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Telehealth Adoption Is a Challenge Worth Meeting

AACE leaders on embracing technology in medicine

by Howard M. Lando, MD, and Susan L. Samson, MD, PhD 

September 18, 2020

Telehealth has been available as a tool for health care practitioners for years but, until recently, it was primarily used to treat patients in rural areas and with various restrictions, including where the service could take place and licensure limitations. The practice of telemedicine has shifted dramatically in six short months. Although expansion of telehealth services has raised new challenges, telemedicine has been critical to provision of health care during the COVID-19 pandemic and can continue to deliver essential benefits into the post-pandemic future.

As the pandemic rapidly spread in the U.S. in mid-March, the Centers for Medicare and Medicaid Services (CMS) took swift and significant action. CMS expanded Medicare to permit all beneficiaries, regardless of location, to receive telehealth services, which allows clinicians to continue treatment for many patients while following social distancing guidelines. Other rules announced by CMS made it easier for a variety of providers, who conduct services such as psychotherapy, radiation therapy management and emergency response, to use and expand their telehealth services.

The result is that approximately 10 million people with Medicare have used telehealth services since the onset of the pandemic through early-July, compared to only 14,000 beneficiaries using telehealth services per week prior to the COVID-19 pandemic. This greatly expanded access, but the rapid growth of telehealth leaves several questions unanswered. Do the benefits of telemedicine outweigh the difficulties? How are healthcare practitioners pivoting their services in the era of telemedicine? What are the best practices to follow with telehealth?

As the president and secretary of the American Association of Clinical Endocrinologists (AACE), we believe that endocrinologists, along with all healthcare practitioners, must embrace telehealth as part of the future of medicine. Telehealth provides an opportunity to free up resources and provide expanded access to essential care for patients, especially for underserved populations or in geographic areas that lack endocrinologists.

Telemedicine also offers new opportunities for efficiency, since the majority of the care endocrinologists provide is in the outpatient setting. Implementation of a telehealth option can reduce “no show” rates, especially for follow up visits. This efficiency can increase adherence to treatment plans, which can be crucial for our patients with chronic conditions, such as diabetes and obesity. In addition, telemedicine appointments will likely become a standard of care in the future for people with diabetes between in-person visits to better monitor their condition and blood sugar levels.

While we feel comfortable with this format for follow up visits with established patients, there remain many barriers and challenges with telehealth. A recent AACE survey that assessed members’ views on the impact of COVID-19 on their practice demonstrated that about 65% of clinicians felt very or extremely concerned about the ability for their profession/industry to operate effectively (e.g., as a result of social distancing guidelines, professionals becoming ill). Telehealth is now being used for at least half of patients by nearly 40% of our AACE member clinicians, according to the survey results.

When faced with a difficult or subtle diagnosis, such as giving a third opinion for Cushing’s disease, not being able to perform an in-person examination can diminish feelings of security and confidence on how to proceed. The inability to conduct physical examinations, schedule imaging, or monitor laboratory values for medication safety continue to be key challenges with the telehealth format.

We have also experienced many logistical barriers to telehealth work. Approximately 70% of the AACE survey respondents felt that they encountered technology issues with telehealth. On a larger scale, many of us are still lacking interstate licensing, which makes it difficult to continue care with established patients that live in different states. Other issues include inconsistent reimbursement, legal or regulatory challenges, privacy concerns and a lack of evidence regarding the impact of telehealth on health care costs. As health care providers and endocrinologists, we need to do our utmost to navigate the complicated circumstances in order to continue treating our patients with telemedicine.

Below are some best practices to overcome these challenges and support your telehealth visits, improving the experience both for yourself and your patients:

  • Make sure you have the appropriate set up that will support successful telehealth visits, including a strong wifi connection, sufficient internet bandwidth, a quiet or private space, and clear video of you
  • Explain to your patient why you are using telemedicine, and consider providing them with a telehealth checklist so that everyone can come to the visit prepared (see a checklist on AACE’s website)
  • Begin the telehealth visit by introducing yourself and acknowledging the patient (and anyone else who may be with them). Confirm that you can see and hear each other
  • Empower the patient to speak up if something is not clear
  • Look at the camera to maintain “eye-contact” with the patient and use your body language as appropriate during the conversation. This helps maintain a level of comfort and interaction usually present during in-person visits
  • Consider using dual monitors to document or access the EHR while speaking to your patient. This can make it easier to take notes or look up reports, if necessary
  • When appropriate, it can be valuable to share your screen, such as with radiology images, laboratory values, or online patient education materials, so the patient can also have information provided visually
  • To prepare other staff (if applicable) for telehealth visits, develop a written or video training guide with step-by-step instructions
  • Remember that patients may experience initial difficulties with virtual visits as well: be prepared to support them with scheduling or technical issues
  • Collect patient and staff feedback, and incorporate as appropriate
  • Use the new CPT codes for telehealth patient visits and physician or specialist consultations. Note that, during the COVID-19 crisis, Medicare and most insurance companies are allowing usual office visit codes to be used and paid at those rates

AACE also provides a range of telehealth resources to assist clinicians, ranging from coding and billing practice management tips to presentations detailing how to set up your telemedicine service. We encourage you to take advantage of telehealth options, provided your practice has the appropriate resources. The long-term benefits of telemedicine are sure to outweigh the challenges of building or improving upon existing infrastructures.

Though the U.S. will one day see the end of the COVID-19 pandemic, it is our prediction and hope that health care providers will continue to expand the use of telemedicine to ultimately improve patient care and access to care, as part of a safe and healthy future.