Telemedicine tips for internists in the era of COVID-19

With the coronavirus disease 2019 (COVID-19) pandemic in full swing, internists are using telemedicine to provide safe care from a distance.

“We know that the virus can't be transmitted unless people come in contact with each other. So being able to care for patients, while not being in the same physical space together, really provides an incredible opportunity to keep people safe while not delaying care,” said Ana María López, MD, MPH, MACP, a Past President of ACP and professor and vice chair of medical oncology at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.

Although the science around COVID-19 changes by the hour, optimizing your telemedicine practice doesn't have to be a frantic process. ACP's telehealth resources include a COVID-19 toolkit, which offers coding and billing tips for physician practices. In addition, ACP Internist spoke with telemedicine expert Dr. López on March 31 about the many uses of telemedicine during this time of emergency, as well as her own personal setup.

Q: How can telemedicine be used to address COVID-19 specifically?

A: One of the things is if a patient feels that they are ill, they've got some respiratory illness, we're asking that people not show up in the emergency department, No. 1. The emergency rooms are generally getting fuller and fuller, but we're setting up these different telemedicine clinics that really just focus on COVID. There, the person would interact with a physician or an advanced practice practitioner, provide a history that could then be assessed on how to proceed: testing, quarantine, check in in a couple days, whatever the right direction should be. And those algorithms are also changing almost daily as we learn more every day about this disease.

There is also remote monitoring that could take place. It would be possible for, let's say, somebody who is at home convalescing to get a monitoring kit so that their vital signs could be monitored. This gives you a way to provide the patient with a higher level of care, almost like a tele-home health visit. You could check in with the patient, they are able to stay at home, but they're able to get the needed evaluation through remote monitoring. There is also the ability to, for example, use same-day shipping to send a patient, let's say, an electronic stethoscope, so that their lungs could be assessed at a distance during their whole convalescing period. All of these things could be very helpful to help patients stay in place if they're doing OK and to do so with close follow-up in care.

And then there's a situation where a patient may show up in the clinic and may have a cough, may be ill, needs an evaluation. Now, there could be systems where the patient could be quickly provided with a mask and directed to a testing center now that more of those are available. But there are also places who give the patient a mask and direct them to an isolation/telemedicine room. The patient is in the room, there's an iPad in the room with directions, and the patient can then connect [virtually], even if it's with somebody in that very same clinic, for a safe virtual evaluation.

Q: What are some of the barriers to effectively using telemedicine at this time?

A: Because we have smartphones, iPads, etc., and maybe we do a lot of Zoom already or WebEx meetings, it may seem like it's super easy to just switch [from in-person to telemedicine visits]. And it is certainly a lot easier to do a telemedicine visit than it was starting this in the '90s. At that time, you would talk to people about “It'd be like seeing your doctor on TV.” But now, everybody's done FaceTime, and people have experience. So it's easier to explain, but not everybody has the technology, and those are some of the challenges.

I was talking to a patient the other day, and we were talking about getting her connected to a telemedicine visit. And she has a flip phone. That's the extent of her technology. So if we want to be equitable and be able to provide the best care for all people, is it actually incumbent on the health system to be able to provide the patient with those resources? I think there are a lot of questions there.

Also, if you looked at a map of the U.S., there are places that would not have broadband access. You might say, “Oh, it looks like it's pretty well covered across the country.” But it doesn't really mean that where it says there's coverage that there's coverage for every single household in that area. Again, not everybody has the same sort of connectivity. And if we're connecting with very fast broadband connections and the patient has limited connectivity, that will impact the quality of the interaction. I think there's a way in which the technology can really help support access, but something that we need to be very careful about are the differences that still exist so that we're not unintentionally reinforcing barriers.

Q: What's your practical advice for conducting a good telemedicine visit?

A: I think the most important [point] is to remember the “medicine” piece and not so much the “tele” piece. In the interaction, your camera is a tool. Think of it like your stethoscope: If you use it correctly, it will be effective; if you don't use it correctly, you may not be able to really engage accurately with the patient. So, some things to think about: Where's your camera? What's the distance that you are from the camera? How are you appearing to the patient on the screen? Because [depending] where the camera is and where you see the patient on the screen, you may look to the patient like you're looking away from them, or depending on how you've positioned your technology, they may be seeing a part of your face. Really think about your technology as a clinical instrument. Test your technology; test your audio. Have backup plans available.

[As for] how long it takes, I think it's like any clinical encounter. If your appointments are generally 15 minutes, if your appointments are 20, 30, whatever you normally do in the in-person setting, just translate it into the virtual setting. Your documentation requirements are the same. Even if the patient has done tele before, I often start with, “Thank you for meeting through telemedicine,” and then just give a very quick explanation of how this works and reinforce that this is still their doctor's appointment.

And then the technology can have different attachments. Like I mentioned, you could ship an electronic stethoscope to a patient. If you were concerned about otitis, you could ship an electronic otoscope to the patient. But not everybody has all these attachments, right? … I think it's really important to mention at the beginning of the encounter how you may guide the patient to help you in the physical exam: “Since I'm not there with you, I may ask you during the visit to help me out to better understand what's happening with you physically today. I may ask you to ‘Move your body in a certain way’ to show me the rash that's bothering you or ‘Stand a certain distance from the camera’ if I'm going to evaluate your range of motion.” I think those preparatory comments are really helpful to the patient to know what to expect. The telemedicine experience is still new to many people.

Q: Can you describe the current regulatory landscape in terms of physician reimbursement and payer coverage for telemedicine?

A: All of a sudden, in order to protect people, we're doing a lot more telemedicine than we have ever done. And we're doing it out of necessity. Because of that, regulations are quickly changing—either at CMS or at the state level—and keeping abreast of those is very important. For people in large centers, they may have a group that can guide them on this. For smaller practices there are resources as well.

To really be mindful of what the guidelines are for your state, there's a group called the National Consortium of Telehealth Resource Centers. It's across the entire country, so you can find the Telehealth Resource Center that is connected to you, and then you can see exactly what the laws are for your state. Another good resource is the American Telemedicine Association. They have a lot of the information regarding telemedicine regulations.

In general, there's been a lot more flexibility around the rules to allow people to get care. There's some relaxation around the restriction about in-state licensure, but again, you've got to check with your state. Just yesterday, there was a press release from CMS that [said] there could be coverage for telephone interactions, as well as with video. … Being able to have phone interactions reimbursable is really the acknowledgement, I think, that all of these interactions that we have with patients are clinical, and from that sense, are valuable clinical experiences. Having all of these virtual interactions be reimbursable activities makes sense, so it was very good news that there's movement in that direction.

Again, these [regulations] are changing on a regular basis. And also, because some of these may be retroactive, [it's] really important to remember that the big part of telemedicine is the medicine. So you're still practicing medicine. You want to document as faithfully as possible, like you normally would. And if part of that is, “I saw the patient, I started as a telemedicine visit, and then we had technical difficulties, and we switched to phone,” or “This was a phone visit from the outset,” just really document everything, because the rules may be shifting and you want to have your accurate documentation so that you can move forward.

Q: What's your personal telemedicine setup?

A: I have an iPad for the telemedicine interaction, where I see the patient, and my laptop where I have the EMR and can document. The most important thing is [video] access has to be through a HIPAA-compliant platform. Now, there may be, again, some relaxation that may come up during this time of COVID, but in general, that's really been foundational, that the platform be HIPAA compliant. Again, I can't stress this enough, I feel like it's really important to communicate with the patient because it's new to them too. So I point out to the patient, “I'm looking at you here, but every once in a while, I may turn away so that I will be looking something up on the electronic record.” This way, the patient understands that you're not just turning away from them.

Q: What do you think the future holds for telemedicine?

A: In the last two or three weeks, our world is completely different. I'm hoping that this will be a positive change for access to care through telemedicine. People think about telemedicine for rural populations, people think of telemedicine for isolated populations, but in an urban setting, it can be really hard to go from one place to another … [for] a 15-minute appointment. So really, what a big boost for our patients, who all of a sudden have [some] time back. And when you think also about the level of frustration that you lose by decreasing the commuting hassles, there's a lot of positives in that on the one hand. On the other hand, we want to be sure that as we increase access in one area, we're also supporting equity so that we're not reinforcing inequities in care or in access.

One of the things that I've been thinking about … is people are isolated, people are scared, and in what ways can we use the technology to help support people better? One of the things we're starting up is virtual support groups, where people can engage. People miss those interactions.

And I think the other thing that's really, really important … is if you're not comfortable as the physician, if you feel like, “I kind of think this, but my clinical judgment would say I'm not sure,” it's really important to say, “You know what, I think I need to see you in person.” I think that [telemedicine] is not a best guess; it is really a clinical tool, and we want to do what's right by the patient. So I think telemedicine will, and has, changed practice.

And I doubt that whenever the all-clear is proclaimed, that the next day we're going to go back to life as usual. It will be different, but I really want life to be better. There is so much that we're going to learn, and we'll be able to take those lessons learned to be able to provide better care for people. … The thing is, we don't know when that'll be.