Telemedicine | October 2020

Lessons learned from telemedicine

Although many internists may have felt inexperienced with telemedicine before the pandemic, they could well have been doing it all along.

By Mollie Frost

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None. That's how Lauren Nelson, MD, FACP, described how much experience she had in telemedicine before March.

Zero. But when the COVID-19 pandemic hit, she had to learn the ropes—and fast. “Between March and June, almost all of my visits were telehealth,” said Dr. Nelson, an internist in private practice in Omaha, Neb.

Zilch. And she is far from alone. In April, nearly half of Medicare primary care visits were provided via telehealth, compared with fewer than 1% of in February, according to a July HHS report. One reason for the lack of widespread use of telehealth services prior to the pandemic was the lack of reimbursement.

“Telemedicine, as far as we were aware, was not a reimbursable service, and it was difficult to sell patients on the fact that they could have a visit from the comfort of their own homes if insurance companies were not prepared to foot the bill for the visit,” said William E. Fox, MD, FACP, Chair of ACP's Board of Governors.

Although many internists may have felt inexperienced with telemedicine before the pandemic, they could well have been doing it all along, just not getting paid for it. “While it was very common for us to talk to patients on the telephone, which we did all the time, no one ever had any expectation that that time we spent on the telephone would be reimbursable,” said Dr. Fox.

Due in part to advocacy from ACP and other groups, CMS responded to the pandemic by reimbursing telemedicine visits, whether furnished by phone or video, to a level equivalent to in-person visits, as well as relaxing the rules on HIPAA compliance. These flexibilities currently extend to Oct. 23 and are set to be renewed based on the public health emergency.

“As miserable and devastating as the pandemic has been, one silver lining has been many regulatory groups, as well as CMS, being proactive in making it feasible for physicians and other clinicians to expand the use of telemedicine,” said Tabassum Salam, MD, FACP, ACP's Vice President of Medical Education.

As ACP's physician lead for telemedicine, she led the development of the College's telemedicine module in response to a 2019 survey of ACP members that showed a very low usage of virtual visits. By coincidence, the module launched in March. “Thank goodness it was ready for launch because it was sorely needed by our membership, as well as those members who are educators,” said Dr. Salam.

On the morning of Dr. Nelson's first telehealth visit, she visited ACP's website and completed the module. “That was my crash course in telehealth,” she said. (See sidebar for more information on this and other ACP resources.)

While resources like this have helped many clinicians get up to speed on telemedicine, the shift has had its challenges. Internists shared the lessons they've learned and spoke about how they're planning to use telemedicine during this flu (and COVID-19) season and beyond.

Testing, testing …

Once the Trump administration declared a public health emergency on March 13, “Everything ground to a halt, and nobody was coming into the office,” said Dr. Fox, an internist in private practice in Charlottesville, Va.

The practice had to work fast to create an option for telemedicine visits. While one platform his partner found was easy to use and HIPAA compliant, it only worked with a Chrome browser on a PC. So to accommodate patients with Macs, the practice also offered the option of using FaceTime or another smartphone-based video conferencing app, Dr. Fox said.

“We quickly discovered all of these as we were going along and then quickly converted everybody to telemedicine visits. … I went from absolutely zero experience in telemedicine to this is all that I did in the span of just a couple of days,” he said.

Even at Thomas Jefferson University in Philadelphia, which already had its own telemedicine platform, primary care clinicians had not fully embraced virtual visits, said Lawrence Ward, MD, MPH, FACP, executive vice chairman in the department of medicine.

“There was still resistance by a lot of patients, and there was a lot of this resistance by certain clinicians as well,” he said. “The nice thing was, when we were all forced by the pandemic to do telehealth, a lot of those hesitancies fell by the wayside.”

The clinicians had to learn fast, as demand for Jefferson's telemedicine services, which operate 24/7, spiked after the pandemic. “That expanded our work hours and made it harder to separate when you are at work and when you are not at work,” said Dr. Ward, who is also professor of medicine at Jefferson. “It was a pretty exhausting first eight weeks of the pandemic.”

But demand for telemedicine has not been high everywhere. For Jason M. Goldman, MD, FACP, an ACP Regent who has for several years offered telemedicine visits at his solo practice in Coral Springs, Fla., even a pandemic has not led to wide implementation. He estimated that at the height of the pandemic, the proportion of his visits that were virtual was still fewer than 20%.

“Telehealth in my area has not necessarily really taken off too well, at least for my population, for many reasons,” Dr. Goldman said. For example, he said his elderly population does not necessarily embrace telemedicine technology.

To address the technology barrier, Jefferson created a way to send a direct link to those who are having trouble accessing visits through the patient portal, Dr. Ward said. “People really found we needed a way to reach out to patients if they can't get on the portal,” he said. “I think that has helped many patients who are not tech savvy to be able to link into telehealth more easily.”

Sarah Candler, MD, MPH, FACP, an internist and care team medical director at Iora Primary Care in Houston, recalled one patient who told her she missed her and wanted to see her, but didn't know how without coming into the office. Although the patient had video capability through her phone, she didn't know how to use the technology she already had, she said. “I feel fortunate to have a team that I work with … and one of my team members helped walk the patient through that.”

Even still, some patients lack the technology necessary for video visits altogether. For Ankita Sagar, MD, MPH, FACP, a general internist at Northwell Health in Great Neck, N.Y., visits with older patients tended to be via telephone since most of them didn't have smartphones.

“There is a limitation in that,” she said. “But over time, I think we were able to ask particular questions, listen to how they were breathing on the phone, understand that they were struggling to breathe, and to quickly triage and see what we can offer to them.”

Dr. Candler estimated that about 10% of her patients have a technology barrier, such as not owning a tablet or phone or having insufficient internet bandwidth. In May, her health system began experimenting with delivering patients tablets with the capability to do video visits.

“In some of our markets, they have started delivering the tablets right before the visit so … that we can provide safe, socially distant visits to our patients in a way that feels more comprehensive than just a telephone call,” she said. “Our current program loans the tablets just for the duration of the visit.”

Looking ahead

Telemedicine appears to be here for the long term. As Seema Verma, administrator of CMS, told the Wall Street Journal in April, “I think the genie's out of the bottle on this one.”

But as of August, many internists were seeing their telemedicine visits dwindle as their in-person visits increased. For Dr. Sagar, there are two reasons behind the transition away from telemedicine.

First, she said many of her patients have very complex illnesses and require in-person visits. “They really do need to come in to be evaluated, whether that's diagnostic testing, lab work, or just a physical exam,” said Dr. Sagar. “So we are trying to focus on that right now while our COVID cases in New York are pretty controlled.”

Second, she said her practice is putting an emphasis on in-person visits as a one-time check-in ahead of the fall flu and COVID-19 season. “We have our older folks who usually come in for their annual physicals in the springtime that really did not get a chance to come in due to COVID, so we're trying to catch up with them as well, just to make sure that we are getting all of our preventive services appropriately completed ahead of the winter season,” Dr. Sagar said.

At Jefferson, the proportion of telemedicine visits was about 100% at the height of the pandemic but has settled in the 20% to 30% range, said Dr. Ward, who is also Governor for the ACP Pennsylvania Southeastern Chapter. Telehealth will likely continue to comprise a substantial portion of visits for as long as the pandemic lasts and even beyond, since patients and clinicians feel more comfortable with it, he said.

“I'm interested to see if during the cold and flu season actually the proportion of telehealth visits bounces back up again because we're going to be using it as a major way to manage patients that are calling in with colds and flu symptoms, rather than bringing them into the office,” said Dr. Ward.

Telemedicine will also continue to be a large part of practice at Iora Primary Care, a national company that has grown as a result of the opportunities of telemedicine, said Dr. Candler. “Our goal is to be conducting at least 30% of our visits by telemedicine even after a vaccine. Even when things look better, we think that this is the future,” she said.

Part of the reason for the health system's success is that it works in a value-based payment model as opposed to a traditional fee-for-service model, said Dr. Candler. “Because Medicare has said that video visits count for some of those high-risk adjustment scores, the hierarchical condition category scores, we were able to still capture our value while providing a safe way to interact with our patients and our staff,” she said.

For Dr. Candler, the best part about telemedicine has been that it encourages patients to reach out more frequently than they might have otherwise. “Sometimes that means people who have a rash know that, even if it's after hours and I'm on call, they can send me pictures of it or we can video chat and see what it looks like,” she said. “It's not that I wasn't available to do those things before, but something about the instant gratification … is really reassuring for people.”

In addition to evaluating rashes, telemedicine is particularly useful for visits related to behavioral health issues like anxiety and depression, said Dr. Nelson. “I would say the majority of my telehealth visits not related to COVID [at the height of the pandemic] were actually anxiety and depression related, and I'm really glad patients had that access,” she said. “Especially during COVID, I'm not sure some of the people who did the telehealth visits would have come in to get an appointment.”

Dr. Nelson recalled one patient who was feeling depressed and isolated during the pandemic, but telemedicine offered a clue that an in-person visit would not have. “I could see that she was in her house with all of her curtains closed,” she said. “It wasn't going to be a cure, but part of my approach was just saying, ‘Hey, let's open the curtains. Maybe you can't go outside and socialize, but it's bright and it's daylight.’” (See sidebar for 10 tips on conducting telemedicine visits.)

Telemedicine is also useful for follow-up visits and drug refills, but there are gaps in certain clinical areas, particularly cardiology, said Dr. Ward. “Our cardiologists are doing minimal telehealth calls,” he said. “They really feel that they need to see people in person and obviously need to see them in person to get their [echocardiogram] and that sort of stuff.”

While patients may be able to provide data for certain vital signs, like temperature, blood pressure, and weight, listening to a patient's heart murmur just isn't feasible during most telehealth visits, Dr. Goldman added. “You have to know the limits of telehealth and how to utilize it, and that comes with experience,” he said. “When is telehealth appropriate and when should you do an in-person visit? That's just, in some ways, common sense, and then, in other ways, it's medical judgment.”

An in-person visit is warranted whenever a physical examination or a procedure is paramount to the care of that patient's condition, said Dr. Salam. “Even though we have some remote devices that can fill in some of those gaps, when a physical examination and/or a procedure are central to the care of the patient in that visit, that's the time when it's absolutely the best for the patient to come in,” she said.

Some larger health systems are investing in remote monitoring devices, although they have not quite become mainstream. “We really leveraged remote patient monitoring in the setting of COVID to keep patients outside of facilities who either were suspected of having COVID or were confirmed positive,” said Todd Czartoski, MD, chief medical technology officer of CE Telehealth at Providence St. Joseph Health in Seattle.

In March, the health system ordered 5,000 non-Bluetooth-enabled pulse oximeters and 5,000 digital thermometers at a cost of $30 for each combined kit, he explained at the Virtual Summit for Health System Recovery from COVID-19, held in June. Patients with suspected or confirmed COVID-19 were sent home from the clinic, ED, or hospital with a kit.

“Then we used a secure texting platform to text them three times a day and have them answer a few questions about their breathing, how they were feeling, their respiratory rate, their pulse ox,” said Dr. Czartoski. “And then we put that on a dashboard, and the dashboard had green, yellow, red in terms of risk stratifying them, and that allowed [us] to monitor up to 100 patients per nurse and only focus on the ones that were of concern.”

While ACP's telemedicine module does not discuss remote monitoring, this technology may well appear in the College's future modules and educational products, said Dr. Salam. “It's an ever-growing field, and I think now that so many physicians and patients have become more comfortable with video visits, for example, remote patient monitoring is the next step where comfort is going to creep in,” she said.

Perhaps the biggest uncertainty surrounding the future of telehealth is reimbursement. ACP is urging CMS to consider continuing pay parity for audio-only and telehealth visits even after the public health emergency is over. As Dr. Salam put it, “We are advocating for a sensible balance” of virtual and in-person visits going forward.

“There are several types of care you can offer through the telephone or video visits, and there are several that you cannot. And there's a place and time for all of them,” she said. “We really think it should be a shared decision between the physician and her patients, and there's a lot of potential for improving continuity of care by making the safety and convenience of telemedicine readily available when it's the right modality for care.”