Only weeks ago, American doctors’ waiting rooms were bustling with patients of all ages. This was no surprise as it is estimated that in an average year the U.S. healthcare system provided an estimated 278 office-based physician visits per 100 persons, for a total of approximately 883 million visits per year.Chronic conditions were the major reason for 37% of all office-based physician visits, and visits for chronic conditions were predictably higher among adults than children.
In the last few years, these visit patterns were changing, albeit gradually with increases in the adoption of telehealth visits. Indeed, adoption of telehealth visits did increase from 5% to 22% between 2015 and 2018but many barriers remained to broader adoption of telehealth, among them uncertain reimbursement for these types of visits and at times lack of physician buy-in2.
In January 2020, the Coronavirus (COVID-19) pandemic began to unfold having a profound impact on how ambulatory health care is provided in the U.S. Faced with a highly contagious novel infectious agent spreading rapidly through communities across the country, it became apparent that in-person doctor office visits in many settings were impractical and for many patients, could even be dangerous. The prospect of doctor’s office waiting rooms filled with older frail patients waiting to see their provider for treatment of ongoing chronic conditions, sharing the space with patients with suspected or confirmed COVID-19 was clearly of great concern.
This unfortunate new reality thus created a compelling use case for telehealth. Patients with COVID-19 could be evaluated remotely, avoiding the risk of contagion for the office staff and providers, those deemed seriously ill could be referred to the emergency department with prior notification of their arrival. Patients deemed stable with milder presentations of COVID-19 could be followed and monitored at home with serial telehealth visits. Patients with ongoing chronic conditions who are at high risk for complications from COVID-19 infection, could be provided with needed care via telehealth from the safety of their homes.
Until the COVID-19 pandemic, Medicare would only pay for telehealth services on a very limited basis: only when the beneficiary receiving the service was in a designated rural area and when they left their home to go to a medical facility (i.e. hospital or physician’s office) to receive a service from an approved provider in a different location through a real-time audio and video telecommunications system. The service delivered also had to be among the list of visit codes designated as “covered” by Medicare for telehealth4; and finally, only applied in situationswhere the beneficiary had an established relationship with the provider performing the telehealth visit.
In response to the pandemic, Centers for Medicare & Medicaid Services (CMS) recognized the urgent need for broad implementation of telehealth services waiving the qualifying rural area and facility requirements, enabling the delivery of telehealth services in all areas of the country to patients who can remain in their homes.
Additionally, the U.S. Dept of Health and Human Services (HHS) Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive all patient cost-sharing payments for telehealth visits paid by Medicare. Beyond Medicare, state Medicaid programs and commercial payers have also announced new telehealth policies related to the COVID-19 emergency3.
Rapid integration of telehealth visits into a practice’s workflow is a complex task and requires clinical and administrative leaders to develop an effective strategy for implementation of this modality. Assuming a practice has not had prior experience with telehealth, selecting the telehealth platform is one of the first decisions the practice will face. In making this decision, it is important to recognize that the technology selected will likely need to serve the practice after the current crisis subsides and that a long-term view is necessary.
Using telephone only or free video stand-alone applications might satisfy the HIPAA requirements temporarily relaxed during this crisis but will not be robust enough to support the requirements that will prevail down the road. Stand-alone telehealth applications might be easy to deploy, however, in the long run, they may not integrate with the provider’s Electronic Health Record (EHR) workflows. The ability to integrate seamlessly into the provider’s EHR is crucial for usability, physician adoption and consistent documentation of telehealth visits in the EHR.
Once the technology or platform is selected, the practice is faced with many decisions surrounding the specific guidelines that will govern the deployment of these visits. A decision needs to be made whether telehealth visits are to be provided by all physicians or only a select team of physicians and whether advanced providers participate in the provision of these visits. Is the practice going to make telehealth visits available to all patients or reserved for patients with certain diagnoses? If only certain diagnoses are selected, the practice will need to determine how this triage will occur, and by whom.
It is helpful to determine if the practice or the health plan requires a certain length of time to be spent for each visit, and what specific documentation templates or billing codes they require. It is extremely important to decide whether all schedule time slots are eligible for telemedicine visits or whether providers should assign dedicated blocks of time for these visits, allowing more predictable allocation of support staff who may not play as central a role in these type of visits, since patients do not need to be “roomed” in the traditional sense.
It is necessary to plan for training staff, providers and patients on the use of the telehealth tools. This is an area that is significantly impacted by choosing a highly usable, mature, purpose-built, EHR-integrated telehealth platform, as doing so will reduce the time and effort of implementation, training, and adoption of this new modality.
Telemedicine holds great promise — beyond its obvious advantages in these troubled times, it offers patients enhanced access and convenience. Correctly deployed and reimbursed, it also has the potential to reduce physician burnout. It improves quality and outcomes as it facilitates engaging more patients in a cost-effective manner. As the COVID-19 pandemic expands, we are observing an unprecedented increase in the adoption of this modality and telemedicine is clearly coming of age. This might be a silver lining in an otherwise very challenging time.