Telemedicine and COVID-19: One Year Later

What to know, where to get help, and how to reassure your patients about telemedicine for their endocrine disorder.

With Joseph C. Kvedar MD, Shahrzad Akbary DO, Todd Czartoski MD, Mary Kress Lemley NP, Caroline Apovian MD, and Elena Christofides, MD

For decades, Joseph C. Kvedar, MD, a professor of dermatology at Harvard Medical School and president-elect of the American Telemedicine Association, has urged his fellow physicians to consider practicing virtual medicine. He would say: "Think about interactions you have with your patients where you don't need to touch them."

The reaction? "People laughed," says Dr. Kvedar, who has been practicing telemedicine, also called telehealth, for nearly 30 years.

Times have obviously changed. These days, in the midst of the COVID-19 pandemic, numerous physicians are trying to get up to speed on telemedicine quickly. With COVID-19 making office visits dangerous, switching to telemedicine is a viable solution.

Clinics have to adjust as practitioners shift to virtual medicine, says Todd Czartoski, MD, a neurologist and chief medical technology officer at Providence Health System in Renton, WA, which includes 51 facilities. Since the start of the pandemic, his telemedicine system gave access to over 7,000 new physicians. ''What we are seeing is a rapid conversion," he says. "This is really a paradigm shift in how we deliver care. Once we get through the pandemic, I think it's going to be an irreversible one."  

For those new to telemedicine, there's help at hand.

Expect patient acceptance—but ask for their patience

Patients are generally accepting of telemedicine, Dr. Kvedar says, and with many nervous about COVID-19 transmission and stay-at-home orders, they may be even more accepting than in the past. "When you give people convenient access and a high quality product, they absolutely love it," he says.

Of course, not all care can be done virtually. "Sometimes being in front of them is more effective for caring," Kvedar says. But the amount and level of care that can be given virtually may surprise those who have never tried it.

If you are a physician newcomer to telemedicine, solicit your patients' patience, he advises. In turn, be patient with your patients who may be less than skilled with technology.

Guidance from HHS and Medicare

Federal officials have made it easier for practitioners to offer telemedicine during the pandemic emergency. The Notification of Enforcement Discretion, issued by the Department of Health and Human Services' (HSS) Office for Civil Rights (OCR), applies to all health care providers covered by HIPAA who provide telemedicine during the emergency. According to HHS, telehealth may be provided via audio, text messaging, or video communication technology, including video-conferencing software. However, HHS notes that certain payors, including Medicare and Medicaid, ''may impose restrictions on the types of technologies that can be used."

According to HHS, covered health care providers ''will not be subject to penalties or violation of the HIPAA Privacy, Security, and Reach Notification Rules that occur in the good faith provision of telehealth during the COVID-19 nationwide public health emergency." (The notification does not apply to other health care areas outside of telehealth.)

Health care providers can use ''any non-public facing remote communication product that is available to communicate with patients."  That includes popular applications such as FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype. However, HHS warns that Facebook Live, Twitch, TikTok, and similar apps, because they are public facing, should not be used.

HHS also has an online Q and A fact sheet to answer additional questions.

The Centers for Medicare & Medicaid Services (CMS) have broadened access to Medicare telehealth services, enabling beneficiaries to receive a wider range of services without traveling.

Other health insurance providers are addressing the telemedicine issue, too, in a variety of ways. Some are waiving all costs to patients for telemedicine visits. Other plans are reimbursing providers for telemedicine visits the same as traditional ones. America's Health Insurance Plans provides a summary of numerous plans and what they are doing in response to COVID-19 on its site.

Professional guidance

Several professional organizations, including the American Association of Clinical Endocrinologists, have posted information on their websites, including details about payments, how telemedicine works, valuable coding information, and billing practice management tips.

AACE member Gregory Dodell, MD, has put together a slide deck on how to set up and operate your telemedicine service. It's also on the AACE website. He offers additional tips via his twitter account, @DodellMD.

Likewise, the American Telemedicine Association posts numerous resources, including webinars, waiving of state licensing requirements, best practices, and more. 

Tips from the trenches

Those who have been doing telemedicine have some tips. Elena Christofides, MD, CEO of Endocrinology Associates in Columbus, OH, suggests keeping realistic expectations. Patients are not always expecting exactly what they get in a traditional office visit, she finds. "Many patients are looking for reassurance, not a full thesis or dissertation on their condition," she says. "Use the KISS principles regarding our evaluation, management and requests of the patients."

If you're really unsure, Dr. Christofides suggests doing your homework to educate yourself (via the sites above, a colleague who is experienced, or a coach) about how to properly conduct a video appointment. "It isn't the same thing as Facetiming our kids," she says. "You need to learn how to read people when they aren't in front of you, as usual, among other skills."

The virtual appointments ''typically take longer than an in-person visit because of external distractions and technological challenges," she says. "Be prepared for this—expect things to go wrong—and time the appointments accordingly."

"It takes just as long as an in-person appointment, or longer," agrees Caroline Apovian, MD, professor of medicine and pediatrics at Boston University School of Medicine, because you have to really talk to the patient in the absence of vital signs usually taken in the office. When caring for your non-English speaking patients, she suggests "get the interpreter on the phone first, then call the patient."

"Expect that the flow of how the visit goes is going to be completely different than anything you have probably done in the past," says Mary Kress Lemley, NP, a pediatric nurse practitioner in New Haven, CT. Know, too, that if you are a ''touchy-feely, hands-on" person, the virtual experience may be a challenge at first, she says. "My biggest hurdle has been on the technology side."

For instance, patients may not check their device ahead of time to see if their camera and microphones are enabled. "As patients get more experience doing this themselves, it gets easier."

If you have a choice of modalities to use, ''ask your patient what platform they like," Dr. Kvedar says. Whatever platform is used, he says, remember that the visit may be virtual, but the paperwork must still be done, so it's crucial to record the visit details in the electronic record.

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