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With the coronavirus threatening to become a pandemic, health systems and telehealth vendors see this as an opportunity to bring connected health to the forefront – and reshape the future of healthcare.

 By Eric Wicklund

March 05, 2020 – As Congress votes on a funding package that includes Medicare waivers for some telehealth services and the Health Information and Management Systems Society (HIMSS) cancels its conference in Florida, healthcare providers across the country are looking at how connected care programs can be used to handle the coronavirus – also called COVID-19 – threat.

Most see the exercise as an extension of their preparations for flu season. Some see this as an opportunity to lobby for telehealth adoption across the board, saying a possible epidemic offers ample evidence of the value of telehealth and mHealth.

DEFINING TELEHEALTH’S VALUE IN A CHANGING LANDSCAPE

“COVID-19 is different because we do not know all the factors surrounding transmission and its effects on patients,” Jason Hallock, Chief Medical Officer for SOC Telemed, points out. “Because coronavirus is new and there have been a significant number of deaths, the uncertainty surrounding that is scaring both patients and the general public. Our healthcare workers do not have all the answers yet. Telehealth providers are challenged to make recommendations when there are still many unknowns. Telemedicine can be useful to evaluate and reassure patients in alternative settings, and also can be used to help patients decide who needs to be seen in the hospital or an alternative setting like an urgent care.”

Hallock says telehealth can help by enabling healthcare providers to treat isolated patients, thus preventing the spread of what has so far been an extremely contagious virus.

In a Q&A with mHealthIntelligence, Peter Antall, MD, President and Chief Medical Officer for American Well, offered an in-depth take on how telehealth might be used.

Q. Telehealth has long been seen as an ideal means of expediting care during flu outbreaks. How is the coronavirus scare different? Does this pose any unique challenges that telehealth can address?

A. The novel coronavirus, or COVID-19, is similar to influenza in how it is transmitted (airborne), how symptoms manifest themselves, and the fear it stirs among those individuals at risk. When evaluating patients through telehealth, we use similar methodology as that used for influenza, except that the current Centers for Disease Control and Prevention (CDC) recommendations call for risk stratification based on known exposure or travel to endemic areas and referral for testing for those at high risk or those who are sick enough to need hospital care. Also, unlike with influenza, there are no current specific treatments, like antivirals, for the coronavirus at this time. 

If local person-to-person spread expands to wide community spread, we expect care will need to evolve to a method that is quite similar to how we treat influenza today. Under those circumstances, we will likely begin diagnosing coronavirus-like illness (CLI) on a clinical basis, without testing. We would likely then only be expected to refer inpatients with CLI who need hospital care clinically, while those with milder symptoms will likely be treated and monitored at home so as to limit the spread of this disease and not overwhelm our healthcare facilities.

In this way, telehealth is an ideal venue for an outbreak like this. We can increase access to care. We can offer care that is commensurate with the acuity and nature of the symptoms and make referrals as needed. This helps with infection prevention and control and also allows patients to receive their care in the home without exposing themselves to further illness.

One other notable point is the potential for telehealth to help in providing routine care for other conditions and offset coronavirus fears in the . Patients have other healthcare needs unrelated to coronavirus, but many are afraid to go to healthcare settings for fear of catching disease. This has begun to result in a migration of patients to telehealth. For example, on February 25, we saw telehealth urgent care patient volume that was 11 percent higher than expected. Many patients are now sharing anecdotes indicating they were afraid to sit in a waiting room, so they used telehealth instead.

Q. Are there new tools or technologies available that can be useful in dealing with the coronavirus?

A. Telehealth itself is a tool in this fight. Keep in mind that there are many varieties of telehealth. It can be used to connect a doctor or other provider with a patient in the home via smartphones or tablets. It can also be used for provider (specialist)-to-provider consultations in remote areas, for example. Telehealth carts also exist in healthcare settings and can be used not only to import care, but also to limit healthcare workers’ exposure to the virus by using a cart in the isolation room.  We see patients primarily through live video interactions, but we also can fall back to informed telephone calls, synchronous chatting for therapy and asynchronous secure messaging for ongoing communications.

The use of symptom trackers and chatbots is another promising area for coronavirus response. These technologies allow algorithms to be created and adjusted as more is learned about the coronavirus. These bots interact with patients and can perform assessments, triage and ongoing support. The bots can even escalate an interaction to a telehealth encounter or refer the patient for in-person care.

Finally, home monitoring and medical tricorders are another promising approach to care. Traditional remote patient monitoring has established value for managing certain chronic conditions, but the next wave of home monitoring includes consumer devices like smartwatches (like the Apple Heart Study), home TVs, and home medical tricorders like Tytocare that can perform a remote examination. These tools aid clinicians and patients and provide more robust health data conveniently from the home setting. Providers can also use the data generated to better care for the patient or regularly monitor certain conditions.

Q. What must care providers know about telehealth before using it to deal with the coronavirus?

A. Providers must know and understand their role in this or any other healthcare crisis. They should be well informed and trained to follow current CDC or World Health Organization guidelines. They should also understand that telehealth is a powerful tool for helping fight this outbreak. And they should know that telehealth is a safe way to treat and/or triage these patients. Whether the provider is a primary telehealth provider or is not using telehealth today, there is a real opportunity to participate and play a role in the response. 

Providers who have a brick-and-mortar practice should be encouraged to use telehealth as a triage tool. Providers also need to understand that during this time, patients with other non-respiratory conditions also need care. These patients should be afforded a safe way to access care without risk of infection. Telehealth is also a tool to aid in this process, as some patients are fearful of going to healthcare facilities right now. The office-based provider can likewise process other patients by practicing this way.

Q. What are the barriers or challenges associated with using telehealth to deal with the coronavirus scare?

A. Telehealth visits are typically sufficient to complete a robust initial assessment. This allow the provider to assign a risk category, make other diagnoses, or deem the patient as “worried well.” Some patients may require additional care, as most telehealth in the home lacks certain medical peripherals that might be needed. Other reasons for referral would include a high-risk patient who needs to be tested or a patient who requires escalation of care due to the severity of their illness. Telehealth visits are generally sufficient for screening patients, assigning a risk category, answering questions and recommending the next steps a patient should take.

The barriers to telehealth—such as instances when the patient and provider do not yet have a relationship—are easily overcome providers receive similar training around the use of telehealth and as longitudinal patient records become more available to guide care. Occasionally the lack of medical peripherals or the inability to touch the patient during an exam is a barrier, as some patients need hands on care (e.g., IV, procedures). We have policies that mitigate these problems in most cases. However, on occasion, a telehealth patient must be referred for in-person evaluation.

Q. Is there anything that the CDC or any other government agency can do to support telehealth adoption to deal with the coronavirus? 

A. It is useful for the CDC (and the WHO) to highlight the important role of telehealth in this outbreak because it certifies our role within the broader medical community and raises awareness about this tool.

It would be helpful if the CDC were to make specific recommendations to telehealth providers that relate to telehealth evaluation of the coronavirus and associated referrals, coding and monitoring. It would also be helpful if the CDC were to play a role in advocacy efforts focused on government reimbursement, particularly in this emergency situation. Efforts to increase consumer awareness about telehealth as a safe option for care also could prove essential. When this outbreak settles down, we would encourage the CDC and HHS to collaborate around coronavirus standards of care and preparedness so that patients can expect telehealth providers to be ideally prepared and well-coordinated for the next outbreak and so that we can offer high-quality care in this manner to all Americans.

We also believe that our public health system would benefit greatly from owning its own telehealth network infrastructure. This would allow the CDC to better scale up, solve for geography and improve surveillance. It would even allow its public health workers to use technology to monitor patients under quarantine in the home, saving themselves travel and limiting healthcare workers’ exposure.

Q.  What more can be done with telehealth in the future to plan for these types of outbreaks, or to perhaps address them before they become serious?

A. Much needs to be done throughout our country to better prepare. We need permanent leaders placed at the U.S. Department of Health and Human Services, the National Institutes for Health, the US Department of Homeland Security and other key areas, and we need to reinstate a pandemic-preparedness role at the National Security Council. We need to fund international efforts to improve screening and research for emerging diseases, and we need surveillance programs and good international coordination. We need to fund (not decrease funding) for our frontline groups, like the CDC, HHS and local public health services. These are our fighters, and we need them ready and funded properly as an outbreak like this is a national security issue. We need stockpiles of materials. Finally, we should be partnering with the pharmaceutical industry on affordable medications and vaccine research.

Our national telehealth operation today acts like an emergency alert system. We see cases or potential cases before they are reported. At American Well, our influenza activity indicator map is more accurate and more timely than that of the CDC. We already play a meaningful role in many disease states, including outbreaks. There are still many adoption and awareness challenges that exist when it comes to telehealth. Hopefully this unfortunate event will help consumers, providers and others start to more clearly see how they can and should use telehealth for future healthcare needs.

Another barrier that we continue to work on is that of reimbursement. Telehealth is a cost-effective way of receiving care, but it is still not always a covered benefit by insurance. Most commercial plans are reimbursing and there is increasing adoption in Medicare Advantage and Medicaid managed care. But there are still gaps, including a big gap in fee-for-service coverage for Medicare coverage in the home. Efforts at reform are underway (see the CONNECT Act), but more work needs to be done so that all Americans can take advantage of this amazing service.

Additionally, with coordination being so important during outbreaks like this, the simple step of integrating telehealth with other health information systems, such as EHRs or clinical-decision support, can make care more seamless and foster better care coordination. This would speed up access to critical care. Case in point: Consider a scenario where a patient consults with a physician over a telehealth network and displays symptoms of COVID-19 while presenting one or more correlating risk factors. The physician could easily document the experience, dispatch an alert to a local ED, and ensure precautions are taken by medical staff to usher this patient into a contained room or unit to begin testing and treatment. We’re working to ensure this type of communication is happening at all levels, but there’s still much room for improvement on this front. 

HEALTH SYSTEM EXECS RESPOND TO THE THREAT

In an op-ed prepared for the Alliance for Connected Care, Todd J. Vento, MD, MPH, Intermountain Healthcare’s Medical Director of Infectious Diseases Telehealth Service; Ethan Booker, MD, Medical Director of MedStar’s Telehealth Innovation Center; and Lawrence “Rusty” Hofmann, MD, Stanford Health’s Medical Director of Digital Health, made their pitch for telehealth:

“Telehealth, which has proven to be a very useful tool in addressing patient needs during flu season, will improve our collective ability to address COVID-19 if it hits on a larger scale. Telehealth offers several advantages over in-person care in the event of a pandemic.

One key advantage of telehealth is speed,” the three wrote. “Patients can access clinicians 24/7 without an appointment or physical trip to the doctor. Using telehealth, our providers in the Stanford Primary Care team, MedStar Health and Intermountain Healthcare have been actively evaluating and treating patients with influenza.  Current providers at Stanford Health estimate that almost 50% of patients are getting oseltamivir (Tamiflu).  Because there is no current, specific medication for Coronavirus, we must be able to advise patients of reasonable self-directed treatment and surveillance to keep them home. 

Keeping patients at home is a significant advantage of telehealth. In-home video visits limit community exposure by allowing patients to avoid contact with other patients in waiting rooms and direct contact with providers during the exam.  Our health systems have providers who are equipped to work from their own homes, significantly increasing the safety of providers and bolstering the workforce to respond to crisis.  Workforce readiness in a crisis that may include such dramatic measures as school and day care closures is a significant concern for health systems which may be strained to respond.  Health systems are also using telehealth to continue surveillance of patients already identified as at risk while keeping them at home.

Next, telehealth ensures that treatment in brick-and-mortar settings is reserved for high-need patients.  Moreover, with patients being seen in their own homes, providers and health systems will be able to triage and screen exponentially more patients with telehealth vs. an in-person visit.

Finally, telehealth allows patients who do not have access to infectious diseases (ID) specialists to access this specialized care from the small number of experts across the country. When Intermountain first offered ID telehealth consultation to rural systems throughout the west, one provider fielded 1,000 consultation requests in the first fifteen months. To date, the service has provided telehealth care to over 4,700 patients, 50 percent of whom are over 65 years old.

Each of these advantages illustrate how telehealth can thwart the spread of COVID-19 and stop it from overwhelming our already stretched medical system.”

The three health executive also urged lawmakers to take action to reduce barriers to telehealth that have kept adoption low:

“Congress must act to ensure that seniors – a particularly vulnerable population generally and for this virus in particular – are able to receive necessary triage and care through telehealth. 

Today, there are restrictions in Medicare that prevent providers outside of very rural areas from being paid for care provided through telehealth. As a result, many providers do not offer telehealth services to seniors. The lack of reimbursement creates a perverse incentive of encouraging patients to come for in-person care, which will only overwhelm our health system as well as augment the virus’s spread.

Congress must give the Secretary of Health and Human Services the ability to waive these restrictions in times of public health emergencies. As part of the bipartisan, bicameral CONNECT for Health Act, telehealth champions in Congress foresaw this need and drafted a provision that would give the Secretary the ability to waive telehealth restrictions just as he/she would waive Conditions of Participation, Stark Laws licensure, or other requirements when public health emergencies are declared.”

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