Telemedicine and technology are crucial ways to deliver care and keep our health care workers, patients and vulnerable populations safe, especially amid the COVID-19 pandemic. This discussion is designed to share best practices and the latest policy and payment updates to support physicians and practices in expediting the implementation of telemedicine. This conversation should also outline the ways in which technology and telemedicine can strengthen physician/patient relationships, even in trying times like those of the current COVID-19 pandemic, so care can continue to be provided to those who need it most.
Telemedicine usage is skyrocketing given Covid-19 pandemic; what is the expectation once stay at home orders are lifted? Your data suggest a jump from 14% to 28% since 2016, my guess is that figure has jumped since patients who normally wouldn't consider telemedicine are now being forced to use adapt.
Secondly, where can I find raw data pertaining to usage? By demographic, specialty and state level?
Are there any cost/benefit studies out there?
For G0438 and G0439 via telehealth -vital signs needed for reimbursement?
When doing G0438 and G0439 via telemedicine - are the vital signs still a required piece? For G0438 is an eye exam still required for billing/reimbursement?
How is telemedicine now adapting to support those with chronic illnesses that are slightly more rare/difficult to diagnose? (i.e. autoimmune conditions, genetic joint conditions, pain conditions, etc.).
How is telemedicine adapting to the Specialty physicians who typically treat them in person? (i.e. Rheumatologists, neurologists, gastroenterologists, endocrinologists, etc.)
the first thing to ask yourself is, "what data do I need to make a decision about diagnosis or management and can I obtain that data with the patient in a different location. if yes, you can perform your service by telehealth. lots of different options and use cases to digest.
There are many ways to answer that question and it reflects the technical sophistication and payment paradigms you work with. The potential for more expert input, co-management, and better diagnostic and therapeutic choices is there, but is at the next level of telehealth than most are working in at this time. Payment that rewards outcomes and cost efficiency (value) and is convenient and appreciatred by patients is the goal.
This includes Remote Monitoring of patients in section 14. Please partner with companies to receive these reimbursements.
Just keep in mind that the definition of "eligible providers" is a bit restrictive.
This is a phenomenal opportunity to connect the 37 million U.S. households that lack internet and connected devices.
I urge anyone considering applying to connect with local and national organizations that are expert in connecting unconnected households.
The National Digital Inclusion Alliance (digitalinclusion.org/) institutional members and local affiliates across the country can strengthen your applications and implementation strategies around:
Identifying the patients in need of devices and dataplans;
Procuring, configuring and delivering devices to patients;
Providing technical support to patients;
Training your staff to perform some of these services
Please contact me for more information and/or to be put in touch with NDIA affiliates in your community.
We are building a product incorporating both traditional telemedicine (voice and video consults, secure messaging, etc.) along with connectivity to monitor patients' vitals like BP, glucose, pulse ox, etc. to actually try to manage the patient fully virtually. It seems like a requirement in these times when these types of higher-risk patients are most vulnerable to coming into the practices. Has anyone in this group experienced something like that or have thoughts in how it might be implemented in a practice managing conditions like diabetes and hypertension? It also was intended to help practices offset the revenue losses from the lack of patients coming on site by creating the infrastructure needed to bill for remote monitoring, chronic care planning, and virtual visits.
If anyone has some feedback or would be interested in piloting with us, I would love. to get that feedback.
Don't forget weight, pulse rate
We are tracking a lot of the user measurements like weight, BMI, glucose, BP, HR, movement, sleep pattern, activity level, EKG, etc to try to give a physician a complete view of their patients regardless if they have the ability to come into the office or not. There are so many data collection opportunities out there, we are trying to collapse that all down into a simple to use app for the patient and a consolidated web portal for the physician to manage or integrate the data back into their EMR. It will be interesting to see where the demand for those services moves in the combining months and years as patients' and physicians' behaviors evolve.
And temperature of course
Could have a look at Datos.
Thanks for sharing! That is similar to what we're doing, but focused more on chronic health, so imagine that home hospitalization patient with diabetes automatically streaming their weight along with the glucose & activity levels up to her doctor. Is your practice doing anything like that now, or contemplating something? Do you have any input on how it might be used in your clinical setting? I appreciate the feedback!
The VA does use remote monitoring devices in its telehealth program, for chronic management of hypertension, heart failure, diabetes, and other conditions. It also has a home video connection service for use with patients. These two systems are not usually used in tandem currently-- remote monitoring is often coupled with telephone discussions-- but they certainly could be at any time, without the need for technical modifications.
Do you have a way to identify and reach patients who are not currently connected to or comfortable using the internet and devices?
I encourage you to connect with the National Digital Inclusion Alliance (digitalinclusion.org) to identify organizations in your community that know how to help individuals get devices, free or low cost dataplans and basic digital skill training. We can also help train your staff to provide the technical support that patients may need to use these devices.
Contact me for more info: email@example.com
There is an insurance group that has been doing this in San Diego with hopes to help decrease re-admissions. One of the issues has been providing the feedback back to our private practice. There does not seem to be enough integration of these systems with the primary care providers.The real time data is not provided to our office, so it is not really helpful to get a report several weeks after the evaluation occurred. Another issue I run into frequently is insurers covering these wearables. For example, I have a hard time getting continuous glucose monitors approved in elderly diabetic patients where both the patient and I could greatly benefit from this data.
That is actually a good point of reference. Do you know if they have any success indicators in that program? It sounds pretty similar to our model, but ours may be more integrated onto a simple platform to also increase engagement and get people to take their measurements.
Thanks, Marina. We've been focused initially on the Medicare population and the reimbursement around chronic care planning and remote monitoring. We work directly with the physician practices, so you would be able to get literally realtime data on your patients. I am actually here local in San Diego as well. Are you currently treating patients at I-Care that we could maybe set up a pilot cohort to test case with? I would love to get your feedback on the downsides of the insurance program versus something inventing back at the physician level.
I have a MA licencse and practice in MA on the border of RI. Can I do a telehealth visit with a patient who has a lives (has a legal residence) in RI? What if that pt has a legal residence in RI but is visiting family in MA? Can I provide telehealth services while they are in MA? If I have snowbirds who travel to FL for the winter, does their legal residence have to be in MA to provide telehealth services?
I guess the question is when providing telehealth service is it the legal residence or phyisical location of the patient that matters? Thank you in advance.
I'm not an attorney, but my reading of this suggests that, for CMS, any location within the national emergency area would qualify, though a facility fee would not be covered outside the usual (non-emergency) qualifying locations.
Does the physician's physical location matter? Meaning, regardless of patient location, is the physician able to conduct a billable event if at that home for example? Or must they be in their usual practice location or hospital? Must it be on a formal EMR system?
Hi Joseph and Christopher - the short answer is, it varies by state. Although CMS issued a waiver allowing licensed providers to render services outside their state of enrollment, this does NOT obviate the need to follow state licensure requirements. Now, many states have altered their licensure requirements over the last several weeks, but the waivers are not consistent. If helpful, take a look at this webpage: nixonlawgroup.com/covid-19-tel....
About one-half of low-income patients lack devices, internet access and digital skills needed to use telehealth. Are you encountering patients unable to use telehealth? Do you resort to inferior "cellehealth" if they don't have video? Do you offer them any resources to address their barriers to telehealth? Would you consider adding a digital connectivity assessment as part of patient screening to identify patients that cannot use telehealth?
Hi Amy, we at Delve Health (www.delvehealth.com) utilize a hybrid approach to engage patients. For ones that do not have devices, we ship out the device to them. However, the provider or pharma organization pays for that cost.
That's a great approach. Do patients need/get technical support to use devices?
About one-half of low income patients lack devices, internet access and digital skills needed to use telehealth. Are you encountering patients unable to use telehealth? Do you resort to inferior "cellehealth" if they don't have video? Do you offer them any resources to address their barriers to telehealth? Would you consider adding a digital connectivity assessment as part of patient screening to identify patients that cannot use telehealth?
Great question, at UNC we offer phone or video options as telehealth communication mediums. To your point, some patients especially rural and underserved populations, have limited internet access and they typically choose telephone call for their telehealth visit. Happy to provide more around workflow if helpful.
This is such an important question.
With the rapid COVID-19 related expansion of telehealth, we see that, for various reasons, many patients rely on the telephone, over AV tools. For the duration of the emergency declaration, the telephone may be used for billing telehealth encounters and they are covered by CMS (CPT codes, 99441-3). The payment rate is lower than the corresponding E/M codes, which some have questioned.
At the same time, there has been loosening of the security and compliance requirements surrounding telehealth further enabling its use, including the telephone.
On a practical level, this is all a good thing. We can quickly and safely reach patients without being slowed by technology and other issues which could be barriers in normal times.
But, here is what it is really important. We are living through one of the largest telehealth pilot studies in history. 6, 12, 18 months from now, we will look back on this time to objectively evaluate what worked and didn't work. And why. The quality of our interactions, patient experience, outcomes and documentation will be an important parts of that analysis.
The FCC has just offered funding that includes purchase of devices and dataplans for patients to use telehealth! Message me offline if you are interested in applying. amy.sheon @ gmail
Dr Silva is spot on. Folks who have expanded the use of virtual visits need to plan now for how to study the implementation science, process outcomes and clinical outcomes of this response to the crisis.
You provide technology along with compassionate staff that hand holds patients who are not able to use technology via non face to face interactions that is getting reimbursed under CMS as Chronic Care Management.
Great observations here. We are seeing and speaking with a lot of practices who are conducting telephone visits. As clinicians, we have been providing care and advice over the phone for years and know it is helpful and easy (although uncompensated prior to the past month). If someone does not have access to internet or is not tech savvy it's a tried and true option. While doing visits over video would be optimal (having two senses of sight and sound involved in a clinical interaction offers more value than one) in the end the most important thing is that it's about providing the care and advice - the means by which it is conveyed becomes secondary if technology is a barrier.
Hi Amy Can you post the information? Thanks
Here's the link for funding they just opened this portal on the 13th and please see FAQ's on it.
We are thinking of adding it to our free Covid-19 web tool which helps to lighten the load by automating some clinical workflows. Basically we would incorporate complex scoring systems to predict the chance of cytokine activation. Would greatly appreciate your feedback and insight.
Thank you so much!
For reference here’s our Coronavirus tool which has CDC plus additional treatment guidelines and protocols, mayamd.ai/coronavirus-help/
This could eventually be useful, but I don't know of a current drug or other approach that targets COVID-generated cytokines via a preventive strategy. One might emerge through findings from clinical trials.
The tool appears to be basically an algorithmic progression, therefore, the database the it is using is the key. The more data, the better the predictions it can make and the better the movement through the progression chain. The key is data in. The same would apply to a cytokine tool.
The AMA's Chief Health Equity Officer, Dr. Aletha Maybank cites a lack of racial and ethnic data relating to COVID-19 in her recent NY Times op-ed piece. Dr. Maybank writes, "This data is central to understanding injustice and ensuring the optimal health of people, but it is gravely missing in this crisis — missing from health department websites, daily updates by political leaders and, until recently, news reports." How can we gather this data to better understand and address these health inequities? What do we risk in not collecting this data? Can telemedicine be used as a tool to collect this data?nytimes.com/2020/04/07/opinion...
yes, it can but it will require a commitment by all practitioners to collect a structured series of data as they roll out these visits. Given that the implementation of widespread telehealth has been chaotic and rushed, I am, sadly, skeptical.
One important thing to collect is the patient's internet access and skills. Without both, no telehealth! (Yes, they can do audio only but I call that "cellehealth" AKA second class care.
I believe it is important to have the private community physicians/groups involved in the pandemic response. I suggest smaller task forces of physicians in each community with resources to educate and test. There is disparity because the leaders of the community, have not been working with the community physicians. Over a month ago, I noticed test centers were predominantly in affluent areas, and none were close to the community where I was practicing. My patient population is predominantly Mexican, Central, and Latin American. My fellow private physicians and I tried to organize a drive by test site, even found rapid tests kits and PPE for ourselves. We just needed the funding to purchase the kits to test 50-100 symptomatic patients a day. We had bought our own PPE. I called the state offices, I called our local public health department, I called the Mayor of our Chula Vista community. We did not get support nor response to inquiries, and I could not find avenues for funding to apply for during this pandemic. I feel that in general they were not prepared and scrambling, so our concerns were not being heard. This was extremely frustrating. I am glad I started educating my patients at the end of January regarding how to stay safe, gave them masks, and instructed them to prepare for several months at home during our office visits. As a primary care physician, I know the community I practice in and understand my patient's needs.
Appreciate the work you are doing. Do your patients have internet at home? Are they able to use telehealth? Kids able to do online school work?
Most of my patients are elderly, and do not have smart phones or internet. We have been doing phone encounters, video visits with others, and patient visits for emergent issues.
I am currently working on a solution for this, though my barrier is building the technical team to assist in the programming.
We have been working on a similar study looking at social determinants and telehealth. Here is a recent study around this topic. Happy to chat if interested.
The divide that we see has been growing for decades. It is not just an economic one. It is a divide of education and skill sets. Telehealth tools are fine for the web literate, and there are many, but not for those who are web "illiterate" or lack access or band width to allow the full potential of telehealth to be realized.
Joseph--you are spot on. I hope that providers will not accept lack of patient connectivity as a given. If there was ever a time to end the digital divide, it's now. Please advocate for getting your patients connected. There are simple steps you can take, starting with screening your patients and referring them to local services if they do not have connected devices and broadband or mobile dataplans.
my guess is that your data curiosity is ahead of what we have collected. Here is one non-scientific accounting of how things have skyrocketed. beckershospitalreview.com/tele...
That will partly depend on the regulations and acceptance from government and insurers as far as whether telehealth will continue to be utilized as a main platform for health delivery. That being said, the technology side of the existing platforms is not ready for full telehealth visits. I have had experience using a few platforms, there are many key components missing, and the efficiency can also be improved to encompass a primary care/specialty visit.