients who needed health care but didn't want to leave their cars for fear of exposure to COVID.

"It's hard to remember (now), how scared we were in the beginning. They (patients) had fears. It helped soothe their fears, as well as providing security for our staff. The days when we were wiping down everything, scared to go to the grocery store," she said.

Pivoting to virtual medicine came quickly and easily for Variety clinics in the Oklahoma City area, as virtual care for behavioral health had already been available at some of their rural clinics.

"We already knew how to do it," she said.

"I think telehealth is the wave of the future. I see my own physicians by telehealth," she offered.

Variety is the state's largest community health system; it is a non-profit, federally qualified health center which served nearly 200,000 patients in 18 clinics in 2021, ranging from medical, dental, vision to social services. Another clinic is scheduled to open this summer at 11220 N. Rockwell in Oklahoma City.

In 2020, 15.8% of their patients opted for virtual visits, which translated into 18,425 telehealth appointments for that year.

In 2021, virtual visits declined, as only 9.1% of their patients, or 14,774, met online with a provider.

For 2022, the average number of telehealth visits is 1,742 a month, according to data supplied by Lance Evans, director of communications for Variety Care.

The nominal cost for a medical visit — whether in person or virtual — is $35, Evans said. Insurance plans, Medicaid, Medicare, grants and financial aid programs may cover visits, and a sliding fee based on income is also available.

"We don't turn anyone away," Evans said.

However, Nightingale worries that not everyone shares her enthusiasm for telemedicine.

"There's a fear that when you see a provider by telehealth you won't have as good a visit as it would be in person," Nightingale said, but she insists that's not correct.

Nightingale imagines a practice where the virtual connection might make the physician/patient encounter even better.

In the future, Nightingale believes a virtual appointment has the potential to provide more opportunity for a physician to interact more closely with the patient.

And because most remote visits occur in the patient’s home, there's the ability to learn something about the patient's surroundings and their home environment which can be helpful to the provider.

“One of the things telehealth has taught us ... is to listen to the patient and not be distracted by jumping straight to an exam. When we actually listen, and look at the surroundings they're in ... in many ways, that can enhance the visit," she said.

Working with staff at Variety, Nightingale's been trying to determine the best practices for promoting education efforts, but says that reliable internet access is still a major obstacle with her patients.

"You can't do telehealth without internet access. This is a statewide concern. This will have to be addressed for telehealth to be successful," she added, as "enormous barriers still exist."

Another issue is that many patients still can't afford digital devices which are sophisticated enough to access the platforms needed to connect with a doctor.

Many patients can only afford flip phones — some of which only allow audio calls.

Because the provider cannot see the patient, the audio call is the least preferable for a virtual appointment but it's better than no contact at all.

In fact, Oklahoma is listed as one of the states with several counties where more than 50% of all telehealth visits are audio-only, according to Trilliant Health, a national all-payer claims data base.

Many of Nightingale's patients have financial difficulties, she said, and they're often using "to go" phones, which are purchased for a short period of time. The phone numbers on these phones are often temporary, as patients can't afford to keep them active. They make an appointment with one phone number, and when the clinic calls back trying to reach the patient, the number has been changed or is no longer working.

Even those with a smart phone face obstacles.

"The people (who have a phone) will go to a public place to use the internet, like going to McDonald's for connectivity, but it's hard if you're trying to have a private, telehealth care meeting with your psychiatrist or therapist," she said.

'A clue as to how sick someone is when you look at 'em face-to-face'

Dr. Jason Hill, D.O., medical director, Choctaw Nation Health, Talihina

President of the Oklahoma Osteopathic Association

Telemedicine is not used that much in Talihina, or anywhere else in southeastern Oklahoma, said Dr. Jason Hill.

Hill, who has been chief medical officer for Choctaw Nation Health for 17 years, said the main reason is pretty simple.

"You may have Wi-Fi in Oklahoma City, but we don't have it in Talihina," he said bluntly in a phone interview from Talihina.

Located about 180 miles southeast of Oklahoma City, the lack of internet access and the great physical distances separating residents from medical care impacts all aspects of life.

Hill oversees about 180 physicians in eight tribal clinics, one private clinic and one hospital.

Physicians tried tele-psychiatry on a very limited basis about 10 years ago and it worked well.

Patients would check in at a clinic with a special internet portal and a nurse would take vital signs. The patient would then sit in front of a computer with a screen monitor and a camera and talk virtually to a psychiatrist.

It was popular, Hill said, and the demand was great, but the physical distances — the clinic was 100 miles away for many patients — precluded many people from making appointments.

Instead, Hill ended up hiring "a bunch" of psychiatrists to meet in person with patients in the various clinics that were better distributed in a wider geographical area. That worked well, too, until the pandemic forced people to stay home.

But the need for telemedicine decreased, Hill said, as the pandemic wore on.

Telemedicine is still an option today but seldom used, Hill said.

Many of his clinics are spread out throughout southeastern Oklahoma with many patients living just across the borders of Texas and Arkansas.

Greater reciprocity between the states for out-of-state licensing for physicians would be appreciated, Hill added.

Many of those out-of-state patients routinely drive across the border for appointments with his physicians in Durant, Idabel, and Hugo. But during the pandemic, if telemedicine was needed because of the lockdown, this caused a quandary.

Even though these patients were firmly established with the medical practice, "Was it legal for our doctors in Oklahoma to perform a telemedicine visit in Arkansas and Texas?" Hill asked.

He ended up purchasing medical licenses for his physicians whose clinics were located 20 miles from the borders of Texas and Arkansas.

Those "dual" licenses continue at this time.

Although many of his elderly patients prefer virtual appointments, internet access is minimal, and if they do have it, the patients often don't know how to use it or have the necessary digital devices to make it work, he said.

Hill approaches telemedicine with great caution, and urges caution for all the physicians he oversees.

Remembering the Hippocratic oath he took as a physician "to do no harm," he says, "You don't want to injure someone by what you've prescribed."

In making a diagnosis, he says there's a "lot of 'ifs' there, if you can't meet face-to-face and be hands on. If you can't get monitoring labs or diagnostic imaging."

"There's some things that kind of give you a clue as to how sick someone is when you look at 'em face-to-face.

"I want to look in their ear drum. I want to look at their throat, and see if they have strep because I don't ever want to miss strep. That's where seeing them in person really helps, to determine whether they really need an antibiotic," he said.

But he says he has learned to "relax" more.

"I can extend re-fills for prescriptions for a while using telemedicine, so patients can decrease their amount of exposure to COVID," he says.

But that's about it.

'I use it on an as-needed basis'

Dr. Daniel Shen, D.O. family practice physician at Perry A. Klaassen Family Medical Clinic, Oklahoma City

Just because telemedicine worked so well during the pandemic doesn't mean physicians are overly eager to continue using it.

Many younger doctors, like Dr. Daniel Shen, who practices family medicine at Perry A. Klaassen Family Medical Clinic in Oklahoma City, were already familiar with telemedicine when the pandemic surge occurred.

"It's easier to pick up, I guess. There's less of a learning curve," he said.

But he's still very cautious about using it.

Telemedicine's practice was discussed in the medical school from which he graduated, OSU College of Osteopathic Medicine in Tulsa. And he did some telemedicine during his residency at St. Anthony's Hospital in Oklahoma City.

Shen says telemedicine does increase health options.

But prior to the pandemic, it was seldom used at the clinics where he works — Mary Mahoney Memorial Health Center and Perry A. Klaassen Family Medical Center — primarily because of reimbursement issues. Both clinics are federally qualified health centers that provide primary care on a sliding scale basis.

Despite his familiarity and comfort level with virtual care, he's very cautious about the patients to whom he offers it.

"I use it on an as-needed basis for patients who have transportation issues, or those who don't need as much clinical, objective data," he said.

During the pandemic surge, Shen said he saw about half of his patients using telemedicine. Today, he sees no more than one-fourth of his patients virtually.

"I only use it on patients I don't feel are at risk for not having the clinical, objective data, patients outside of an emergency situation," Shen said.

Shen predicts that some telehealth visits in the future will likely monitor patients' vital signs, such as pulse, temperature, blood pressure and other data from the watch or monitor a patient might be wearing. Many watches on the market today are already doing that, and are capable of transmitting the data to a provider.

Telehealth might even be more expensive in the future, he surmises, as the technology becomes more sophisticated and even more mobile.

"It will be pretty seamless when we start to incorporate other electronics," he said.

In the beginning, when people were being asked to remain home if at all possible, Shen said he had elderly patients who actually refused to do telehealth.

"They didn't know how. But it improved over the pandemic. They later eventually learned it, they were required to learn it, and the learning was equalized," he said

For community health, telemedicine is "actually quite useful" for those who don't have immediate access because of jobs, social situations, and transportation, Shen said.

His own clinic is in the process of piloting a blood pressure program that had been discussed prior to the pandemic but the events of the past two years pushed the initiative up.

The clinic is getting data from patients who remain at home and monitoring them through telehealth. The patients will be seen in the clinic once or twice a year but their vital signs are being monitored while they are at home.

There's a particular group of patients that Shen is reluctant to see by telehealth, and those are patients with kidney issues, diabetes, and heart failure.

"I need to see them in person and get objective data, get labs, to determine whether the person will be better or needs to be sent to a hospital.

"In those situations, I prefer not to use telehealth."

Recalling the Hippocratic oath, Shen said, "Do no harm. First and foremost. If it could do more harm, unless I have objective data, I won't do it. I would re-schedule it for a day when they can be seen in person."

'Telemedicine saved lives'

Rhett Stover, chief executive officer at OSU Center for Health Sciences, Tulsa

And, Bill Schloss, chief operating officer at OSU Center for Health Sciences, Tulsa

Making the pivot to telehealth in the midst of the pandemic was likely easier for the OSU Center for Health Sciences in Tulsa, as their physicians have been involved in telemedicine for nearly 20 years, but it was still daunting during the earliest days of the pandemic in 2020.

"The pivot was so quick and so intense and under such stressful circumstances. The learning curve had to be steep but also short," said Rhett Stover, chief executive officer for OSU Center for Health Sciences in Tulsa.

This year marks the 50th anniversary of their osteopathic medical college, and ever since their first graduating class of physicians in 1976, their medical emphasis has included a special focus on rural and underserved areas.

Far from the medical buildings and hospitals with soaring atriums, fountains and lots of glass, many of their graduates have traditionally gravitated to the farthest, most remote corners of the state, wherever the need is greatest.

A curriculum teaching the foundations of telemedicine was introduced in 1997, according to Melani Hamilton, managing director of marketing and communications for OSU Center for Health Sciences.

OSU established the state's first HIV telemedicine clinics in four communities about 15 years ago. Clinics in McAlester, Poteau, and Tahlequah are still operating today.

Five years ago, OSU launched Project Echo, a telehealth program connecting their medical expertise with 150 providers throughout the state, ranging from nursing homes and hospitals to clinics in rural areas.

However, despite all their previous expertise, once the pandemic struck, they were attempting to connect 26 out-patient clinics in 18 locations in the greater Tulsa area.

An average of 70% of the clinic visits moved to virtual, compared with the average of 10% from pre-COVID. Those clinic visits included all family medicine, primary care and behavioral medicine/addiction clinics.

Ever the pragmatist, OSU's chief operating officer for the OSU Center for Health Sciences, Bill Schloss, described telemedicine as a "blessing" that might not have emerged as quickly as it did, had it not been for the pandemic.

He is convinced, "Telemedicine saved lives."

The average cost for a virtual visit at OSU clinics ranges from $85 to $125 per visit and is reimbursed at the same rate as an in person visit at this time because telehealth emergency waivers were extended. How much out of pocket a patient pays depends upon insurance coverage and their plan covering co-pays and deductibles.

As rapid testing, masking and vaccines became available, patients felt more comfortable coming in person to the clinics, and virtual visits declined.

But Schloss said when omicron peaked in January 2022, "we cranked up the machine and visits were up 30 to 50%."

Once the emergency waivers expire, OSU administrators say there must continue to be parity in payments, or reimbursements in order for telehealth to be a viable option.

"Doctors for some time have given free care to patients over the phone, and phone calls they get after hours from home. Or curb-side consults. You can do that for a small number of your patients .... but you can't do that forever, giving out free medical advice," Schloss said.

Parity in reimbursements does more than just pay physicians their salary or keep the lights on.

Parity will help all medical practices, but especially those hospitals and clinics in small towns, as those businesses — and they are a business — are least likely to be available to afford the expensive upgrades to support telemedicine without adequate reimbursements.

Just as doctors can't afford to work for free, smaller hospitals can't absorb too many periods of a low cash flow.

During the first round of CARES federal funding, OSU benefitted "significantly" in receiving money which allowed it to invest in their telemedicine infrastructure.

This funding allowed them to "transfer" — by virtual care — their medical expertise 24/7 as hospitalists (specialists in internal medicine) to small hospitals in as many 20 "critical access markets" during the height of the pandemic in 2020.

Now that the pandemic appears to be receding, the demands for 24/7 expertise are less than what was critical during the pandemic, but the expertise is still needed at various times. OSU still serves eight of those markets with 24/7 access, in such communities as Poteau, Stroud, Fairfax and Avant.

Many of the state's major hospital systems have smaller, satellite clinics in small towns, and have the financial resources to invest in greater tech infrastructure, and can more easily absorb major deficits or holes in the safety nets, but clinics or hospitals in small towns are less likely to do so.

Also, these small hospitals would benefit, Schloss said, by having greater access to out-of-state physicians who are available for tele-consults, especially at odd hours.

Schloss says credentialing out of state physicians to do telemedicine in Oklahoma should be easier to do.

"We have doctors who are providing the service now who live in Georgia. Without them, the patients might have to leave their home and go to Ft. Smith or Tulsa ... for the expertise," Schloss said.

"It's not an argument against credentials (or background checks), but it's more about reciprocity between states and trusting that if somebody went through the process in Georgia, if they do a good job in Georgia, he or she could do a good job in Oklahoma," Schloss said.

Both Stover and Schloss emphasize that they want the patients they serve to feel "good about the care they are receiving.” They want to know that the care they have received through telehealth has helped them to heal.

Schloss said telemedicine should be viewed as complementary to seeing your physician in person, even though the in-person visits might not be as frequent as they have been historically.

"The journey that we're on is not to replace physician care, but it's to strengthen our capabilities to improve health outcomes in communities across the state," Stover said.

'A different mode of delivery for health care'

Dr. Todd Hoffman, M.D., chief medical officer, Blue Cross Blue Shield of Oklahoma, Tulsa

The future of telemedicine in Oklahoma may depend upon how much private insurers are willing to pay or reimburse for telemedicine visits, regardless of what Medicare pays in the future when the waivers cease.

Providers might possibly have a friendlier face at least at one bargaining table when it comes time to negotiate a new contract for services.

"We're kind of cruising along in January (2020) and within a short period of time, six weeks, eight weeks later? It (number of claims) had gone up 40 times ... that's monumental," Dr. Todd Hoffman, chief medical officer at Blue Cross Blue Shield of Oklahoma, Tulsa, recalled recently.

"I tell you, telemedicine took off like a rocket," he said. And to his surprise, the majority of the claims — 80% — came from members in rural areas, not from the state's two largest metro areas, Tulsa and Oklahoma City.

Spending for telemedicine also increased, up 50 times more compared with the previous year.

A later statement from BCBSOK noted that "since the initial increase (in claims) we've seen a drop in utilization, but telemedicine volumes continue to be much more than what they were in 2019, pre-pandemic times."

Hoffman said he was pleased that telemedicine was "one of the main routes" for members to continue receiving medical care during the pandemic.

"Patients still need to be seen. Their physical exams, their chronic illnesses, all have to be managed. And you have to do that, while — not only protecting the physician and the nurses, and the patient — how do you do all that?” he asked.

As for the increase in spending, Hoffman is sanguine.

"Here's the thing. In some ways, it is extra money, and in some ways, it's not. Some of those telehealth visits were visits that were replacing face to face visits, right? Not all of that is going to be extra money. I will say, we did a ton of spending during the pandemic. .... Our costs went up ... not just in telehealth in general, but we're talking COVID, and the testing, and everything," Hoffman said.

Some of the visits might have been first-time encounters from members who did not have an established relationship with one particular doctor, he surmises.

"There may be members who had the 'white coat' fear of going to the doctor and maybe (now) they're more comfortable doing it via telemedicine.

"And so, there may be an opportunity to do it. I always try to look for the lemonade in the lemon," he said.

While he wasn't surprised at the increase in telemedicine visits, he said he was surprised at the geographic breakdown of where they came.

"We saw an 80-20 split .... 20% of our business came from the metro areas of Oklahoma City and Tulsa, and perhaps, areas surrounding them like Broken Arrow and Norman.

But the vast majority — 80% — came from rural areas, or outside the greater Tulsa and Oklahoma City areas.

"It tells me that our members, those patients out in those rural areas that don't always have access for various reasons to high quality health care, were able to access that," he said.

Issues that Hoffman sees in the future of telemedicine include making sure that the quality of care is as good as the care one might receive in the traditional physician's office.

"The pandemic opened all of our eyes, not only here at Blue Cross, but I think, in society in general. It's a different mode of delivery for health care, right?”

Another major issue, especially for physicians and providers, is parity of payment for reimbursement for providing telemedicine.

There's a lot of factors that go into determining payment, said Hoffman.

"Do you get reimbursed as a physician the same ... for doing a telemedicine visit? Obviously it's a different mode, it's not being in the office," he said.

Physicians often claim that private insurers — like Blue Cross Blue Shield — will only reimburse if Medicare is willing to pay.

In other words, if Medicare won't pay for a treatment or procedure, or won't pay very much, then private insurers, like Blue Cross, are less likely to pay for it.

Hoffman says that assumption is incorrect.

"As far as Blue Cross is concerned, those reimbursement levels are part of the negotiations when we get with our providers and we do our contract negotiations. There's a lot that goes into what that payment reimbursement is going to be, and yes, the Medicare rate is probably one piece of it, but there's much more," he said.

Hoffman might be one of the few physicians at the negotiating table with experience in telemedicine.

After he graduated from OU College of Medicine in 1999, he did his emergency medicine rotation in Kansas. As an ER resident in the local emergency rooms, he received EKGs directly from ambulances on stroke or heart attack patients using telemetry, which was one of the first, earliest uses of telemedicine.

Telemedicine has actually been around a long time, he said, but utilization was "low" for a lot of reasons.

"A lot of physicians didn't see a whole lot of value in it, or they just didn't have the capabilities, they didn't have the technology, they weren't up on it.

This article originally appeared on Oklahoman: COVID-19 pandemic forced many health professionals to turn to telemedicine